‘Compassion’, ‘dignity’ and ‘respect’ in care: we need to walk the talk
Meet Charlie: Charlie, a middle aged man who until recently had a career in the leisure industry, is a care worker in a home for adults with profound disabilities.
Charlie recently told me: “Having respect for other people is really important to me. I see everyone as an individual and enjoy taking time to get to know them well. Trying not to pre-judge I know that being respectful means different things to different people. Learning from people and finding about their interests and experiences is really interesting for me. One of the ways I show my respect is by making sure when I cook the food is nutritious, tastes great and, even though it is liquidised to help people swallow and digest, it always looks great on the plate. I wouldn't settle for anything less for myself”
We would all love to be supported by someone like Charlie - every employer would want workers like him. Charlie not only has an intuitive understanding of the value of respect, but he also demonstrates this through his behaviour - the extraordinary care he takes when preparing food, an everyday task in every care and nursing home in the UK.
Charlie, for me, embodies the concept of compassionate care and treats the person he cares for with dignity and respect. But while he is clearly able to translate the rhetoric of compassion, care and respect to the reality of his working day, not everyone is like Charlie. And that is a fundamental problem at the heart of health and social care: we all agree that values are important, we all believe we all know what they are - yet what are they?
Compassion, respect, dignity are health and social care buzz words, but are often expressed with such vagueness; it is assumed there is a common understanding about what they are. What’s more, there also appears to be little understanding of how to translate these three values into action. The discussion of these values in national policy circles remains distant from reality. This can create an illusion of certainty or competence.
The recent scandals in health and social care tell us what is wrong - it is harder to know what is right. Even the judgement of the regulator, the Care Quality Commission (CQC), is being challenged: Camilla Cavendish, in the Sunday Times, quoted the owner of a care provider as saying: “the CQC cared more about the temperature of his fridges than whether his staff were compassionate.”
Yet there is a national movement for change. As a response to the inquiries into the neglect at Mid Staffs NHS and Winterbourne View, many of the reports, concordats and reviews have called for a review of how frontline, health and social care staff, are recruited, trained and supervised.
The Cavendish Review, published today, is the latest such piece of work. Launching the review, health secretary Jeremy Hunt explained: “We want everyone receiving treatment to get the most safe, effective and compassionate care. So we need to make sure that staff tasked with carrying out some of the most personal and fundamental jobs have the skills, values and behaviours needed to provide this.”
Other important work includes the joint Skills for Care and Skills for Health excellent code of conduct, the National Skills Academy and the academy’s new values based recruitment tool due to be launched later this month. This will include the use of personality profiling for new applicants to frontline roles (the importance of which is something I’ve blogged about before on these pages). These initiatives either help to define value based behaviours, show how to recruit for those behaviours or show how to put a whole leadership system together to reinforce and sustain those behaviours.
Yet despite this groundswell of opinion and agenda for change, we still have the behaviour of Charlie on one hand, and on the other, what we witnessed on the recent Panorama documentary.
Secret filming showed two staff doing the same activity - helping an elderly, confused woman who has a lot of pain to change her clothes and freshen her bed. An everyday task but one person did it really well with lots of reassurance and one very badly causing a lot of distress. Same organisation, same situation, both probably had the same basic training, followed the same “safe” manual handling procedures but what was different - the relationship.
Strip out the extraordinary, overbearing, complexity of the health and social care sectors and the organisations within them and it is all about people - relationships and interactions between people. The core of good care and support is all about frontline workers and their engagement with individuals through their daily interactions - in whatever situation or circumstance.
Put simply good interactions result in positive experiences for both individuals. It’s what we all want. By working in a warm, attentive and engaged way, interactions will be good. The question is how do one’s values impact on likelihood of working in this way?
There are certain elements of our current care framework that undermine the movement for change. Procurement and commissioning practices, for example, that reduce the workforce to a commodity to be bought, sold and deployed for the lowest price.
And there are care contracts being moved from one provider to another with almost total disregard to impact on relationships and workplace culture. I recently heard about the retendering of a longstanding contract from a fully compliant and trusted provider with a well-established track record of good care.
The procurement process was a purely paper based exercise, with no consultation with the people affected and bizarrely explicitly excluded consideration of past performance in its assessment. Itwas said that to take past performance (good or bad) into consideration would be unfair - to whom exactly?
In addition, there are other aspects that would help the movement for change, but are missing.
There is an important opportunity within the drafting of the current Care Bill to place a formal duty of care on all workers to uphold a common standard of acceptable behaviour. This could include an obligation to incorporate the code of conduct, referred to above, in all job descriptions and be included in induction and training standards. The CQC has a regulatory duty to ensure all people supported within regulated settings are treated with respect and dignity. This duty could be enhanced by adding a requirement on all employers and employees to satisfy some new standards of compliance with the code of conduct.
In terms of what else is missing, employers need to do more: there is no doubt that the financial squeeze and the low wages are issues we need to face for the foreseeable future, there is much that can and should still be done to improve organisational culture and staff engagement.
The vast majority of people who come into care and nursing do so because they want to make a difference, they want to do a good job. Learning to interact well can be learnt. Simple “show and teach” techniques through video clips, for example, have been proven to be effective. Interactions can be broken down into specific behaviours - eye contact, smiling, listening – each behaviour can be considered as a skill, and skills can be learnt and developed.
So it is imperative that we seize, hold onto and effectively deliver the sometimes slippery concepts of compassion, dignity and respect. In our haste to chase these concepts, if we are not clear about how we put such values into action, and fail to spell out what they mean in reality, then all our good efforts will be ineffective.
This is what I mean when I say to my MacIntyre colleagues: “People don’t experience our values they experience our behaviours”. Or to put it in more dramatic terms (with a line borrowed from Shakespeare’s King John), “be great in act, as you have been in thought”.
We must stop assuming there is an automatic understanding of how to transform value-based vocabulary into action. We need to start articulating the words at the heart of the value-based debate through our deeds. Only then will there be any real, lasting difference to the people we support.
Download the Cavendish Review (PDF)