The Royal Pharmaceutical Society’s chief scientist Jayne Lawrence gave an interview on the BBC on Wednesday 5th November arguing that doctors needed ‘binding targets’ to reduce the over-prescription of antibiotics. Despite the fact that everyone knows we are becoming resistant to antibiotics, including and especially doctors, still the amount of antibiotics prescribed has risen rather than fallen both in the UK and across the world. It was unclear from the interview with the BBC journalist exactly how these binding targets would work – and Dr Lawrence was taxed on this very point by the interviewer. What happens when the annual target for prescribing antibiotics has been reached and yet there are more patients who need them? However, one of key her arguments was that targets help GPs keep the issue ‘in mind’.
This is a good example of what has become an accepted response to a general, population-wide problems. It has become taken for granted that the first recourse must be to set a target and preferably to make it binding. So we have the Millennium Development Goals (MDGs) for social development in developing countries, global emissions targets which are binding depending on whether a particular country has signed up to the Kyoto protocols or not, and a variety of targets for the NHS, Education and schools in the UK with more on the way (the Deputy Prime Minister Nick Clegg has just announced forthcoming waiting time targets for mental health patients). These are then backed up by apparatuses for scrutiny and control so that the targets can be enforced and made ‘binding’.
On this blog I have posted a variety of articles here, here and here where I have suggested that setting targets has become axiomatic in organizational contexts as a way of declaring seriousness of intent and sometimes moral purpose; as a way of exercising disciplinary control by ‘naming and shaming’, including and excluding when targets are taken up as cult values; and as an authoritarian theory of motivation (that staff in organizations will not do things unless they are forced to do them and then inspected to make sure that they really have).
One way or another targets are usually met by staff in organizations, but this often tells us nothing about the gaming strategies, subterfuge and aspects of the work process which have been neglected in order to do so. It is not hard to think of examples where staff in organizations have hit the target but missed the point, or confused what is countable with what is valuable. What we notice about targets is that they do not just measure the work, they shape it at the same time.
What I was struck by in this interview was Dr Lawrence’s idea about what it means to hold something ‘in mind’ and the link one could make to ideas of motivation and identity. It seems to me that the idea of a target carries with it an extrinsic assumption of motivation – in other words we need some kind of external reference point to do the right thing. Some rule or target ‘outside’ needs to impact on individual minds ‘inside’. A similar approach has been adopted in the NHS concerning the values of nurses, midwives and care staff. The six ‘C’s, care, competence, compassion, communication, courage and commitment will be widely promoted within the NHS and will be used as the basis of hiring, firing and promotion. Promotion within the NHS is dependent on at least an outward show of adhering to the six ‘C’s, which is elicited in individual appraisals.
In contrast to the news item, the previous week I had met two NHS colleagues who were talking about a project they had been engaged in to reduce the number of patient falls in their hospital, which seemed to me to be working with an intrinsic theory of motivation and a very different and social understanding of what it means to hold something in mind.
Patients falling over in hospital, particularly if they are frail and elderly, is an endemic problem in a variety of care environments and all hospitals monitor and publish their fall rates. At the very least falls seriously disrupt patients’ care and at worst can lead to serious illness and even death, so it is right and proper that managing and preventing falls should be a high priority amongst nursing and care staff.
But how might overstretched and under-recognized nursing staff keep the patient’s potential for falling over ‘in mind’, particularly if there is a prevailing and unhelpful taken-for-granted assumption that elderly people falling over is inevitable and unavoidable?
The two NHS colleagues I met undertook to work with nurses in a particularly shabby and neglected ward where the patients had dementia and the fall rate was unacceptably high. But they refused to set targets or take an overtly disciplinarian approach. Instead, one of the colleagues I met, an experienced nurse herself, worked on a daily basis alongside nurses on the ward encouraging them to make sense of what they were doing as they were doing it, and particularly so around incidents where patients had fallen. The other colleague worked on securing her the organisational legitimacy to continue to work in this way. The premise, then, was that nurses on the ward were engaged in a social activity together which would become more visible through the cycle of action and reflection on action, a method which I have written about elsewhere on this site, and which is aimed at greater reflection and reflexivity on the part of practitioners. The nurses were invited to take greater notice of what they are doing in relation to others, particularly the patients, and to bring this more prominently to mind as a social activity. This also involved the practitioner confronting nurses on some of their assumptions that falls were inevitable and reigniting their ability to place themselves in the shoes of others. On one occasion the practitioner colleague challenged a nurse who had said that falls were inevitable (and by implication acceptable) by asking her how she would feel if the person falling were her mother. The practitioner was working alongside nurses as a support, as critical friend, as a model, as an enquirer and as a facilitator of reflection and reflexivity.
One way of understanding her interventions with the nurses was that they were aimed at making nurses more conscious of processes of mutual recognition, of making the nurses more mindful of themselves in relation to others. This also helped bring about a different sense of ‘we’ identity, as a group of practitioners who were mindful of falls. It provoked conversations about who ‘we’ are, what ‘we’ think we are doing, and what ‘we’ care about. From the testimonies of the nurses involved in the project it seemed to make the idea of falls and their prevention easier to hold in mind because they were integral to practice and talking about practice and what the group valued as nurses.
The two NHS colleagues set out a very interesting alternative to the instinctive recourse to targets and extrinsic approaches to motivation, where it is assumed that care staff need some kind of external reference in order to behave well. However, this way of working is both labour intensive and takes time, even though the approach has brought about a dramatic reduction in the number of falls.