Second year clinical psychology trainees from the University of Leicester share their thoughts on the implications for the profession of the Francis Report
Earlier in the summer we engaged in an integrated learning task to learn about the Francis Report and its impact. We worked in small groups to gather information about how services where we were on placement had responded to the Report, and how practice had or had not been effected by its findings. We also carried out a critical evaluation of the psychological responses to the report and its implications for clinical psychologists. After hearing back from the small groups we held a debate. The motion, which was carried, was the following: ‘The Francis Report offers the opportunity for strengthening local professional leadership to promote an ethical culture in the NHS. This house believes that clinical psychologists should be taking on roles of local professional leadership to develop an ethical culture and to promote safe and compassionate care in healthcare organisations’.
This blog post describes and summarises the information and experiences of the second year trainees who engaged in this task.
‘‘Between 2005 and 2008 conditions of appalling care were able to flourish in the main hospital serving the people of Stafford and its surrounding area” (Francis, 2013). Up to 1,200 avoidable deaths and cases of inhumane treatment were revealed in the three-volume report of the public enquiry led by Robert Francis (2013). The report also described a target-driven working culture, which operated at the expense of quality care for patients. The Francis inquiry also highlighted concerns within children services including a lack of leadership, failure to hear children and young people’s voices, a workforce lacking in relevant skills and compassion, systemic issues regarding openness, and children’s safety being insufficiently regarded or assessed. Similar issues were reported at Winterbourne View, a private hospital facility that allowed extreme neglect and institutional abuse of vulnerable adults who were dependent on the staff who worked with them.
Numerous psychological studies and theories can help to explain and understand some of the mechanisms underlying the ‘inhumane treatment’ and behaviour that has been reported. The ‘Bystander Effect’ was an idea developed by Darley and Latane (1968) following the infamous murder of Kitty Genovese in 1964. Kitty was stabbed to death outside her New York apartment while onlookers simply stood by and did not offer help or contact the police. Latane and Darley (1968) attributed the bystander effect to the perceived diffusion of responsibility (the more people present the more responsibility is diluted) and social influence (individuals in a group observe and look at others around them to determine how they should act or respond).
Similarly Zimbardo’s (1971) Stanford Prison experiments also help us to understand the salient issues arising from the Francis Report. In his experiments, those who were placed in a position of authority and put in charge of prisoners subjected them to treatment that seemed to go beyond moral limits. This reflects the incidents at Mid Staffs and Winterbourne View; staff appeared to unquestioningly obey those in power and authority and accept a negative culture that had developed regardless of the accompanying patient distress and suffering. Research into conformity by Asch (1951) may also help to explain this negative culture and practice. Conformity illustrates a tendency for people to align their beliefs and behaviours with others around them and demonstrates how challenging it can be not to give in to social and group pressures, regardless of how conflicting they may be to the individual’s own personal values, beliefs and attitudes.
In providing an understanding of the psychological mechanisms underlying these events, Clinical Psychologists can help to tease apart some of the key factors and variables that relate to the institutional culture of an organisation and the people working within it. So, what do we think psychologists should be offering?
- Strategic, collaborative and relevant research to bring attention to the impact of NHS changes on staff and patients.
- Ongoing compassionate, person-centred, collaborative working (e.g. formulation, active listening) in daily practice.
- Promoting and facilitating reflective practice throughout the trust. Psychologists working across different services should take a joined-up approach assuming the role of ‘Reflective Practice Ambassadors’.
- Adopting and promoting a systemic, non-blaming approach to understanding complex NHS issues.
- Turning their therapeutic skills to the teams in which they work (e.g. formulation, introducing change, reflection) to highlight current team cultures and promote alternative ways of working.
Culture generates meaning about what the organisation stands for. At an individual level, it answers the question of how a representative should act. If the culture provides a context for the practice and behaviour of staff, then cultural shifts might yet be possible. The inquiry resulted in 290 recommendations and influenced government initiatives such as the introduction of the ‘Six Cs’ and the ‘Friends and Family Test’ which encourages feedback on the patients’ experience and how likely they are to recommend the service to their friends and family. The Six Cs have been widely adopted in various health disciplines with the aim of promoting fundamental principles such as care, compassion, courage, competence, commitment and communication in daily practice in the NHS.
Although such strategies might aim at making more visible the work ethos of the NHS Constitution and improving patient care, we might ask ourselves the question on whether these could effectively create a compassionate culture across organisational levels. The answers are yet to be known. However five important questions for NHS staff may be helpful to discern whether a cultural shift towards compassion has occurred:
- Do you feel cared for?
- Do you feel a sense of self-worth?
- Do you feel protected by the organisation?
- Are you able to speak up, without fear of reprisals?
- Are decisions that are about you, made without you?
Nathalie Gray, on behalf of the 2013 Leicester DClinPsy Cohort