A former colleague’s mum died recently: she was on the Liverpool Care Pathway and did not have a ‘good’ death.
In her powerful article in Disability Now, From fact to fiction: the making and breaking of the Liverpool Care Pathway , Nikki Kenward in turn educates and dismays us about its misuse. She concludes with: “The fight will not be over until we can trust those employed to care for us” .
The complex mechanisms of authority, compliance and obedience at work often undermined some of the families’ efforts to make their relatives’ death more humane. How these mechanisms worked reveals clues about bringing about change.
Last week I had an experience which illustrated the complexity of authority and compliance. My story is a small one. I needed two injections before a short medical procedure. So routine, so normal. But I have to be careful about needles in my arms owing to operations I’d had a few years back. I had already had a blood test that morning so I asked the technicians to use my other arm to spread the risk of damage.
The two technicians checked the computer and said no, they could only use my left arm. They told me that I had agreed eighteen months ago (it said on the computer) that only my left arm could be needled and they were only authorised to do that. I pointed out that I was giving them permission in the here and now. They declined to accept that permission.
No matter which way I explained the risk I faced, they insisted on holding their position. It was upsetting but in the end, and against my better judgement, I complied. It is that act of compliance, the feeling of being forced into doing something against my better judgement, which disturbs and interests me. It made me think of those other patients and families feeling forced to comply to something which felt wrong and in some cases flew in the face of common sense, let alone patient centredness or even plain humanity.
There is a large body of work in social psychology on obedience and compliance, of which the enduringly controversial Milgram experiment of the 1960s is the bedrock. I went back to it. I was interested to learn that this field continues to inspire interest and study today. I thought that the Milgram experiment and its successors, replicated across the years and across cultures, shed light on what had happened to me. Why? It is all about the use different sorts of power operating simultaneously in order to bring about compliance:
- The technicians used procedural and legalistic power: they were procedurally correct to obey the hospital policy but they had not really understood it. They chose to ignore the rational, common sense and well informed information that I presented.
- Power of (withholding) information: the Technicians were authorised by the hospital to be the co-signatory of a form which permitted them to use both my arms. They withheld this information from me.
- The computer says “No” – Technological power: preferring the power of the recorded document rather than my, here and now, permission.
- They held the balance of technocratic and institutional power. It provided them with an opportunity to express disapproval of my non compliant behaviour. I was worried and upset: they were just doing their job.
- Experiencing disapproval sent me not-so-subtle messages about how ungrateful I was, which made me feel uncomfortable and deviant, not a good feeling in a hospital which is meant to be helping me and always has in the past.
- I was advocating my own interests above the policy of the hospital, and this was seen as disagreeable behaviour, which they were quick to point out.
- The authority of the uniform. A small point but a powerful one. Uniforms do what they set out to do: provide positive authority and reassurance but human history abounds with examples where this is not the case.
The many sources of power and authority, some subtle, some direct which come into play to ensure compliance makes change problematical. The small voice which says: ‘this is not right’ is more often the recipient of sanction than of action.
Organisational statements about listening and people engagement are good and ethical positions to take but incomplete. For those of us involved in behaviour change in organisations the question is: how can we enable the organisation to learn to listen, consider and take action at a consistent, personal level rather than drawing upon all its sources of power to expel or make comply that small voice?
Today I saw a the phrase ‘learning how to be human’. It struck me that power, from whatever source is comes, is something about which we must spend a lifetime being vigilant – not only of others, but as individuals in organisations, of ourselves too.