I once sat in a child safeguarding case review, as a clinical psychologist, with a young woman with serious mental health problems who was about to lose her child to the care system. Although she knew on some level that she couldn’t cope with the demands of parenting, the meeting was still devastating for her because she loved her child and had wanted things to be different. She got upset and angry; she struggled to listen and she raised her voice. The experienced social worker who was chairing this meeting scolded her for being too emotional; she seemed cross that this young woman was making the meeting more difficult. I was shocked at her lack of empathy and wondered how often the social worker got irritated with vulnerable people, but I didn’t mention it to anyone.
Years ago I worked with a nurse who was consistently unkind to patients with dementia, talking down to them like children and dismissing them in an irritated way if they made demands on her time. I wondered whether I ought to say something to the ward manager but ultimately took it no further. As one off incidents these are not too bad but if they are indicative of more pervasive behaviours then this is worrying.
I sometimes think about these scenarios and I wonder why I didn’t speak up. If you were aware that patients were being exposed to a risk that you wouldn’t want for your loved one, would you raise the alarm? Also, if someone had concerns about your clinical practice would you want someone to mention this? How much has the Freedom to Speak Up review (February 2015) had a positive impact on how NHS organisations are dealing with these issues on the frontline? Although there is a new policy document covering whistleblowing procedures in my mental health trust, I am sceptical about whether fellow healthcare workers or I actually feel more confident to disclose our concerns now.
The Freedom to Speak Up review is a valuable document; it highlighted the shocking lack of freedom that healthcare workers felt they had to raise an alarm in the face of poor patient care. Few health workers would be surprised to learn that their wider colleagues also felt scared of being labelled troublemakers or that they would rather keep their heads down for “a quiet life”. It doesn’t surprise me to learn this either but it does make me angry and sad.
In mental health services in particular we see people at their most vulnerable, often ostracised from family, peers and society because of their issues and in grave need of compassionate care with healthy boundaries around it. If we can’t stand up for them if we feel something isn’t quite right then who will? If we don’t stand up for them and we allow them to feel worse about themselves then we are repeating unhealthy patterns from their lives and slowing their recovery. In the case of the dementia patient, the nurse’s behaviour could have been deemed emotionally or physically neglectful.
A quick survey of colleagues past and present reveals a variety of viewpoints but all with a common thread. We would love to raise certain concerns and sometimes we have tried but who will listen and what will change? One of my colleagues raised a couple of issues but was told by her manager that she would be seen as a troublemaker or bully if she continued to pursue them. Being a less senior member of staff, she has backed down. What is the point of trying to change the unchangeable? Why tell a manager about something that concerns you if the staff member is question is their friend and they have protected them in the past? Learned helplessness can make clinicians more stressed; stressed out mental health services can’t support stressed out clients.
In addition to the earlier incidents, I have been exposed to a handful of other examples of at best thoughtless care – interventions with a lack of evidence base carried out by inexperienced clinical staff; students sent out to see our most challenging clients due to a lack of available qualified staff; a locum worker trying out a new therapeutic approach without supervision. Certainly not what I would wish for my loved ones.
I am hopeful that at least my organisation has acted on the recommendations of the review. I would like to believe it is possible to create a culture where we can support each other to do a better job by reflecting on our strengths – but also on our limits and mistakes. Turning a blind eye to poor practice helps no one; the staff member doesn’t get the opportunity to see if they can develop better skills or they don’t get the negative consequences that perhaps are fitting. Meanwhile patients don’t get the chance to experience the good quality care they deserve and perhaps they sometimes suffer more. Speaking up is essential when safety and wellbeing are at stake and something we ought to be less afraid of doing in mental health services.
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