Institutional / Professional Caring

The concepts of caring and several main caring theories have already been discussed, it is also important to consider the notion of institutional or professional caring. This requires contemplation in order to take what is considered personal caring and clarify the relationship between the two. Caring as a concept in relation to health care is a highly complex issue which involves a diverse range of disciplines including science, art, philosophy, sociology and religion. It has a long tradition of being difficult to define and almost impossible to determine (Royal College of Nursing, 2003).

The health system of the United Kingdom has and continues to undergo dramatic changes both in terms of roles and responsibilities for health care professionals and changes in the way that health services are delivered. The current Health and Social Care Bill 2011 represents the greatest shake-up of the NHS since its inception (Kingsfund, 2011). Jenson and Mooney (1990) warned that re-organisation of health care services would witness a move from a deontological ethical framework of care which promotes individual caring to utilitarianism which is concerned with the realization of benefiting the greatest number. These changes are in danger of dehumanising care and caring. In recent years Hospital Trusts have moved the focus of traditional caring, as perceived by patients admitted to hospital, to one of productivity and profit making. As the Guardian, (2010 p. 1) reported:

Page | 36

‘Elite NHS Foundation Trusts are gearing up to lure private patients from abroad and home as health budgets are squeezed- a decision made possible after Health Secretary Andrew Lansley said he would abolish the cap limiting the proportion of total income hospitals can earn from the paying sick’.

A hospital is now considered in terms of a business rather than a place to care for the sick and injured. Emphasis is also placed upon the need to reduce length of hospital stay so that Government targets are met and hospitals are not penalised for failing to comply, finding themselves highlighted as poor performers in Government National League tables. The economic and political reality of the modern health care system means that health care professionals are faced with current reductionist strategies such as Clinical Pathways and Enhanced Recovery Programmes (NHS Institute for Innovation and Improvement, 2010) designed to reduce length of stay, improve patient outcomes, and speed up recovery ultimately saving the National Health Service millions of pounds. Enhanced Recovery Programmes claim to ensure that patients are active participants in their own recovery process, receiving evidence based care at the right time (NHS Institute for Innovation and Improvement, 2010).

Within the field of orthopaedics Enhanced Recovery Programmes are currently topics of debate with rapid implementation encouraged at the highest levels (Wainwright and Middleton, 2010). A patient undergoing a total hip replacement ten years ago would have expected a stay in hospital of approximately ten days, recent Department of Health initiatives such as the Enhanced Recovery Programmes (ERP) and Quality, Innovation, Productivity and Prevention (QIPP) expect length of stay for this procedure today to average no more than two to three days (Department of Heath, 2010). Therefore, by enabling patients to go home from hospital earlier Trusts will save a significant amount of money.

Austerity measures for the National Health Service were announced in March 2010 by the Department of Health which required NHS Trusts to make substantial savings of £20 billion by 2014. Critics of the cost saving plan feared that many frontline services would be affected and subsequently standards of care would fall (The Independent, 23 March,

Page | 37

2010). One such Trust, Mid Staffordshire has been the subject of an intense public, Government and media inquiry into poor care. The Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust (2013) documented that patients and relatives expressed concerns about the lack of compassion and uncaring attitudes shown. The inquiry also reported that the priorities of the Trust were target driven to save money rather than patient focused.

Professional caring; defined by Hawthorne (2005) as a unique relationship centring around responsibility and trust between a health care professional, such as a nurse or doctor and their patient, may not necessarily be thought of as caring in its fullest sense if we consider the definition of Kitson (1987), here Kitson offers a an explanation of caring that is three fold: the carer is committed to the provision of a sustained and seamless service for as long as it is required; the carer has the knowledge and expertise to meet needs; an understanding exists that the relationship upholds the individual integrity of recipient of care.

These three relational characteristics note a division between what the literature terms instrumental and expressive caring activities which are said to denote the important character of caring (Morrison 1992) and which Woodward (1997) refers to as the individual nature of professional caring. What a carer does and the actions involved are said to be predetermined (Leininger, 1988); although skills and knowledge are essential in helping the carer to meet the health care needs of the patient, they should not be considered in isolation of other caring characteristics. To do so may trivialize the individual (Bradshaw, 1996).

In order to enhance the way activities are performed an emotional element is required so that values such as respect for the unique individuality and stated needs of the patient are reflected in the relationship (Morrison, 1992). In applying this to professional caring Griffin (1980) argues that it is this moral emotion of respecting the dignity and autonomy of other human beings, viewed by May (2007) as a motivating and emancipating influence, that is responsible for transforming predetermined action into what we know as caring.

Page | 38

Health care professionals witness human suffering on a daily basis, at the same time they are called upon to provide sincere care for their patients, helping to ease distress (Bolton, 2005; Eide, 2005; McCreight, 2005). The emotions outwardly displayed may not reflect or be consistent with the caring emotions that should be experienced professionally (Merkel, 2002; Smith and Lorentzon, 2005). This emotional process termed ‘emotional labour’ was first conceptualized by Hochschild (2012) in her 1983 book, ‘ The Managed Heart’, and relates to the way in which an individual portrays emotions according to fixed social and cultural norms instead of what they may essentially feel (Fineman, 2000; Newbold, 2004; Turner, 2007).

This concept is important to caring, experiencing emotion is necessary for any health care professional in order to deal with morally difficult situations in the caring environment, and to ensure that any interaction is undertaken ethically and with genuine feeling in the caring relationship (Benner, 2000; Glannon, 2005; Soares, 2000). The concept of emotional labour requires us to ‘grapple with the conceptual complexity of defining care especially in relation to its emotional components and demands’ (Smith, 1992, p.9). Smith implies that health care professionals need to concern themselves with describing implicit skills associated with emotional labour, the concept needs to be grounded in formal health care professional education and training so that it becomes visible and valued and therefore the needs of the patient and carer are not ignored or exploited (Huynh et al., 2008). Acknowledging emotional labour helps to embrace the holism of the human experience (Hunter and Smith, 2007), recognise the immense emotional effort that accompanies the act of caring (Archer, 2007; Huynh et al., 2008); its association with self-awareness (Kerouac et al.,2003), role identification (Mackintosh, 2007; Fineman, 2008), its social norms foundation conditioned by personal variables (e.g. age, gender, emotional adaptability) and the organisational environment in which the caring interaction takes place (Schaubroeck and Jones, 2000; McCreight, 2005).

To explore this further it is important to consider if caring relationships in hospitals exist in such a way that they meet the needs of the individuals involved and that moral emotions exist as described. All human beings have a perception of caring which has evolved from their own personal experiences of caring relationships, such as those

Page | 39

between husband and wife, and parent and child. Some caring relationships may be considered more loving than others and involve varying degrees of intimacy.

Health care professionals may be faced with too few resources, such as physical resources in the form of manpower, or psychological resources in the form of emotion. As a consequence caring may be distributed unevenly between those being cared for, implications for ethical caring such as justice and equality in care then become issues for consideration.

When considering professional caring reference must be given to the motivation of health care professionals. As we have seen from the literature thus far the expression ‘to care for’ is used both as a form of moral motivation and the action performed to meet needs irrespective of the motivation. Wanting to meet the needs of an individual is carried out for the best motivational reasons in society in general. However, if we relate this to the nursing profession recent literature warns that individuals may currently enter nursing for reasons of job security, more flexible working hours and good promotional prospects rather than for humanitarian motives (Watters, 2009).

If this opinion is true we could see the emergence of people performing a duty of care regardless of whether they care or not. On the other hand, if the act of care is done and done well then it will be perceived by all involved as a ‘caring act’. Although it may be fair to conclude from this that professional care may never really achieve the richness and complexity that caring achieves out of a sense of love for another person.

2.7. Influences of historical social context