In order to investigate the experiences of a care staff worker dealing with the expectations of care staff working in the NHS, I interviewed Floss. I examined Flosses’ story using interpretive phenomenological analysis. When beginning this investigation of expectations of care staff, the focus was intended to be was on how the system requires a care worker to be a multi-faceted worker being given tasks that a trained nurse has no time to fulfil, or duties that the trained nurse can delegate to the care staff so that she can do more of the clinical tasks required on her shift. The care worker would discount one’s own feelings for the sake of the professional environment and being required to continue with day to day tasks following major traumatic or stressful events. What transpired over the time of the interview, however, was that the experience of the care worker was that of affect, transferential experiences and issues with self-worth on a day to day scale of the work environment and the stresses and traumas of working on the ward shift itself, giving the care worker feelings of being discounted, low self-worth and isolation. These emotional consequences were not from events of a traumatic nature as according to the NHS guidelines of how to support staff for PTSD following an event, but instead they were from an ordinary days work in a hospital ward when the ward has patients that require special care for specific conditions such as this case for reduced mental capacity. It has become clear that literature on the topic of non- catastrophic trauma is lacking in accounting for the experience of the care worker dealing with the expectations of care staff who work in the NHS.
Introduction and Literature
The NHS is one of the largest employers in the UK and for the most part is reported to be one of the best healthcare systems in the world. In its 70 years, the NHS has built up many services, from GP practices to prosthetic parts, governance to equipment, all of which are there to serve the general public in their wellbeing, health and welfare. More recently however, a focus has been placed on the wellbeing of staff and the services that uphold the running of the institution and a decision was made set an agenda to improve the working environment of the NHS staff. The NHS England Chief Executive Simon Stevens in 2015 (Stevens 2015) set up a drive to improve the health care system. This drive was based on what Stevens named three pillars:
- First, a major drive for improved NHS staff health, spearheaded by a group of leading NHS hospital, mental health, ambulance, community and clinical commissioning group employers, in partnership with NHS Employers and Public Health England;
- Second, a new nationally-specified occupational health service for GPs suffering from burnout and stress, in partnership with the Royal College of GPs and BMA General Practitioners Committee;
- Third, national action by NHS England working with Public Health England and other agencies to challenge and support catering contractors and PFI providers to raise the standards of food and nutrition.
Although it is clear from the implemented drive that it has become apparent to the Chief Executive that there is a need to improve all three areas of the health system and those within it, focus of this research is for the first pillar: the health and wellbeing of the staff working within the NHS.
The NHS has many systems in place to deal with most parts of the sectors within the facilities of the NHS. One of the systems is a recording system. This system is a reactive measure taken to account for and record events and incidents to seek trends to enable change and improvement to departments and workforce. There are support systems in place for the hospital trust to account and record mistakes and events either by staff or patients (Datix system 2014). This system discriminates between trips and actual falls, equipment damage or breakage, malicious and clinical assaults on staff. In the case of assaults on ward staff, a staff member can report and ‘Datix’ an incident which can then be identified should treatment or poor health follow the event. The system works so that if there are many Datix for the same period of time with the same person, the appropriate Datix manager will come to the ward and offer counselling for the person if they require. This means that they still class the Datix input data as incidents, which is not a support for an ongoing situation as recording it as an incident suggests a one off occasion. The Datix gives a restricted menu of choice for the member of staff and there are no menus for such things as trauma. It refers to was the staff member ‘upset’ or physically injured. Generally within any of the recording Datix systems there are few open questions to elaborate on the story. However there are a few given chances to explain the incident and the manager may come to about things even when trauma is mentioned. When talking about trauma, the Datix manager or equivalent are referring to incidents rather than accumulative trauma. One problem I had researching this topic was the definition of what was meant by events, what was perceived as trauma by researchers, all of the new procedures implemented deemed useless to this research as they all miss-defined the meaning of the event as the research confines its topics to catastrophic events and what to do about the following treatment, or, violent attacks on patients or staff and what procedures to follow. Although they are required to do so, the staff in the ward in this research are devoid to follow any of the recommendations in the works by Regal (2007), Hoffman (2014) as they do not include the type of trauma that these staff work within on a normal working day. The NHS runs on systems, but if a ward is not definable as a ‘normal’ ward any longer, but also not defined as a ‘mental health’ ward either, the guidelines systems and training becomes items with blurred lines and boundaries.
The clear guidelines on hospital processes and procedures are clear enough for the day to day running of the ward; however the consequences for staff, who are dealing with patients with mental health on an alternatively named reduced mental capacity ward, are more difficult to define. Patients range from mildly reduced mental capacity to aggressively invasive behaviours on staff and potentially other patients for which the aggressive patients are eventually sectioned into an appropriate institution on note of medical improvement (but not before that note).
As my research progressed it was clear that the issue here was quite complex and with many hospital departments involved, if research was taken further than the story of Flo. Concentration on how the systems and the consequential expectations and those expectations and effects on Flo were therefore focused upon.
Literature on the topic of trauma in the workplace is not difficult to obtain. There are many authors who have sort to improve the treatment of workers (Regel (2007)) and who have set out recommendations for major institutions for those improvements in the aftermath of trauma events and major threat events (Hoffmann2014). There is however, far less research to be found for the care staff following instructions on a ward with patients who have a mental health issue. This is not to say that there is no research to be found on staff that work in a mental health institution and are given considerations for the extra skills, different frame of mind and appropriate character/nature for the role. The roles and procedures in a mental health institution are set out clearly and expectations for staff are laid out from the onset of employment as well as knowing what type of institute the employee is entering when applying for the position. No literature was found on the subject of normally trained care staff working within a reduced mental capacity hospital ward and how to support those staff.
The meeting between the researcher and co-researcher was arrangement by mutual consent. We met for ten minutes prior to the interview to go over anything relevant that Flo may wish to ask and to make sure both of our requirements of care and comfort were met in the room. We met in a quiet and mutually agreed room in the hospital. Flo was clearly informed that I would be available to her both before and after the interview if needed.
For the purposes of the study, I had permission (consultant and ward manager) to observe on the premise that confidentiality was adhered to and that no recording was to take place. Observation took place on a midweek daytime shift with the average number of staff present and normal day to day activities occurred as I settled to make my presence have as little impact as possible. This observation was in order that I understand Flo’s environment as she explains her story and feelings in the interview. Readers should be made aware that some of the content within the text is of a graphic or sensitive nature and has remained included within the text as it is of the very nature of the ward that the research is attempting to understand with regard to the co-researchers perspective and to illustrate the situation as the researcher saw it.
The interview with Flo was recorded onto a digital sound recorder. The sound recording machine is not connected to the internet or any other gadget and was held in a locked container in a locked room to abide by confidentiality agreements and the Data Protection Act 1998.
Choice of Co-researcher
For the purposes of the research, the co-researcher needed to be an employee of the NHS working in a specialist ward/unit. This choice was made because the research required a reporter with first hand and recent experience of the required elements of the topic of research.
The choice of co-researcher was actually changed as the initial choice was thwarted when the staff of choice became traumatised by the environment and became absent meaning that they were not actually, mentally or ethically available for the research. The researcher then had to consider as to whether to wait for the return to work of the chosen co-researcher, or to have ethical considerations for the same and change the co-researcher to a more considered member of staff so as to not re-traumatise all over again.
Investigation into members of staff was then underway as the researcher established requirements regarding moral and ethical consideration for contributing to the research. The nature in the ward for the co-researcher post was popular but for many different reasons (as shown in the requirements)) and the following guidelines for care workers was implemented:
The requirements therefore were as follows:
No recent absence from work for Trauma/PTSD (re traumatisation)
No past episodes with regard to Trauma/PTSD (as above)
Reporters can have recent or ongoing issues and wish to voice their opinions with regard to the environment or the treatment of staff within it (objective opinions rather than previous requests with management)
Reporters can have issues so long as it involves the working environment and the establishment, not an issue with an individual within the working environment or establishment (not personal to any particular member of staff with regard to their personal work altercations with other staff with regard to blame on previous occasions regarding this matter and work ethic
The co-researcher who had the above criteria was chosen. She reported anonymously and wished to be named Flo. Flo works in a specialist ward in a UK hospital. Flo has worked for the NHS for many years and has worked on many wards within the hospital she is in now. Her position as care worker has never changed and she states that she has enjoyed her job in the past and the rewards the role brings to her life. She is married with three grown children and regards work as a worthwhile part of her life that she chose to do because she wished to have a role that was useful and rewarding. She states that the ward environment brings friendships and support which she has always enjoyed and valued. Lately, Flo has been on sick leave and has only recently returned. Flo has also mentioned that she has felt a change in her love for the role.
I explained to Flo the following:
– Confidentiality: no-one would read this account except for the marker, my supervisor, a possible third party for standardisation, and herself, should she wish.
– Anonymity: all names in her story would be changed, except place names. (She chose the pseudonym of Flo)
– Right to withdraw: Flo was informed that she could withdraw at any point from the research prior to submission
– Recording of the interview: the interview would be recorded but would be safely and securely stored and, on submission of the finished project, would be erased
– Right to access: Flo could read the script and the project at any time she wished
– Need for a break: if necessary, Flo could interrupt the interview and take a break from the interview
– Memories: should any of her story evoke upsetting memories, we discussed possible solutions, and if necessary, could be referred to a counsellor
Flo confirmed she understood and agreed with all of the above points, and signed the form confirming her agreement (Appendix II).
For the purposes of this research, I chose interpretive phenomenological analysis which is a systemic thematic analysis and used to give the researcher an understanding of the co-researchers perspective of her world. The story was listened to several times all the way through and then listened to in parts as the interview moves from one topic to another. The interview was analysed within those topics as can be revealed in the findings of the analysis.
Themes On listening to the recording of Flo’s story over and over again, several topics were repeated and reiterated in many ways by Flo. It became clear whilst typing up the transcript, that Flo’s interview had several themes. I separated the transcript into the themes I saw into separate piles of information. Three main themes emerged strongly but with those themes, sub themes also became apparent.
The three main themes emerged as:
The co-researcher stated on several occasions that the support was a large issue was the cause of ‘taking the stress of the job home’ in affect causing a poor working environment for the staff of this particular hospital ward. Neglect is always a fear with Flo. Flo states that she often worries about possible mistakes and the consequences for her role if she was ever brought to account for her movements in a neglect case against her. She feels that her role would not be taken as a worker, who has extra responsibility and requirements, but simply taken and considered as a care support worker who did not do her job properly and failed to look after her patients. She states that for those who are not present in the ward, the understanding what goes on in the ward could be misconstrued and the responsibility could fall on her shoulders alone.
The report from the NHS review team led by Dr Boorman (2009) states:
“…it is important that the approach to improving support for staff health and well-being is developed in consultation and partnership with staff and trade unions.”
When approached by Flo and another member of staff, the union relayed their stance of the situation that no rules for the ward or the staff were breached and therefore they were in no position to support Flo in her stressful state. In this respect, Flo feels misunderstood for her situation and is dismayed that in her opinion, there is no real support for her situation from any organisational point of view of the NHS or the union…
“…when a fall happens, do you feel that the support is there..?(31)
“…no, I was left to deal with all of these people on my own. I didn’t feel I had support at all…” (32)
Flo states she feels that lack of support is one of the main causes of her stress
Trauma I found on interviewing Flo that the initial view of trauma as an event was not quite accurate and the incidents that Flo was describing were those of cumulative trauma.
Questions regarding trauma were refined to anxiety and the general anxiety of working in an environment wherein the expectations of the establishment may exceed the reality of the work force in some aspects:
- The ability to control more of the environment than is possible in real terms e.g. keeping hospital patients safe in the ward environment and keep full concentration for a work shift of 12 hours. It is established within all work environments now, that a break following a 6 hour work environment should be given, however no further considerations are given to those who are in environments of extreme stress and anxiety and have to maintain full alert for the length of the shift. If then an event of a fall or a death occurs, the staff have a feeling of responsibility and lack of care. The fact that it is the staff’s job to ‘look after’ patients is of course obvious but the considerations behind the care of the staff to enable them to do the job effectively is not taken into consideration and that in itself is a stress for the staff and also gives a feeling of being devalued. The question of trauma was then adjusted in this research to a question of stress
Flo suffered from the effects of chronic stress by way of poor sleep patterns, poor eating habits e.g. varies times and availability to healthy food, however trauma was present when Flo was talking about the overwhelming feelings of the situations which she frequently ‘took home’ with her and woke up in the night in fear that the patient was again falling but she could not catch them. The fact that no staff are allowed to ‘catch’ a patient on falling is not on the mind of Flo but a fear of causing harm through neglect is constantly with her, even when sleeping. Flo does not believe that trauma is present in her workplace and classes herself simply as a worrier. It appears that even after answering the questions regarding trauma; when asked about being in a traumatic environment, Flo still did not accept, or recognise that there are traumatic events going on around her even when they do not directly involve her in responsibility.
Purpose of ward Flo has worked on the ward for many years but the purpose of the ward has changed in the past few years. The ward used to treat people who had suffered a stroke, another time it had treated those people who required rehabilitation. The ward has been Flo’s workplace throughout all of the changes and she had not a poor word to say about the previous ward purposes in her interview. The ward Flo has worked on for many years is not the same workplace as it has ever been before. Previous purposes have all involved physical, tiring shift work which included day shifts and night shifts. These shift patterns are expected by all care staff throughout the hospital with skills of previous training of skincare, mouth care, potential and care of bedsores and also food and drink intake all backed up by years of experience for all staff alike and passed down through to new staff and temporary staff. This expected and accepted work ethic is the ‘norm’ for care workers and what the job application stated, what the nursing staff previously asked for compliance with.
Four years ago, the ward changed its purpose to a ‘Dementia ward/ specialist unit and the permanent staff were required to interview for their positions as if on a new ward. Nothing was said regarding any special requirements that were to be put in place and the staff were happy to proceed to their previous positions. The behaviours of dementia patients was little known and the extent of 21 dementia patients interacting with one another became evident on my visit as staff attempted to protect patients from other patients behaviours as wandering patients filled their pockets with other patients possessions and fights broke out and visitors complained about the wandering. Visitors were told that the whole point of a secure unit and the defining role of the ward was to have locked doors so that the patients could wander around freely instead of being lost through the open doors of other wards. This however was not the only issue. The patients who are brought onto the ward are unwell, influenced by medication. They are also unsteady in mobility and are at high risk of falls. Watching the risk of falls patients includes bedtime as they climb out of the bed forgetting that they no longer walk, or forget that they no longer walk safely. This means that patients are watched by staff for 24 hours of every day. Care worker duties such as of skincare, mouth care, potential and care of bedsores and also food and drink intake are still required as with other wards but with the added stress of having to watch and either restrain, support, restrict, assist or comfort whilst doing the same duties as usual ward care workers
Training Throughout my dictation of the interview, Flo’s emotions were of an ebb and flow of stress and anger, disappointment and sadness. It became clear on listening to Flo, that she felt missed. She sounded disheartened, was feeling low and helpless. It was also clear that she was efficient at dealing with her emotions outside of work with effective tactics of self-soothing and open dialogue with her family. Speaking about her work environment however Flo conveyed a dampened frustration in her voice, one of being dismissed and feeling isolated. When asked if she felt listened to with regard to making the role better…maybe training, she replied:
“…No never, we are human dogs-bodies….” (104)
I continued to question Flo on the subject:
“Do carers have enough of a voice in this situation?”(105)
She replied…“No, they (the carers) are not entitled to an opinion…” (106)
The question of training may appear to be straight forward initially; however it is not always the training in itself that causes the stress and confusion in the day to day work environment of this care worker. To be given training in this environment would no doubt be advantageous however the establishment have not offered specific training as it would no doubt force the question of payment of a more qualified staff and they are not willing to negotiate the issue. Therefore, the care staffing is still required to do the job without the training or the money. Nevertheless the care staffing on this ward is considered one the most efficient for patient safety of numbers in the hospital trust. However, Flo doesn’t feel that she is trained enough to tackle some of the day to day patient issues that arise. Flo’s feeling of self-worth is again put into question as her words show she feels discounted and not worth the training in their eyes. She shows this when she says:
“… a right to have a voice and obviously to carry out what we are saying. When they don’t listen, it makes you (herself) feel lowest of the low and just to get on with it, no-one cares, no-one hears us (carers), we’re nothing…just invisible” (93-94).
Discounting The lack of acknowledgement for the type of environment that Flo works in is in itself a discount to her daily role and the environment she is expected to deal with on an emotional level in her working day. The disparity between what the ward expectation of the behaviours of the patients and the actual behaviours of the patients is large and yet not acknowledged to be so. The ambiguity of the nature of the ward makes it difficult to work with any clear guidelines for the use of reactive behaviours from the staff in such a ward as the one Flo works in.
“…I don’t know what I’m going to do about this job yet; it’s not good anymore…”
From the TA point of view: The feeling of discount has made Flo begin to think as to whether she should continue with this job that she has done and loved for so many years
“…: I just think sometimes that we are expected to accept what is going on in the ward as part of our job” (95-96)
From an Integrative Stance, there are unmet needs and Flo is feeling unmet in many ways, from security to feeling like she has an impact on another; to valuing to express caring. In the interview Flo stated how she felt discounted and undervalued which had no impact on another in fact was invisible:
“…the right to have a voice… and obviously to carry out what we (the carers) are saying…but they don’t” (112)
Even from the Maslow (1970) view point, this situation is at the very base of the needs of every person; the need for security and safety. Flo neither felt safe or secure in her surroundings in the ward or in the system that catered for nothing that was happening to Flo whilst on duty. According to the feelings of Flo, she either did her job well or it was her fault if something went wrong and someone was hurt or died in her care. The main responsibility for patients whilst on duty is with the nurses; however the direct care for those patients is then transferred to the carer if they require extra attention or help. The nurse would still ultimately take responsibility for the events of the shift however the carer would not just feel nothing about someone being hurt, they would naturally take the feeling of guilt or frustration home with them at the end of the shift and that was what Flo was doing. The responsibility is on the trained staff (nurses) and the Datix system would have questions regarding this but the human view is more of feelings rather than systems. It’s clear that Flo takes her job very seriously but the organisations expectations of her are even higher than her own and she is finding it difficult to deal with that.
As I observed the ward in action, I did see behaviours and incidents that could be ‘Datix’ and would fit into the system to make some improvements, but mainly I found situations constantly going on that could never be explained without the Datix manager being there and seeing the events for themselves and I understood the frustrations of Flo and her feelings of helplessness. My immediate deduction from this observation was: what would they do with the information even if they did see it for their own eyes; how would the system deal with these issues of behaviours from the patients that directly involve the emotions of the staff?
One of the main opinions I got from the interview from Flo was that Flo was asked several times about trauma in the ward and she dismissed the word trauma stating that for her it was stress but clearly from compared to the observations I saw, trauma of physical and emotional trauma was present many times throughout the day and absorbed by the staff to enable them to carry out their duties. For an example of both physical and emotional trauma on a daily basis I shall relay one incident for the purpose of illustration of what would be put into a Datix and what could be done about it all of the time remembering that this is not regarded as a mental health ward but a ‘normal’ ward with patients of reduced mental capacity: Whilst observing the ward, a gentleman stood in the middle of the bay that his bed was in (with another 4 beds) whilst visitors were present, and began to masturbate. Staff attempted to cover the patient to shield him and his dignity as well as shield the visitors. He then fought off the staff whilst continuing his business and staff were punched and kicked. He would not stop until his mission was fulfilled and only then would he move from the middle of the bay and go to his bed. For all of the time that was happening, seeing the advantage they had on attention, several other patients were trying to get out of the bed and the staff had to keep them safe and unharmed whilst still trying to attend to the first situation. At the end of the event, the staff were physically assaulted emotionally drained and had to clean up the result of the man’s ‘actions’. Within minutes the staff did what they classed as their duties and carried on with the other patients and the rest of the duties for the ward. This is Flo’s usual day, going home bruised and wondering if she could have done more to improve the situation. If the ward was categorised as a mental health ward Flo would be trained in restraining (as that would be allowed for mental health patients if needed), restricting (still classed as abuse for ’normal patients’) or any other strategy that may have been useful in that situation. Flo went home wondering if she would be told off for not upholding the man’s dignity and asking herself if she did anything physically to cover him up amidst his actions that could be regarded as abuse. That understandably was regarded as an event but there were several incidents throughout the day that were taken as non-events that were actually emotional events for the staff such as being hit with walking sticks to get out of the way (when actually they have to endure that as they have to stay with patients who are unable to be left unaided as they will fall without the staff’s support); Being spat at, being called names, jugs of water thrown at them and being pushed into walls and doors. Some incidents were put into the Datix and others were not as there was no bruising (as evidence) or cuts to show for the incident.
In this observational time, I found the expectations of the NHS for this ward’s staff to be beyond the realms of a ‘normal ward’ but also found that the expectations of the staff themselves attempting to match up to what was in their perception expected of them.
According to the three themes that were uncovered, I observed that:
Support is found within the friendships of the staff and it is little wonder that Flo doesn’t consider going to another ward where she knows no-one. Another ward would be different however she sees the value of the friendships in the ward and wants to keep them. Friendship support also keeps Flo out of the system of going off sick and being in the stepped sickness system that can bring unwanted outcomes for staff. Support is readily available as long as you can wait on the waiting list which according to Flo is three months long at present, and so long as you can prove (with a doctor’s note) that you are off work due to something that happened on the ward which is possible if physical but I have to reason is not so easy if it is emotional. For Flo the Erskinian need to make an impact is not met within this ward. Feeling invisible, she is far from feeling as if she is making an impact on any other person’s life or emotions. If Flo was in another ward, she may feel the impact of her good work through the thanks and grateful remarks of the patients however on Flo’s ward there are no such remarks to show Flo how much of a difference she makes to anyone or anything.
Trauma is present in the ward but in order that they continue to do their duties, it is ignored or at the least re-labelled as stress. This ‘stress’ is taken home and has caused Flo to become a poor sleeper, an anxious person and one who feels undervalued and helpless to change her situation. Looking at the transcript and noticeable in the interview was the way Flo discarded the word trauma even though she had answered yes to the question when I asked
“Do you think that your work environment involves the presence of trauma or do you think that only A&E has that environment?
“Course it does”
“What makes you think that?”
“for example: In your ward do you have any traumatic events?”
“yes we get physically abused” (5-11)
Being abused is taken very seriously within the NHS and has varying consequences for the perpetrator however on Flo’s ward, abuse appears to be taken as an unfortunate side effect of working within that ward environment. It appears from talking to Flo that she has also taken that opinion on board and deals with the consequences by calling it stress.
Training is a very large issue in all hospital Trusts. Training has a few main areas: Moving and handling, infection control, conflict resolution, fire safety and equality and diversity to name a few. For the staff in this ward some of training agendas can be challenging. For instance, training of conflict resolution is required to be renewed every year. According to the ward manager training is compulsory and does renew regardless of which ward staff are working on. On my observation I saw many instances where the workers were attempting conflict resolution with no positive results. Training does not cover conflict resolution for dementia patients who don’t understand what you are saying yet not further training is given to Flo for would be useful for her to resolve an issue. I could not see in this instance how the NHS expectations for this predicament where anything but more than the actual institute could provide, yet Flo is expected to deal with it without the extra training. Moving and handling was the same as I watched Flo attempt to move bed-bound patients back up the bed with the slide-sheet equipment. I watched as Flo was continually punched in the face, bitten and kicked. Flo had to document that she had moved the patient as required for the prevention of bed sores and alike. Again Flo carried on with her duties. Not once did Flo say to anyone about what just occurred and no-one said to her either after what I witnessed of their encounters. In the interview, when Flo said that she felt invisible, I understood her meaning from what I had seen in my observation time on the ward:
“no-one cares, no-one hears us (carers), we’re nothing…just invisible” (94)
The information in Flo’s interview clearly reflected the events from my observations of the ward as I attempted to understand Flo’s frustration at not being heard and the traumatic events that she has to dismiss to enable her to fulfil her duties and some frustrations may be reduced if the extra training were available. As it stands, my findings show Flo in low mood and feeling discounted and under great pressure to fulfil the expectations that her employer places on her. The way I observed Flo’s behaviours, she also discounts herself and I am found wandering if she has added it to her script of helplessness and invisibility.
Friends It could be said that Flo could just move onto a ward that has patients who are accountable for their actions and she would be on the system like her other counterparts, however one of the main reasons for Flo’s continued presence in the ward are the long standing friends that she has had for many years. Flo wouldn’t like to work in any other ward where she knew no-one and had to start making friends all over again.
I found Flo to be mostly upset about the situation she finds herself in. Her situation comprises of the known and the unknown; the known as in her friends the location and the set out of the ward environment. The unknown as in the change of use of the ward and although the ward has changed its use several times, the duties of the carer has not changed within those changes. This change however brought unexpected issues and requirements that were not clearly identified before the changes were implemented and in the case of Flo, changed her whole outlook on her job, her value to the Trust and her well-being. Several times within the interview, I saw Flo in positions of physical defence, trying to keep herself safe and giving me cause to ask her if it was still alright to continue with the interview. I saw by her facial expressions to me that wished to continue and I did so with reservations to stop if necessary. Friends were clearly helpful in her situation and she wanted stay where she was known. My impression from Flo as I watched her talking to me was that she was in no fit state to begin a new process of making new friends on another ward and felt it unfair if she ever did have the need to do that.
Flo’s need for friends in this situation shows in terms of TA through the need for pastiming to alleviate the responsibilities of the ward and for the integrative terms and the relational needs, the need for mutuality, expression of love ( and care), and a sense of regaining some feeling of being valued and accepted.
Strengths and limitations
There are strengths to this research in as much as it was possible to see a larger picture regarding the NHS. The larger picture brought a better understanding of how the NHS works and improves. I will use this new knowledge in other relevant studies should the need arise. Another strength for this study was my own personal experience working in a hospital and my general understanding of how a ward is usually run making good comparisons for this ward structures and procedures.
At first my thoughts were on how Flo felt about working in a ward that had high expectations of her and her colleagues, however it was discovered that although the expectations on staff are clear, Flo herself also adapted to the environment and therefore the blame or responsibility cannot just fall to the organisation. Flo shows her script in this situation as the reader can see, Flo could actually do more than she does to change her situation but has adapted instead of attempting to improve her environment. Other strengths of this research are that it has brought to light a loop hole in the procedures and systems structure in the NHS; It is clear that if it’s not in a system then it doesn’t exist and although I worked in the NHS before I have never known this fact before. The weakness in this research is my bias towards Flo’s situation. I have been in Flo’s position myself and felt for her stress within her environment. The limitations of the study itself are that we cannot change Flo’s situation, only Flo can do that. I got myself out of the same position yet Flo appears to be stuck in her script and I had my own trouble feeling OK about walking away. Flo may still be there until she retires unless she changes her perspective on herself and as the research shows, Flo’s feeling of self-worth is poor as she spends all day with those who put her down, call her names and treat her like a punch bag. The limitations on the research for background on this topic were total. No evidence was found at all regarding hospital wards that say they are one thing but are in fact another and therefore all of the literature was about how things are going to improve (on the main front of the initiative drives for NHS) or about the shortfalls that caused the need for improvements in the first place. All of which unsettled me and I felt a wish to take this issue forward to the head of the Trust and reveal that there are people in the hospital who thought of themselves as invisible as they came under no category that was on the list. Not on the list that was improvement, not on the list to be improved. In a sentence the results brought emotion to my research and my bias was total. I am very aware that the organisation has no intention of ignoring Flo and that Flo also has a part to play in this issue but I felt for Flo and found it difficult not to be ‘on Flo’s side’ whilst writing this study. Another limitation of this study is that it only studied one person’s view of the situation. Other staff may have a different viewpoint on the environment they found themselves in once the ward had changed its purpose. The research did not expand to looking at other perspectives from other members of staff. Also the research did not explore other wards to see how the staff there deal with patients with mental health issues even if they are of a lesser intensity than that on Flo’s ward. This means that there is no real comparison in perspective to Flo’s ward.
Flo began the interview with a light and clear dimena. It was soon evident however that Flo held emotional fears and sadness about her role in the ward. She looked tired and defensive which she had attempted to cover with makeup and a smile. As we began to talk specifically about the issues in the ward, it was clear that Flo was not as happy in her job as she used to be and as she stated how fulfilled she felt in the past doing that job. Flo sat in the chair showing a general dimena of being a very small part of a very large entity.
On the areas of support, trauma and training, from the research obtained for this study, the NHS has attempted to improve the quality of all three areas for both patients and staff with the following adjustments to previous quality; On the one hand, the NHS is a large and secure organisation to work for. The organisation has systems and procedures to follow on anything and almost everything and have attempted to be reactive to occurrences within the organisation. Flo however, never felt those reactive occurrences had a voice available for her to be present within the organisation and …felt that her presence was more invisible and silent than ever. The NHS is proud of their systems and regularly show achievements and awards via social media and internal correspondence. It is a great achievement certainly to be one of the UK’s largest employers and obtain the achievements that they do. For Flo, these appear to be in another world as she scrambles to make herself heard, or even exist, in this vast maze of process and procedure. On the other hand, the NHS is such a large organisation that anything that requires proactive measures rather than reactive measures, struggles to take the issue down to the personal level. For Flo, the long career she has thought she would have until retirement in that ward is now in doubt due to her feeling un-supported, her long term stress levels, and her uncomfortable feeling of isolation and a sadness that she should feel like this in the once fulfilling and enjoyable role she has held for many years. Support on an organisational level through procedures and new well-being departments could only be seen by most (one supposes) as a good thing to happen and an improvement on a ward sister, untrained for any emotional issues, attempting to console and assist a staff member who has suffered an emotional work event. It does however stay within the realms of how effective is the system when the workforce has to wait three months on average to be seen by such teams of counsellors etc and the staff are at the mercy of the ranks above as to whether they will be classed as ‘sick’ in an already strict absence policy that leaves staff coming into work with illnesses which usually are known to require the person to have rest.
Studying the eight relational needs of Erskine (1994): Security, Valuing, Acceptance, Mutuality, Self-definition, Making an impact on other, Have the other initiate, Express caring; on a human level for the workforce, the NHS have attempted but failed on some levels to meet the needs of the workers yet still have the same expectations from them as it would had the needs been met. The fact that the system does not account for Flo and her working day (or night) to cater for her needs to feel safe secure and valued shows that the NHS however efforts show improvement, still fall short of fulfilling all objective for the staff. As the literature on NHS staff read, care workers are not researched as nurses and doctors are in data for assaults and traumatic events and therefore cannot be accounted for in the same way that these ‘trained staff’ are. It is fair to say that the NHS do attempt to rectify shortcomings when they are brought to their attention on most things but when there is a misunderstanding on what is actually happening, then is it understandably difficult for the decision makers of any Trust to really comprehend the nature of the problem. In general the staff of the wards I have seen and those particularly that I’ve observed have been happy and like to be in an organisation that attempts to care for staff as well as the patients. However, Flo is just one case and I have not observed any other wards of the same type (as there not any others in the region of my location) for this specialist type of care therefore I cannot account for other situations outside of my knowledge where the staff are completely missed as the staff on Flo’s ward are because of their status.
In the case of assaults on staff, several options are given as to and offers an option of a police report for those following a malicious assault. There is no similar option offered for those who are assaulted many times in the day as a matter of fact of the role.
Flo’s low mood and feelings of being misunderstood and dismayed are due to several needs of a worker in this case the person is Flo, being unmet feeling discounted and undervalued. Flo’s own behaviour shows adaptation to the surroundings and parental instruction and has adopted a don’t injunction, one of which I can observe as don’t rock the boat, don’t be important to name a few in this situation.
The NHS is excellent in many ways of trying to improve services across the considerations of staff and patients, external service providers and outside services. From the new initiatives to ensure a higher level of well-being in the NHS workforce, to demanding higher levels service from outside sources who service the food and equipment facilities, the NHS is attempting to react and improve from every report the Executive has requested. From the implementation of the proposals, it has been reported that most initiatives have been found to have a positive effect on staff (NHS England) with improved health on GPs and facilities for hospital workers all of which fit into the system with their own categories of the system; monitored and recorded to evidence any incidents of improvement. From speaking to Flo, one of the main conclusions to this study is the invisibility of some events, dynamics or considerations for those people who work in an area which is undefined or fail to fit into the systems of the organisation. For such a large organisation, the NHS shows due care and attention to its workforce and to the patients to whom they are responsible as a duty of care, however as Flo shows in her interview, not all situations can be accounted for and not all workers can be accounted for. The NHS as an organisation has many responsibilities and fulfils most of them according to their obligations. The trouble with the NHS is that it is run from systems and data and these systems are supposed to ‘catch’ everything that is going on. This research project has shown however, that not all things can be recorded and not all actions can be accounted for as people are adaptive and don’t always see the environment for what it is, or for what an observer may see it as from an outside perspective. I only observed one ward on one day and admittedly it is an unusual ward, but that would be the point and conclusion of this study; that the expectations of a care worker dealing with the expectations of care staff who work in the NHS is devaluing, and dismissive of the work of the staff if that staff member does not fit into a system of the NHS or is not in a situation where they can be accounted for or trained for. It is the conclusion of this study that the expectations of the NHS on care workers is too high and the staff adapt and adopt the same expectations resulting in stress, depression and self-discounting.
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