When I listen to stories from patients, families and older service users I alternate between disappointment and optimism about the future. Mary is a member of a service user reference group that is participating in my research on the professional experience of working with long term conditions. She is 80 years old and lives in sheltered housing. She is severely limited by her rheumatoid arthritis and dependent on help from social care and her daughter. Mary described her relief when a community matron helped to sort out the medication which was giving persistent and unpleasant side effects. “ I really wanted to thank her, but I never saw her again”.

However, there is often a darker side to the experience that older people have of nursing care for example in hospital, being anxious, unsettled and having to cope with an overstretched and chaotic system where the fundamentals are too often neglected such as meals put out of reach, requests for help for the toilet ignored, and well meaning professionals asking the same questions over and over again. How then should nursing contribute to ensuring that the public perception of the variability in quality care is tackled and that individual needs are met with empathy and attention to detail?

The answer will not be found in governments issuing successive policies exhorting the “essence of care” (Department of Health, 2001), promoting campaigns around improving the “confidence in care”, work that I was involved in with the Assistant Chief Nurse in 2005, “privacy and dignity” (Department of Health, 2006) and now more “smiling” (Carvel, 2008)! I fear this finger waving, target setting and collection of compassion metrics may have the opposite effect and create a sense of cynicism and lead to defensive rather than caring nursing.

The seminal contribution made by Isabel Menzies-Lyth (1970) nearly forty years ago was that nursing practice should be understood within the context of the hospital as a social system. This was based on work with nurses at King’s College Hospital and an analysis of the dynamics of the organisation that exposed the hierarchy as being protective of self interest and that nurses who are exposed to the stress of the day-to-day and intimate relationships experience more emotional pressure in contrast to senior staff who are distanced and protected. Her argument was that organisations can create anxiety and feelings of fragmentation for individuals working within them, which people respond to by establishing protective shells, projecting negative attitudes and what she described as defensive behaviour against anxiety. Clearly this has a negative impact on the individual nurse, relationships with colleagues and more importantly with patients and their families.

What then should nursing do to be ready for an ageing population given we have to deliver services within a culture obsessed with performance targets, which are here to stay as resources become ever squeezed for the most vulnerable populations. The Royal College of Nursing’s (2008) recent survey of over 2000 nurses’ views on providing services that are dignified for their patients showed that there are roles and responsibilities not just for individuals, but also for health care organisations and for government.

My personal view is that we need to focus on addressing what I will call here the paradox of organisational cultures. On the one hand most organisations purport to be patient centred and responsive, but in reality are performance and target driven, which in contexts of care for older people and long term conditions often translates into a feeling of dislocation. In my current research we are finding that the factors motivating staff in the care of people with long term conditions are around leadership, support, relationships with others in teams, which are elements of an organisational culture that values the individual and their differences. I would like to argue for a change of direction and to take the heat off individual professional disciplines and instead focus on the groups, systems and cultures of care. If we can shift organisational behaviour then maybe nursing will be able to get ready for an ageing population.

References

Department of Health. (2001). Essence of care: Patient focused benchmarking for health care practitioners. London: Department of Health.

Department of Health. (2006). About the dignity in care campaign. London: Department of Health (available online from http://www.dh.gov.uk).

Carvel, J. (2008, 18th June). Nurses to be rated on how compassionate and smiley they are. Available at: www.guardian.co.uk/society/2008/jun/18/nhs60.nhs1.

Menzies-Lyth, I.. (1970). The functioning of social systems as a defence against anxiety. A report on a study of a nursing service in a general hospital. London: Tavistock Publications.

Royal College of Nursing. (2008). Defending dignity: Challenges and opportunities for nursing. London: Royal College of Nursing.

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