Powerful at every level

Working with a group of nursing students one day, I discussed with them communication skills when caring for people with cognitive impairment, dementia and delirium.

I gave an example of poor care I had witnessed during my 30 years of nursing.

One student could not believe such care had existed. Another disagreed. She had worked in care homes for years and had also seen poor standards. She was keen to learn ways to improve them.

The discussion moved on to organisational culture, which made me think about workplace power dynamics and how the person perceived to have the least power can actually wield the most.

The inquiry into abuse at Winterbourne View hospital in 2011 revealed that nurses in positions of authority were exasperated at their powerlessness to challenge poor care.

It appeared that despite their qualifications and accountability, managers had less power than the front line staff.

Patients now have more rights than in the past, thanks to the Mental Capacity Act 2005, which enshrines in law freedom from abuse and harm.

However, memory loss and cognitive impairment often render a person powerless. They become reliant on others to protect them, which can leave them vulnerable to neglect.

For every top-down culture, there will be a subculture that resists the flow of energy that is hoped for. A bottom-up, democratic and involved philosophy is needed to underpin the system.

‘Leave no one behind’ has become the clarion call, where shared governance councils will soon become part of the everyday fabric of organisations and will be part of any important decisions made.

Things are changing. We are experiencing an ideological revolution. Hospital managers now realise they have to engage everyone, not only to maintain services, but to recruit staff and ensure they stay, while supporting staff in the provision of good care.

As for the nursing students who desperately want to make a positive contribution to the lives of people with dementia and delirium – be reassured. You have a greater power base than you might realise. By seeking out like-minded people and working together, you can be role models for good behaviour and demonstrate excellent standards of care.

This, in turn, will educate front line staff who may have become disillusioned with the system and fallen down the cracks between theory and practice.

Organisational culture might be hard to change, but it can be achieved by collaborative working.

The rewards are worthwhile. I, for one, continue to enjoy the wave of enthusiasm and passion nursing students bring with them. It allows me to continue my journey of discovery in this profession.