The treatment of vulnerable patients will not improve until we recognise that the familiar cycle of investigation, scandal and blame is not making a difference. These events are not exceptions, and rooting out bad nurses and managers in bad organisations is not the solution.
An excellent report – Dignity in practice: an exploration of the care of older people in acute NHS trusts (Tadd et al 2011) – offers a radically different way of looking at the problems. Win Tadd and colleagues' meticulous ethnographic research and interviews in four acute hospitals lead to a radically different conclusion – that these problems are systemic and need system-wide solutions.
They found, for example, that hospital managers and staff either don't see, or don't accept, that their core business is caring for older people. In one of the hospitals, a one-day census of patients in medical beds found that the average age of patients was 82; 10 per cent were over 90. Nevertheless, in interview after interview, staff insisted: 'they do not belong here; it's just not the right place for them; it would be better if they could go somewhere else.'
And they have a point. An acute ward is not the right place for an old person who may be confused and who probably has at least two long-term health problems. The physical design of an acute ward is wrong; nowhere to go away from the bed; no lounge; no dining area; physical hazards everywhere and poor signage. The majority of staff don't have the right training. The intense concentration on reducing lengths of stay and 'pulling' patients through the system means that patients are continually on the move through environments that are not therapeutic or conducive to rest or recovery.
One aspect of institutional life that is especially destructive is the way in which a corporate aversion to risk at board level affects interactions between older patients and staff, stopping staff thinking about the right balance of risk-taking and autonomy for individuals in their care. Observing conversations, the researchers found that the fear of patients falling – or otherwise coming to harm –on the ward has precedence over considerations of patients' dignity, autonomy and the need for control. In one exchange, a patient asked for help to go to the toilet, and was told: 'No, you'll fall, it's better to stay where you are and go in the pad.' In another, the patient asked for his reading glasses and was told: 'No, you can’t have them. You might roll on them and hurt yourself.'
Systemic problems require systemic solutions, and many of these are necessarily long-term. But the recommendations about changing mind-sets and cultures can't wait. The Welsh report calls for recognition at all levels that older people are the main business of our hospitals – it's no longer enough to say 'they ought not to be here'. It calls for compulsory induction and training for all staff in the provision of dignified care and the needs of older people, especially those with dementia. And for staff to have time to reflect on practice, to question inappropriate practices that have become accepted norms including task-driven activity at the expense of engagement with patients.
Time to reflect is exactly what Schwartz Rounds® offer. A Schwartz Round® provides a forum for staff from all disciplines and all parts of the hospital to reflect on the social and emotional issues arising in the care of patients. After two year-long pilots in two UK trusts, our Point of Care programme is helping trusts to set them up and run them. The Schwartz Rounds® provide the space to reflect that the report calls for: they are a place for staff to think about the conflicts and the pressures they are under, and to remind themselves of the value and importance of the real, human, messy business of caring for people who are vulnerable.