Whistleblow or Walk on By? Ethics and cultures of complicity in

health and social care

18 June 2015

International Whistleblowing Research Network Conference

Sarajevo 2015

Dr Angie AshAngela Ash Associates, UK

Whistleblow or Walk on By? 3 themes

… Q of ethics

Context counts

Ethics in context

Angie Ash © 2015

Plan

1. Themes from failure2. Research – care and

mistreatment of older people

3. An ethic of care4. Ethical complicit cultures

Angie Ash © 2015

Themes from failure

1.Abuse has contexts & cultures

2.Fragmented, marketised systems the Holy Grail of box-ticking

3.Professional reluctance to challenge

(Ash 2011)

Angie Ash © 2015

Case study research

What dilemmas do social workers & their managers grapple with when dealing with possible abuse of an older person?

Angie Ash © 2015

Stressed and stretched health services

Hard to engage the NHS NHS care and older people

“I’m waiting for the NHS to re-badge relatives as “partners in care” … (relatives have) to provide so much basic care just to ensure their loved ones get access to adequate hydration during the day” Social worker

“… the way in which nurses speak to relatives and patients. I don’t mean niceties. It might be something like ‘I told you to sit down, so sit down and shut up’”. Social worker Angie Ash © 2015

Dilemmas: speak out or walk on by?

Resource shortfalls – quality/quantity, people/cash

Dilemmas of resources and care trade-offs: collapsed home care situation /risk of hospital-acquired infection / marginal quality care homeAngie Ash © 2015

Real worlds …

“You’ve got somebody broken down at home, the carer can’t possibly cope anymore, you're going to make a placement, it meets regulatory standards, it’s acceptable, but well … that’s a very real world for people”. Manager

“You calibrate what’s acceptable to what you know … you operate in that real world”. Manager

Angie Ash © 2015

‘Barely acceptable’ care homes

… “the whole place is an abuse”“ … if a person got out of their chair because they were trying to attract the attention of someone … before they (could) say anything they were told to sit down”.Social worker

“There’s been all sorts of things down to people being fed slightly roughly or disrespectfully or people not having their teeth in”. Manager

Angie Ash © 2015

Not seeing … ethics & care

“… (the investigation) shocked a lot of people. There’s a lot of guilt around these situations. I've talked to nurses who say ‘I did a review there two months ago why didn’t I pick up these things?’. I’ve talked to social workers who say ‘we've known for ten years (the home) is not a very great place but we've placed people there’. There’s a lot of guilt and discomfort around that”. Manager

Angie Ash © 2015

Normalising not seeing …

“… that atmosphere and that attitude…most people who’ve never been in a nursing home would just be completely shocked by it. The danger for us is that we (get used to it)”. Social worker

Angie Ash © 2015

Walk away or speak out …

“I don’t think for a minute social workers would actually walk away from a situation they thought was abusive, but I do think if you said to social workers ‘are you content with where people are placed, is this the sort of quality of care you’d want’, then probably the answer is no”. Manager

Angie Ash © 2015

An ethic of care … for health and care

AttentivenessResponsibilityCompetenceResponsiveness

(Fisher and Tronto 1990; Tronto 1993)

Angie Ash © 2015

Tronto’s four elements of an ethic of care

Attentiveness… noticing needs is a primary human

task –“You can add all the usual money and

things like that but I think … strategically it’s about giving it attention” Manager

Angie Ash © 2015

Tronto’s four elements of an ethic of care

Responsibility

comes out of recognising need

is embedded in cultural practices - not rules, obligations, duties

Angie Ash © 2015

Tronto’s four elements of an ethic of care

Competence

“Intending to provide care … but then failing to provide good care, means that in the end the need for care is not met”

(Tronto 1993:133)

Angie Ash © 2015

Tronto’s four elements of an ethic of care

Responsiveness

needing care places person in some vulnerability

stay alert to “the possibilities for abuse that arise with vulnerability” (Tronto 1993:133)

Angie Ash © 2015

Angie Ash © 2015

One-to-one – professional, care-giver

Attentiveness Alert and attends to the needs of patients and service users

Responsibility Style and skills = ability to respond to needs;to speak out when needs not met

Competence Demonstrate care in competent practice

Responsiveness Alert to the risk of poor care Speaks out about poor care

Ethical cultures 1

Angie Ash © 2015

Organisational

Attentiveness Attend to making strong organisational cultures that don’t tolerate poor or marginal care,or not speaking out

Responsibility Systems, structures, processes, practices regard rules as the means not the end of good care

Competence Support & adequately-resource employees to deliver competent care & speak out about shortfalls

Responsiveness Walk the talk - self-challenge, critical thinking, questioning, expect reports of poor quality, service shortfalls. Get worried when there are none

Ethical cultures 2

Angie Ash © 2015

Wider system – policy, politics

Attentiveness Attend to impact on health & care of: • fragmented, marketised health and social care

systems• name, blame, shame culture defensiveness,

hedging

Responsibility Held to account for:• realistic resourcing of health and social care• supporting the routine raising of concerns

Competence Fit-for-purpose law, statute, regulation as a means to deliver good care, not a box-ticking, resource-sucking end-in-itself

Responsiveness Listen, protect and respond to the whistleblower Criminalise retaliation

Ethical cultures 3

Cultures of complicity?

“All this activity that goes on often doesn’t seem to get to the heart of how people are living and being cared for. (When a report) throws up quite serious concerns about a place we think well hang on a minute, we’ve had contracts with individual people there for a long time … why don’t we have a full picture of what it’s like to live in a place where the people are subject to abuse?” ManagerAngie Ash © 2015

International Whistleblowing Research Network Conference

Sarajevo, 2015

Whistleblow or Walk on By? 

Ethics and cultures of complicity in health and

social care

Dr Angie Ash

angela ash associates PO Box 16 | Usk | NP15 1YB | Wales | UKE: angie@ashassociates.co.ukW: www.ashassociates.co.uk

References

 Ash, A (2010). 'Ethics and the Street-level Bureaucrat: Implementing Policy to Protect Elders from Abuse'. Ethics & Social Welfare, 4, 2, 201-209.

Ash, A. (2011). Personalisation and safeguarding. What can we learn from serious case reviews? . Paper given to 'Practical Safeguarding', 16th National Conference of Action on Elder Abuse. Manchester Conference Centre, 28 - 29 March.

Ash, A (2013). ‘A Cognitive Mask? Camouflaging Dilemmas in Street-Level Policy Implementation to Safeguard Older People from Abuse’. British Journal of Social Work, 43, 1, 99-115.

Ash, A (2014). Safeguarding Older People from Abuse. Bristol: Policy Press.

Ash, A (forthcoming). Whistleblowing and Ethics in Health and Social Care. London: Jessica Kingsley.

Fisher, B and Tronto, J (1990) 'Toward a Feminist Theory of Caring' In B. Fisher (Ed.), Circles of Care: Work and Identity in Women's Lives (pp. 36-54). Albany, NY: SUNY Press.

Tronto, J (1993). Moral Boundaries. A Political Argument for an Ethic of Care. New York: Routledge.

Angie Ash © 2015