My interest is in the patterns of thinking that people use to understand what they are doing and justify it to others. I am particularly interested in what happens when one or more different ways of thinking come into conflict because they require people to do very different things. I am referring to conflicting subcultures. Activities that can be explained and justified in one subculture can be immoral and harmful for another. How is this resolved?
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We humans struggle to function effectively when we have to work with more than one pattern of thinking. We use a number of terms including cultures, paradigms, ideologies or metaphors, as Annas did in 1995, when he looked at the way different patterns of thought have impacted on the practice of medicine.
Annas pointed out that we are uncomfortable operating with more than one metaphor and we are not easily persuaded by proposals which depend on more than one metaphor. He argued that the weakness in President Clinton's 1993 proposed health care reforms in the USA were that they were framed within two metaphors. This made it difficult to sell as a policy, and exposed it to evangelistic advertising from the republican right, which destroyed it.
- See: Annas G. J. Reframing the debate on health care reform by replacing our metaphors N Engl J Med 1995; 332:744
I argue that as a society we need to address these issues and learn to work with complex situations that cannot be handled within single patterns of thinking and political slogans. One of the major problems in Australia, and in most of the rest of the western world, is that our political process is not structured to handle the complex world we live in.
Political success depends on simplistic ideologies, aggressive assertiveness and catch phrases based on illusions. In depth analysis is inhibited. This leads to the application of simplistic systems of thinking to situations where they are harmful.
Our political process is locked into a competitive paradigm where electoral success is more important than integrity and service to the community. Politicians are unable to extricate themselves from this situation - a situation that we can call "paradigm paralysis"
A particularly difficult situation arises when a subculture that operates for society in one sector and has been accepted is confronted by a very different culture that the wider society of which it is a part has more recently officially sanctioned? The wider culture is prone to impose what it sees as desirable on the places where the subculture operates, and where that is harmful. There is nothing new about this.
... The truth is that medicine, professedly founded on observation, is as sensitive to outside influences, political, religious, philosophical, imaginative, as is the barometer to the changes of atmospheric density ..."
... [Actually there is] a closer relationship between the medical sciences and the conditions of society and the general thought of the time, than would at first be suspected ..."
Source: Oliver Wendell Holmes - US doctor - (1861)
A recent study reported an example in Nazi Germany where doctors and nurses happily killed impaired citizens who did not match their Nazi Aryan ideal. The author thinks that lesson is relevant to how many of us behave today and I agree.
We assume that doctors and nurses adhere to the Hippocratic Oath, an ethical code requiring them to reduce suffering and preserve life wherever possible. In Nazi Germany however, medical professionals were involved in some of the worst crimes in history.
'They came up with these ideas of getting rid of people they considered unworthy of life and useless feeders,' says Shields, who is the co-author of Nurses and Midwives in Nazi Germany: The 'Euthanasia' Programs. 'They were the terms that were used.'
At first the program targeted children with disabilities and then adults with physical or psychiatric illnesses—basically anyone who didn't fit the Aryan ideal or who was regarded as undesirable or a burden on Germany.
So effective was the Nazi propaganda machine and so pervasive the idea of preserving the Aryan race that many nurses felt they were doing the right thing.
'We like to think that we could [resist] but with the propaganda like it was and the community peer pressure, I don't know what we would do.'
Source: Ethical questions raised by 'Nazi nurses' still relevant ABC Radio National July 21, 2015
My experience: My early experience was with the consequences for society and for health care of ideologies like socialism, communism, and apartheid. I also saw the impact of different systems of funding and of different medical structures in several countries.
I have been concerned with the introduction of strong competitive commercial pressures into sectors where it was already known and widely recognised that it did not work and posed risks -- failing citizens. This was already happening but became a far greater problem during and after the Reagan and Thatcher regimes in the 1980s. They supported and imposed what we now call 'economic rationalism'.
Almost every sector in our society has been targeted and required to conform to economic rationalist principles. Those sectors, where economic self-interest was previously considered harmful and that had developed methods of controlling this, have had to conform. Not surprisingly, this has been harmful but those responsible are reluctant to accept this.
As Oliver Wendell Holmes observed in 1861, health care professionals are a part of wider society and have on many occasions compromised their beliefs and bent before the ideologies that have come and gone. People have been harmed. But never before have the pressures been greater, nor have the professions been so forcefully coerced into compliance. The new and the old cultures are contradictory and incompatible.
How do people respond in this situation?
1. Conversion: What individuals in the subculture are now expected to believe and do is very challenging for those whose identity and lives have been built in the old culture and who hold its values dear.
But humans have developed a set of psychological strategies that enable them to cope with stress and survive in situations like this. Those who are most successful at this process of adaptation adopt the new patterns of thinking and become very successful in the new environment. They are seen as credible and are promoted, so becoming leaders. In health and aged care these are often the least suited to be leaders, but their conviction persuades others.
The psychological strategies used to facilitate conversion include selective perception, rationalization and compartmentalisation. When confronted, believers respond by labelling (stigmatising), aggressively attacking and ridiculing critics, and by isolating or persecuting those who speak out (whistleblowers). These responses seem to be hardwired into our makeup. Perhaps they had evolutionary benefits, enabling our ancestors to manage stressful situations during the development of the human psyche, and to preserve group cohesion when it was needed.
2. Other response: Many are unable to abandon their values and struggle to do what is asked of them. Those who are less adept at adopting these ideas will do a number of things.
- Some are unable to cope and they move elsewhere.
- Most will do what they have to do and will lie low, offering a variety of justifications. Gradually they come to accept the new culture.
- Many struggle on and do the best they can. They tend to be altruistic and know that it will be worse for others without them.
- Alienation: Working in an uncomfortable environment like this adversely impacts motivation. Some become alienated and disinterested. Their emotional responses are blunted and they can become uncaring, even callous. In aged care we have seen instances where frustration is taken out on the recipients of care, and where groups of nursing aids amuse themselves by taunting the vulnerable people they should be caring for.
- Whistleblowers: Those who feel strongly about what they observe or who are harmed by the system may be unwise enough to speak out publicly. They are attacked, isolated and fired. Their credibility and their careers are destroyed.
The most extreme examples come with alienation when people become detached from their humanity. Those they are responsible for simply become objects of frustration or else are used for light relief and amusement. The most striking examle of this is probably the Winterbourne hospital for those with disability in the UK. Our gut reaction is to consider the people involved as monsters and not understanding that many of us would have behaved similarly if placed in the same situation. Those who are unhappy go elsewhere so that there is less and less social restraint on behaviour and the situation gets steadily worse and worse.
They were filmed slapping extremely vulnerable residents, soaking them in water, trapping them under chairs, taunting and swearing at them, pulling their hair and poking their eyes. Whistleblower Terry Bryan, a former nurse at the home, contacted the BBC after his warnings were ignored by Castlebeck Ltd, which owned the hospital, and care watchdogs.
The offenders were operating in groups; the offences involved an abuse of power; an abuse of trust; the victims were particularly vulnerable and on occasion the ill-treatment of a patient was sustained, with the consequences of serious psychological effects
The judge condemned Castlebeck for the way Winterbourne View was run. "It is common ground in this case that the hospital was run with a view to profit and with a scandalous lack of regard to the interests of its residents and staff," he said. "A culture of ill-treatment developed and as is often the case, cruelty bred cruelty. This culture corrupted and debased, to varying degrees, these defendants, all of whom are of previous good character," he added.
Source: Winterbourne View care home staff jailed for abusing residents The Guardian 26 October 2012
Note particularly the criticism of the culture that had developed in this facility and the comment by the judge that all those convicted had previously been of good character.
The problems were not localised to one facility. Three more facilities belonging to the same owner were identified and closed. The regulator described a "systemic failure to protect people or to investigate allegations of abuse"
- Winterbourne View hospital abuse Wikipedia 24 Apr 2016
The consequence of a culture that focussed on profit and devalued care for the participants is readily apparent. This is an extreme example of the dehumanising impact of an impersonal external culture imposed on to the caring sector. This should be seen as a red flag to a wider more pervasive problem. It graphically illustrates the dehumanising impact of the system we have adopted in aged care.
In Australia: There have been examples where staff have lost their empathy in aged care in Australia and done stupid things.
In 2007, nurses entertained themselves after a staff party by rolling a resident in tomato juice as a practical joke on another nurse suggesting the resident was bleeding. Another home with the same owner had been sanctioned for breaches of care so there may have been cultural issues.
In another 2007 incident at another owners facility, photographs deceptively obtained as part of a “scientific project” were used in a “guess who” game at a private party. A whistle blower indicated that “morale at the facility was low and personal care workers, who did not have the same level of training as nurses, were being given too much responsibility for looking after residents”. In this instance it was a community not-for-profit facility.
In neither instance did the owners report this abuse of residents to authorities.
- Sacked nurse back at aged care home The Advertiser 16 Sept 2007
- Body parts used in sickening 'game' at nursing home Herald Sun 31 Dec 2007
In the most recent horrible abuse captured on video there were other stress factors but the magistrate identified the role that a changed culture in the fqcility when family ownership chenged to a corporate management.
“Lxxxxx’ treatment of the victim ... was appalling and showed a total disrespect for a person as vulnerable as this particular victim was.
“This was appalling treatment of an extremely vulnerable, elderly, unwell victim.
“I (magistrate) accept that his offending was out of character,” he said.
“(It changed) from a family-operated facility to being operated by a management group and there was a change in support for the staff.
“He was somewhat demotivated and disillusioned at the time, and therefore under quite a bit of stress.
“To his credit, he still takes on board the fact that his ‘taking out’ of all those issues on the victim was totally unacceptable ... I accept that he is genuinely remorseful.”
Source: Cxxxx Lxxxx stressed about work when he abused Cyyyyyy Hyyyy at nursing home, court documents show Adelaide Now 27 July 2016 (Paywall)
A less flagrant example of cultural change is described by a nurse.
... I am an educator for PCA's, and have been a nurse for many years. It saddens me that when my students go on placements they witness everything that I teach them that should not happen. Many of my students are disheartened when they experience 'task orientated' nursing instead of client focused nursing ..."
Source: The Neglected Old Man - Comment by Llyle. Aged Care Crisis article
The consequence of all this is that staffing levels decline, particularly for skilled workers. Standards of care fall. In a market, the debate and the focus of staff's unhappiness is their remuneration.
I suspect that their frustration has as much to do with the stress of working in an environment with which they can't identify. They don't admit this, perhaps because its more difficult to explain and justify. Not only are staff leaving aged care, but the young no longer see it as a rewarding profession. The exodus includes nurses, doctors and other health care professionals - all those who are motivated by an ethic of service. Those in their professions, who are market-focused, replace them. The quote below is from the USA:
"As you have it now, we're stuck with an unhappy, demoralized work force and not enough of them. Realistically, it's a hopeless proposition to improve the quality of care," said Harrington, the professor at the University of California at San Francisco.
Last fall, six women, all nurses or aides, gathered in a hotel lobby in St. Peters and told about co-workers who neglected or abused residents, stole from their accounts or got drunk or high on the job.
They talked of the climate of fear that permeates a home where poor care is tolerated. Some said they were afraid to complain to management because they feared being labeled a troublemaker or losing their jobs.
Source: Woefully inadequate staffing is at the root of patient neglect St. Louis Post-Dispatch October 14, 2002
In 2009, The Age reported on a University of Melbourne study which examined staffing issues and trends in Victoria:
... The surveys also revealed increased levels of aggression from nurses and carers towards residents and vice versa. For example, in 2007, 3.6 per cent of participants said they had witnessed a co-worker being aggressive towards a resident at least once in the previous six months, compared to 7.3 per cent this year.
The aggression included yelling and swearing, pushing, grabbing, shoving or pinching a resident, and threatening to throw something at them.
A report written on the surveys by Associate Professor Leisa Sargent, Professor Bill Harley and Dr Belinda Allen said the more residents each nurse and carer had to care for, the more likely they were to report lower levels of job satisfaction, an increased likelihood of quitting their job and feeling emotionally exhausted.
''Participants also reported that the more residents each registered nurse had to care for the less satisfied they were with their facility, and the lower resident safety and care at their facility was,'' the authors wrote.
In 2007, 11 per cent said they were likely or very likely to leave their job, compared to 15 per cent this year.
Source: Aged care goes from bad to worse - The Age, 30 Nov 2009
What these articles are also describing is a break up of the community of carers, with a loss of identity and a loss of social capital - a process of cultural disintegration. They no longer have any control over their lives and don't have a moral focus around which to organise their lives and their activities.
The impact of time: Another consideration is the passage of time. Older workers who have had experience of a system driven by humanitarian motives are not promoted and are less and less able to function as role models for new staff. When they leave new staff encounter the system aa a "given"- simply the way things are. They know no better and more readily become part of the culture. The situation deteriorates and after nearly 20 years this will be happening now.
Before proceeding further, I want to look more closely at the process of compartmentalisation. It is used extensively as a response to situations where there is a conflict of ideas, particularly when culturopathy is present.
This occurs particularly where individuals and/or groups are put into situations where they are required to apply two conflicting patterns of thinking to the same situations, and where the one they are under pressure to use conflicts with the one best suited to the situation, or one which they already identify with and publicly express. Lets use the word "paradigms" to describe the different cohesive patterns of thinking. Each has its own internal logic that supports it but each contradicts the other paradigm. In the changed context different situations may demand very different responses.
The health and aged care marketplace are good examples because to succeed in the marketplace the business paradigm must dominate. Cost-cutting strategies must be adopted to meet the demands of shareholders and to compete successfully.
On the other hand, to succeed, the organisation and its leaders must profess and commit to the health and community paradigm, which places the interest of vulnerable citizens ahead of any commercial interests. They must be seen to be adhering to the values and norms expected by the community. But cost cutting, which is essential for corporate success, impacts adversely on the care given.
This situation causes intense discomfort and few of us are good enough actors to hide this. We cope with this by putting the two paradigms into two separate mental compartments. We then simply ignore the contradictions. We pretend that they are not really there. We pull out whichever compartment best matches the situation we are in and confidently expound its virtues. If there is a challenge, we rationalise or reject the argument made by attacking the messenger.
This is readily apparent if you examine company reports to shareholders and the market, then compare them with the public addresses by the same executives and the public face of the companies as they sell themselves. It is also readily apparent in corporate responses to scandals. In whatever situation executives find themselves, they will argue strongly within the required paradigm and indignantly deny that they are not behaving with integrity. They are being genuine.
My impression is that compartmentalisation is often accompanied by mentally detaching the paradigms used from the real world that they should represent, an important component of what I have called culturopathy. They can then rely on illusions to justify any explanations needed.
The different paradigms simply become a set of linked words to be trotted out when needed as part of the market game. A classic example is the US health care organisation National Medical Enterprises (NME), which I studied in more detail, after a scandal engulfed the company in 1991. I use it as an example of extreme culturopathy to illustrate what happens.
From Objectives sent out to hospital administrators to be addressed at meetings with hospital managers and staff in 1988
"... To Clear up misconceptions. (Example). We exist as a company to provide a high quality service to our patients (and in some cases society). I have heard individuals within the company make remarks along these lines and it is absolute nonsense. Lets call a spade a spade: We are here for one reason only - to make a profit for the shareholders who put up the money so that we could exist in the first place. "
Source: Court documents wrongful dismissal action against NME
Public statement by John Bedrosian one of Tenet/NME's founders to the Australian public
"--- well earned reputation for high quality patient care. ----- We gained that reputation through a quarter of a century of placing the reputation of our patients and physicians above all else."
"We assure you that those standards are being continuously, monitored at each of our hospitals throughout the world ... and we will not tolerate any practices that do not meet the highest, ethical and legal standards"
Source: ABC TV - Four Corners program, October 1992
"... Our new name says that we have strong values and beliefs and that we will seek out others with similar views for the benefit of both.
Among our core beliefs are the importance of integrity, teamwork and innovation. We will put these into practice daily as we provide the full spectrum of quality, cost-efficient services."
Source: Press release 1994 when NME changed its name to Tenet Healthcare. Eight years later in 2002 an even more confronting scandal blew up.
In 1993, when challenged in court about the contradictions in his statements by the lawyer representing past patients, many of them children who had been harmed, Bedrosian called his statement on Australian television "singing to the choir". He saw nothing wrong with it. For him it was quite legitimate, It was how business worked.
What he was saying no longer had any connection to what was happening in the hospitals. The words had an independent, illusionary existence of their own. I have a collection of documents and letters from doctors in the hospitals complaining about the lack of attention given to standards of care.
... Over the last few years there has been a gradual erosion of the power of the Medical directors so that in many hospitals there was just a facade of clinical care."
"... If people had questions about the tactics recommended from the top, they were not considered a team player and ultimately pushed aside."
Source: Letters from doctors to NME Corporate Executives 1991
Canadian author John Ralston Saul, whom I will quote elsewhere, considers this disconect between the world we think we live in and the real world that our senses and logic should tell us exists as a feature of Western Civilisation in his Massey lectures "The Unconscious Civilisation".
Who to blame?
The main focus of my interest in health and aged care has been private equity groups, and for-profit corporations, particularly those that are listed on the sharemarket. The pressures for profit are much greater for these groups and they more readily adopt the strategies outlined at the beginning of this page. It is because not-for-profits have to compete with for-profits that the not-for-profits are forced to adopt similar practices and strategies that lead to their compromising their mission.
The problem of conflicting paradigms is particularly acute for them, because their humanitarian value systems are an integral part of their identity - who they are and why they are here at all.
While markets in vulnerable sectors do sometimes seem to promote and support "evil people", most are true believers. In a sense, they are also victims of the system. They genuinely believe that this is the best way to provide these services. It is a "system problem" and needs to be addressed as such. It is a problem involving the way we conceptualise the world we live in and what we do there. I argue that this is where we should concentrate our efforts.
This may all sound a little airy-fairy, and why can't the market provide care just as well? The answer is simple, they could, but they don't because this would be less profitable and they would be unable to compete. The best way to answer this is with an example. This company, National Medical Enterprises (NME) looked like a rare aberration but proved to be a red flag to something that was happening across the whole of the health and aged care marketplace in the USA. There are multiple large health and aged care corporations that have behaved very similarly. This example is on the next web page.