Putting compassion back into nursing – how does that work?

nurse_elderly_patientAccording to recent headlines, compassion has somehow got lost from NHS nursing and needs to be re-introduced. This is a difficult concept to get one’s head around especially when the Latin origin of nurse (nutrire) means “to nourish”.

oxytocinIf we think the problem is that our current nurses are no longer compassionate enough, we may even have the genetic tools available to test for this.  Recent findings suggest that there is genetic variation in the receptor for oxytocin which is often referred to as the “love hormone” or “cuddle chemical” because of the role it plays in social bonding, trust, empathy and generosity. Levels of oxytocin increase during orgasm and childbirth, and it helps the formation of bonds between friends, lovers, and parents and children.

Research has shown that people with two G variants of the gene are more empathetic and “prosocial,” showing more compassion, cooperation and positive emotion. In contrast, those with the at least one A version of the gene tend to be less empathetic, may have worse mental health and are more likely to be autistic.

I’m not really suggesting we implement such an employment test for would-be nurses (even if it was legal) but I’m guessing that a test of the current nursing population would show a higher percentage of the genetic variation which favours oxytocin reception than amongst the general population. And this might not have changed from 30 years ago. It certainly would be fascinating to know.

I am more inclined to think that the lack of compassionate (or nourishing) behaviour by nurses might actually be a 2nd order effect of deeper cultural and philosophical aspects of our entire medical profession. As an outsider and occasional patient and relative of patients, the critical aspects I have observed are: the absence of systems thinking, the valuing of specialism over generalism and the belief that not being able to make someone better is a professional failure.

Unfortunately, frail and elderly patients tend to fall foul of all 3! That could explain why they (apparently) suffer most from lack of nursing compassion.

The most highly paid and highly regarded professionals within the health service (and other academically inclined institutions) are the specialists – indeed the more specialist you are, the rarer you are and the more respect, status and pay you attract.

Unfortunately, humans aren’t made up of independent bits. We are complex highly interdependent systems – chemical, mechanical, emotional, mental and spiritual. Alarmingly, this systems aspect is one which doctors seem least knowledgeable about and (maybe as a result) most inclined to ignore.

For example, my late mother suffered from vascular dementia and fell and broke her hip (as many such cases do). The hip specialist did a quick and professional job of fixing it mechanically. Unfortunately, the general anesthetic significantly worsened my mother’s dementia and the physiotherapists told us they couldn’t help her to walk because “she didn’t understand their instructions”. Meanwhile the hip surgeon had a tick in his “fix the hip” records and had moved on to the next patient. My mother never walked again but, as far as we know, she remains registered as a successful tick in the orthopedics register of the hospital.

A few months later, my father was admitted to mental hospital as his emerging dementia started to produce some alarming behaviour. The care for him mentally in that hospital (and other subsequent ones) was good. They were experts on diseases of “the brain” and focussed on that. Unfortunately, they failed to notice the ulcers on my father’s legs and he soon developed MRSA. Chatting to the medical staff on his ward, revealed that they had no knowledge or capacity to deal with ulcers or MRSA and needed to transport him to a different hospital for treatment!

Perhaps most surprisingly, even “General (sic) Practitioners” seem to deal with each symptom presented by patients and each drug prescribed as an entirely independent problem each requiring a separate solution. The sense in which GP’s are generalists seems to be simply that their job is to take the symptoms presented and allocate the patient to one or other medical category which then determines which drug to prescribe or to which specialist to refer the patient.

Let’s get back to hospitals. I fear that what might be happening is that no-one in hospital is responsible for the well-being of the patient as a whole. Once the highly regarded and valued specialist has done their bit, “the rest” is left to the nursing staff as an undervalued “clean up” job which many consultants take little interest in. So, the irony is that nurses feel undervalued in this role, whilst being stuck with managing the most cognitively complex and least understood aspect of medicine! And to make matters worse, specialism has now emerged within nursing and is also equated with professional status. In the past, the highest status nurse was the ward sister and she was arguably the most generalist of the lot. Now, it is the lowest status nurse who deals with the patient’s “non-specialist” needs!

Unfortunately, elderly patients present the toughest case. The older a person, the more likely they will be suffering from more than one complaint at once and the category (or ward) that they are placed in means that only one of these complaints will be of interest to the consultant in charge. Their whole system is also more likely to be frail so, for example, not eating or drinking or moving around are all likely to have more knock-on complications. Demeaning though it might feel, their best chance is to be categorised as “geriatric”. At least that term acknowledges that there might be more than one problem for the patient.

The second issue is that the medical profession gain personal pride and public status (quite rightly) from their ability to fix medical problems, i.e. “to make people better”. When they can’t do that, they feel threatened and uncomfortable and, as a result, often lose interest in the patient and, possibly even resent their continued presence. That is a very human response. Doctors seem uncomfortable around any chronic conditions and particularly uncomfortable around terminal conditions.

I’m not sure that the staff in the much-acclaimed “compassionate” hospices are necessarily any more genetically inclined to compassion[1] but possibly they act more compassionately because they work in a culture which knows, accepts and is comfortable with the fact that it can’t and isn’t fixing someone but is “nourishing” them so the latter rather than the former ability is the measure of their personal status and value.

Unfortunately, once again, elderly patients are the toughest case. Even the ones presenting with “fixable” symptoms have bodily systems in decline – as humans we are not ultimately fixable! We are all going to die and many medical professions would rather not deal with that. It makes them feel powerless and bad. So, once again, they leave it to the less-valued, lower status nursing staff to deal with patients who can’t be fixed but are not well enough to be sent home. We even call them “bed blockers”. The medical profession is embarrassed by their inability to fix them and resents the space they take from fixable (and therefore) much more rewarding cases.

So, maybe the problem is not that nurses lack compassion but the fact that they get left with managing the most complex and least well understood aspects of medical care (people as whole systems) and/or the medical complaints which are not fix-able. These are the problems which the higher status medical specialists are themselves least competent or motivated to focus on.

To make matters worse, scientists and politicians who don’t understand a situation or know how to solve it, often resort to collecting data and taking measurements. Measurement and data collection are obviously critical aspects of any science but they are not a replacement activity! We now have nursing staff who are awarded special status as measurers. It can be more important for them to collect blood and urine samples and record them than to check whether the patient in question is dying from dehydration.

If we are going to spend money re-training nurses about acting compassionately, let us also retrain specialist consultants to take responsibility for their patients as multifaceted, complex and ultimately “un-fixable” people. One day a month working as a regular nurse on a recovery ward might be a start.


[1] That could (in principle) be tested!

Advertisements

About Alison Kidd

Research Psychologist
This entry was posted in Psychology and tagged , , , , . Bookmark the permalink.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s