The first point of contact to raise concerns about the working practice is with your line manager.

These organisations offer further help and advice

Whistleblowing for NHS staff and social care staff: 08000 724 725    Contact the helpline if you have concerns but are unsure how to raise them or simply want advice on best practice

Care inspectorate (Scotland)  Download a leaflet about how to make a complaint http://www.scswis.com/  Complaint about a care service us on 0845 600 9527    Also read the national care standards

Care Quality Commission (England)   Download a booklet about how to make a complaint: http://www.cqc.org.uk/  Customer service number: Telephone: 03000 61616    Also read the standards of care

Bullying and harassment help: ACAS http://www.acas.org.uk (put bullying and harassment in their search box)

There are many other help and advice organisations on line. Go well.

Carers

Conflict in care settings

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People usually go into care work because they care. The nursing and social care students, trained staff and managers we meet, express their genuine desire to make a positive difference in the lives of people who use care services.

There are many fantastic staff who save lives and boost spirits on a daily basis. People use care services because they have nursing or daily life or mental health needs. Some people need a safe place to stay.  They may be vulnerable to drink or addictions, to abuse, to falls, or neglect, to self-harm, to causing harm, to poor mental health, or physical deterioration and a wide range of other issues, which necessitate compassionate support.

So how does it go wrong in care settings?

I think there are several contributory factors to abuse within our care systems and social structures. Blaming and distancing ourselves from the issues is not helpful. Violence and aggression threaten our well-being, dignity, confidence, and lives. We have probably all experienced moments of feeling sheer anger and aggression. We need to understand how that happens in carers…. not to justify it, for there is no justification… but to ensure the systems, people and practices improve.

Our care organisations operate beneath an umbrella of important legislative policy, procedures and standards. Organisational culture consists of people’s habits, beliefs, values and rules. At a very basic level, these elements create closed or open cultures. Closed cultures tend to be institutionalised and oppressive. Abuse can hide more easily where individuals do not recognise their freedom to speak out. We all want more open cultures, where people can voice concerns and fears; where complaints are regarded as messages of hope for change; and where time and opportunities are given to discuss complex issues.

What really makes an organisation is the people; from the care and support staff to the managers and CEOs. The standards of care depend on their values, rules, knowledge, skills, awareness and understanding. Staff do what they learn how to do within their perceived roles. This is influenced by their experiences, by how they are treated, their individual capacity for learning, clarity of responsibilities; their personal values, and their mental health.

Sometimes the carers’ personal beliefs get in the way of working in an inclusive, person-centred way. They might struggle to see how someone with late stage dementia could be included in anything. This leads to more isolation and can easily slide into neglect.  But supported reflective practice and learning can help staff see possibilities and improve quality of life.

Occasionally a significantly damaged and damaging individual slips through the selection and recruitment process. Whilst the majority of staff go into care work to care, occasionally there are people who are attracted to the work because they are personally in need of care. Somehow they miss the regular support systems all the way through life, and come in to the system as a worker. Some wounded healers are actually very good carers. But others are clearly not. Add to this an environment or culture that does not offer regular supervision, nor pick up signs of disturbance through mentoring, or observations, and we have trouble.

Burnout or carer fatigue is a big sign to take notice of.  Emotional, physical and mental exhaustion is caused by long periods of stress. This affects people in different ways. Some people may be present in body, but emotionally shut down and seem to lose the ability to connect on a humane level. Other people become hypersensitive to the suffering they see around them. They feel helpless and are in constant emotional pain. Either way requires intervention, support, and change.

Many people go in to care work with good intentions. The core care values about dignity, respect, rights and choices, effective communication, promoting self-worth, improving inclusion, honouring privacy and protecting people from harm, resonate deeply with them.

I’ve met carers who discovered these purported values could not easily be promoted within the care systems. When staffing levels are short or a regimented routine is in place, the staff do their best to keep delivering from the core values. But something happens to people when their personal values (those care values that meant so much to them), are constantly hindered by the environment in which they work.

There is an internal conflict. The gap between what they want to do, and what they feel they actually can do becomes increasingly difficult to deal with. It is at this point of stress that things happen. Staff might decide to leave and find a place that walks its talk, where they can deliver the good practice they believe in.  Or they may become ill and go off sick, or become emotionally distant. Or they become increasingly frustrated and angry. Bullying in the care sector is known about.

Managers and team leaders need to be equipped to deal with signs of staff burnout, to deliver regular supportive supervision, and understand how to motivate and inspire their staff. They need to listen to what is happening and be willing to question their own practice, values and rules to see how to operate in more person-centred ways. And to do this with their staff, and with the people using their services, and with all the organisations who can help them.

It is of no surprise that staff who feel confident, happy, valued and appreciated deliver good services. Staff who are undervalued, unappreciated, underpaid, and lacking in confidence can also deliver great services, but at a high cost to themselves. We owe it to everyone using care services to support staff to do their work well.

This article is an extract from my writings (copyright KMarshall2011) Please share

Carers

Help and advice

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Response

The following questions may help trigger some ideas for resolving the situation. We start with the most basic or obvious and work through to some obscure questions or thoughts.

Do you know what your gran likes about the bathroom?  Or what she does in there? If this conversation is possible, there may be ways to recreate these needs outside the bathroom. But maybe she is unable to engage in that conversation?…

Does your grandmother have a constant physical feeling of needing to go to the toilet? There may be other bladder or urology issues to check beyond infections, such as for diabetes or stress incontinence.  If the GP / nurse checks don’t show anything, we could still see if wearing a light pad offers any reassurance for your gran. As someone else suggested: would having a toilet / commode  in her own bedroom help the situation?

I usually ask in what ways being-out-of-the-bathroom can be made more attractive than being in it.  It sounds as though the family do a variety of activities to support their gran to live a quality life.

Sometimes due to family busy-ness or a need to be somewhere else, we can become more demanding in our requests. If this starts to happen, it can be better to take a break. Leave your gran (unless there are serious risk factors which you have not mentioned in the question). Do something else. Return with a brighter, welcoming voice, and a genuine offer of something positive to come out for… be it a hug, a game, a walk, a cup of tea.

If the previous points are not working for you, the following questions are simply to try and get an understanding of what keeps your grandmother in the bathroom.

Is there something about the bathroom that feels different/ better/ brighter/ quieter/ private/ safer/ than other spaces? (I once worked with someone who loved being in a room with no carpet, and the bathroom was the only space like that).

Is there something your grandmother does in there (fold toilet paper/ wash hands/ talk to herself in the mirror/  …) that isn’t available to do in other spaces?

From her point of view, what is there outside the bathroom (apart from anxious people wanting her out of there)? Would a pet, or dare I say puppet, be more appealing to your gran?!

At home, is the bathroom required by others? If so, the need to help your gran come out is clearly a family need too, causing more anxiety or stress. This might be escalating the situation. How easy is it to feel relaxed about it? Would having less focus on ‘getting gran out the bathroom’ be more or less effective in the situation? This is a tricky one, if the family are queuing up to use the toilet!

Is there a pattern to your grandmother’s use of the bathroom? for instance a regular time of day or night? or a trigger such as a word, an activity, a change in atmosphere, something that happens,  that sends her off to the bathroom? Does she seem extra anxious to get there at that moment or is it a relaxed stroll to the bathroom? Sometimes keeping  notes of what happens before, during or after the bathroom events can help us see a pattern that can be responded to. – And sometimes there appears to be no rhyme or reason that we can see. 

Does your gran ever come out of the bathroom on her own? Or is it always some sort of cajoling that helps her out? What happens when she does come out?  (I worked with a family whose dad enjoyed hiding behind doors for ages… he would be found and the family would laugh and joke with him about the drama. He would beam with pride. But it became a problem, as he found more places to hide for longer periods, which caused timing problems with appointments etc. So they needed to find other ways to give their dad that buzz of pride.)

And now the off-the-wall questions: What do you think might happen if you didn’t coax your gran out? What if it was the most natural thing in the world to want to spend all day in the bathroom? What fears would you have about her being in there that long? And how could these be addressed without her needing to come out?

Would your grandmother ever invite you into the bathroom space, simply to share time there, so you can get a sense of what she gets from being there? These are not necessarily things for you to try, but sometimes experiencing something from that different perspective can help us come up with a creative solution for everyone.

The point of these questions is to explore things and see which aspects could be changed, and where the bottom line is. If there was a simple solution, it is likely you will have found it by now. The challenge is therefore to understand what your gran gets from being in the bathroom … or what she doesn’t like about being out of the bathroom, and respond from that point.

Carers

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