May 16 2013

Understanding and preventing patient neglect in hospitals

by Tom Reader and Alex Gillespie

The recent Francis report into poor care at the Mid-Staffordshire Trust revealed that up to 1,200 patients died from systematic patient neglect. This involved patients not being fed, hydrated, washed, treated, acknowledged, respected, or managed with dignity. Over 200 recommendations for reducing neglect were made, and there is now a concerted drive by policy makers, the media, the public, and charities to reduce instances of patient neglect (Department of Health 2013). Solutions include reducing targets and bureaucracy, creating a culture where compassion and care are prioritised, ensuring staff feels able to report on poor care, and improving organisational management. We have investigated the processes and causes of patient neglect. Our research considers the ‘social psychology‘ of neglect, as this appears essential for aiding policy makers to understand why poor care occurs (Reader and Gillepsie 2013).

Lack of an evidence base

Patient neglect has largely been ignored within the academic literature. We found only 10 articles that directly focus on patient neglect. Instead, poor care is understood by academics (primarily) through the concept of medical error, on which there are 1000s of research studies. The reasons for the lack of patient neglect research are not clear. It may be due to the toxicity of the subject (i.e. it calls into doubt the motivations and attitudes of healthcare staff) or to the difficulties of conducting research (can healthcare workers honestly discuss neglecting patients?). A key problem in researching neglect is that the behaviours that constitute neglect (e.g. rudeness, ignoring patients, not maintaining their hygiene) do not immediately cause harm, and are not captured by healthcare institutions (e.g. in patient notes). Furthermore, the outcome of patient neglect (e.g. malnutrition) is often not linked to a specific caregiver – rather it emerges from a distributed lack of caring across a team, over a quite long period of time. This is qualitatively different from the types of problems investigated in medical error studies.

Dimensions of neglect

Two dimensions of neglect have been identified. First, there is ‘procedure neglect’: this refers to failures by healthcare staff and organisations to meet standards of care (e.g. feeding patients, issuing medications) that can be objectively measured by the organisation. Second, there is ‘caring neglect’: this refers to failings by healthcare staff and organisations in aspects of care that cannot be objectively measured (e.g. compassion, helping behaviours), yet are highly visible and important to patients. Although hospitals can objectively monitor for procedure neglect (e.g. through checking patient nutrition), they cannot monitor caring neglect because it refers to micro-behaviours that exist below the threshold of institutional measurement (e.g. ignoring patients) and are subjective (e.g. compassion). Whilst procedure neglect might occur due to a mistake (e.g. forgetting to give a medication), caring neglect relates to the attitudes of staff towards patients (e.g. showing empathy). Furthermore, systemic caring neglect (e.g. not helping a patient to eat) will eventually result in procedure neglect (malnutrition).

Lastly, we find that patient neglect occurs due to a range of institutional and individual factors. These include ‘on-the-ground’ factors such as breakdowns in the relationship between patients and carers, burnout and compassion fatigue, high workloads, targets, and a lack of training. These, in-turn, are caused by the wider organisational environment, for example resources, management, policy, and culture. Consistent with organisational psychology theory, behaviour ‘on-the-ground’ is shaped by the institutional environment, and it must be changed if neglect is to be avoided.

Policy recommendations

Academic knowledge with regard to patient neglect needs to be strengthened if interventions are to be effective. For example, many of the interventions for patient neglect (e.g. checklists) emerge from theories developed to explain safety and quality in high-reliability industries (e.g. aviation, nuclear power). Yet, the relational aspects of patient neglect (care and compassion) are not such critical features of these environments. 

Furthermore, what we call ‘caring neglect’ appears to capture public concerns over poor care, yet it is subjective and difficult to control. It is not possible to make someone compassionate, and it is not feasible to regulate and measure every aspect of their behaviour. Alternative metrics such as patient complaint data (over 100000 complaint letters are received by the NHS every year) could be used in order to pro-actively identify instances of neglect before they become systemic in an organisation.

Lastly, and related to the point above, the solutions to reduce patient neglect may be counter-intuitive. Clearly, organisational environments need to change. However, creating a compassionate environment is likely to involve reducing rules and regulations. This is challenging for risk managers and policy makers, as it involves reducing control over healthcare. Yet, patient neglect occurs, in part, due to the over-management of healthcare staff (e.g. in terms of ensuring staff activities are monitored, logged, and directed towards certain behaviours). They lose the discretion, space, and motivation to care. Bradshaw’s (2009) work on the ‘McDonaldisation’ of nursing care indicates that adding new targets, regulations, or competencies will not create a compassionate environment. As found at mid-Staffordshire, it may indicate compliance with a new set of rules, yet this will be a façade and will not reduce the underlying problems that lead to patient neglect.

References

Bradshaw A (2009) Measuring nursing care and compassion: the McDonaldised nurse? Journal of Medical Ethics, 35, 8, 465-468.

Department of Health (2013) Patients first and foremost: the initial Government response to the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (Vol. 8576), The Stationery Office.

Francis R (2013) The Mid Staffordshire NHS Foundation Trust Public Inquiry, The Stationary Office.

Reader T, Gillespie A (2013) Patient neglect in healthcare institutions: A systematic review and conceptual model, BMC Health Services Research, 13, 1, 156.

About the authors

Dr Tom Reader is a lecturer in Organisational and Social Psychology, and a Chartered Applied Psychologist.

Dr Alex Gillespie is a lecturer in Social Psychology and Co-Editor of the Journal for the Theory of Social Behaviour.

Both are based at the Institute of Social Psychology, London School of Economics and Political Science.

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