[Guest post by Connor Kinsella]
At great risk to the reputation what has always been one of the more respected organs of the health and social care blogosphere, I’ve been invited to contribute to the Not So Big Society blog. This may turn out to be about as welcome as a knighthood for Piers Morgan, but before I outstay my welcome I want to draw attention to an issue which, in public at least, remains remarkably under-discussed. It’s more than just the Elephant in the Room. It’s a bloody great dinosaur crouching on the mantelpiece belching loudly while everyone sits on the sofa wondering what’s happened to Patch the family Labrador.
I come to this subject on the back of a previous NSBS post. In Nursing Degrees aren’t the Problem, Zarathustra looks at poor care and the perceived erosion of compassion within the nursing profession, often attributed to the elevation of nurse training to degree and diploma level. The ‘too posh to wash’ argument is, as Zarathustra points out, thoroughly flawed on a number of counts, but one highly significant issue raised in the piece is the seeming impotence of practice tutors, mentors and academic supervisors to weed out the sort of students who really shouldn’t be let loose on an ant farm let alone caring for the sick and the vulnerable.
Failures in care can and do arise from the sort of systemic factors highlighted so ably by this blog among many others. Poor or non-existent resources, savage cuts and the sort of target-obsessed management twonks who punctuate every other sentence with ‘going forward’ are never going to further the cause of good quality care. But many years of mental health nursing and social care training delivery have left what is (to me at least) one undeniable conclusion. There are far too many individual workers who are simply not up to the task of working professionally and appropriately with vulnerable people.
And I’m not talking about the headline makers: the Shipmans and Allitts, nor the ‘care’ staff of Winterbourne View. I’m looking toward the day-to-day awfulness of the sort of workers who, as Zarathustra points out, could and should have been rooted out at an early stage long before they have gone on to cause misery to every patient, client, service user and colleague that has the misfortune to cross their path.
If you’re reading this as a health and social care professional, you probably know who they are. The ones who attract enough complaint letters to wallpaper a small room. The ones who know better than decades of random-controlled trials and decide that the holistic tree-bark infusion they read about on the internet is so-oooo much better at treating depression than “any of that CBT and medication nonsense.” The ones who think of clinical supervision as a) a tool of Satan or b) a personal affront to their professionalism and years of experience. And the ones who seem to think communication skills are the ability to post snaps of their buttocks on Facebook but who can talk to neither colleague nor service user without causing them to run sobbing to the nearest cupboard.
In the first (and ultimately overlong) draft of this post I embarked on a trip down memory lane to describe my fantastically dysfunctional intake of student Registered Mental Nurses way back in the early 1980s. This was as ghastly a bunch of ne’er do wells, inadequates, love addicts, perverts, substance misusers and pure textbook psychopaths as were ever let loose on the mentally ill.
But this was a skewed sample. The old institutions of the sort where old-timers like me first cut our mental health teeth were replete with flawed characters, and my cohort of student drama queens and underwear sniffers (yes, really) went barely noticed among the general monstrosity of a Victorian asylum. But as time went on and my clinical and training career took me to all corners of the health and social care universe, I really did begin to wonder what it is about this most demanding of fields that attracts so many unsuitable staff. Whether it’s damaged people seeking self-help, taking solace in working with those even more fragile than themselves or (more worryingly) meeting a need for power and control over society’s most vulnerable, this is perhaps a research study yet to be carried out. For even the power of Athens and Google fails to yield much in the way of answers.
Not that having the odd psychological peccadillo is always a harbinger of bad care. Some I have worked with have used difficult life experiences to very appropriate and professional effect without compromising those professional boundaries which are so often crossed by the wayward.
This is where we return to Zarathustra’s post. In particular a paper cited there (forgive the repetition) which I read at the author’s recommendation and can highly recommend again to anyone reading this, particularly if you have any responsibility for mentoring or supervising students, probationers or junior staff.
Kathleen Duffy’s 2003 Failure to Fail paper is the ‘go to’ qualitative study of factors influencing the assessment of nursing students’ clinical competence. Or more to the point, incompetence. If you’ve ever wondered how the care equivalent of Dr Mengele can somehow manage to hop from one disastrous placement to another without sanction, the all too familiar quotes from mentors and lecturers have the sort of chilling resonance that will ring bells for any care professional who has experienced student placements featuring laziness, disinterest, lack of empathy and even personal hostility and threats but have been too ‘nice’, too ‘conscientious’ or in some cases, even too scared to criticise or fail a student. This is indeed an eyebrow raising paper.
But sooner or later we come back to the big picture. As we’ve seen only too graphically at Winterbourne View and Mid-Staffordshire, dysfunctional environments may not be the genesis of dysfunctional staff but can certainly provide an environment where the bad apples can fester and even flourish.
In one NHS Trust I worked for, it was common for poorly performing clinical and/or managerial staff to be shuffled off to a desk, given a laptop and assigned to some ‘special project’ with a Mickey Mouse job title and the licence to carry on irritating and hindering people to their heart’s content, only on a less damaging scale than they achieved as manager of a ward.
On the other hand, the more successful, therapeutic environments I’ve come across over the years do things a little differently. Strong leadership is demonstrated by canny recruitment, proper and functional supervision, and a robust approach to casting aside those who haven’t the competence or attitude to care.
It is of course difficult to simply rid ourselves who aren’t performing to the required standard. For starters, what is the required standard? We can easily identify the member of staff who is consistently late or doesn’t turn up at all, but how do we tribunal-proof the getting shot of that care assistant with the interpersonal skills of a sofa, or has an attitude to superiors leaving managers checking the underside of their cars for bombs?
Please don’t go having nightmares about bad apples or even that dinosaur on the mantelpiece, but make no mistake. They’re out there.