Penny Campling: Thoughts on a healthcare culture—part 3

Why do good staff become bad? This seems a particularly pertinent question for those of us interested in healthcare in the aftermath of Mid Staffordshire, Winterbourne View, and the repeated and deeply depressing glugs of distasteful information coming through about our callousness towards the elderly. There is certainly no evidence that healthcare staff are more or less psychopathic than the general population, yet the ordinary person in the street is horrified and bemused by the vivid descriptions of neglect and cruelty that abound.

Looking beyond healthcare, this is a problem that philosophers, theologians, writers, and scientists have struggled with for millennia. There are many perspectives that can aid our understanding, some of which I’ll be exploring in this blog. As a group therapist, I’m particularly interested in the functioning of groups and organisations and how these dynamics affect the behaviour of individuals. To quote Nietzsche: “Insanity in individuals is something rare; in nations, groups, parties, and epochs it is the rule.” Most of us recognise that the people we work with, the team or organisation, can affect the way we feel and behave. We might even admit that we occasionally catch ourselves behaving “out of character.” But in the main, there is a tendency to underestimate the power of the group dynamic despite the accumulated wisdom of centuries and the theoretical and experimental evidence of the last few decades. In a world where personal autonomy is valued so highly, it is uncomfortable to think of behaviour being driven by—often unconscious—group forces.

A number of classic social psychology experiments have famously demonstrated how easy it is to impair the individual’s capacity for independent thought and moral judgment and illustrate the universality of the problem. These emerged, not surprisingly, in the decades after the second world war, when the world was trying to find a way of thinking about the industrial scale of sadistic homicide and the widespread collusion with such atrocities.

An instructive experiment in 1951 by Solomon Asch showed the powerful capacity of the group to undermine individuals’ belief in the information that they are receiving from their senses and the overwhelming inclination in most of us to conform to the group.  His study involved groups of nine people, only one of whom was a real volunteer participant: the rest were confederates of the experimenter. Groups were asked to make judgments in a series of questions comparing different lines in a diagram.  Once the experiment got going, the eight confederates would give wrong answers and the effect that this had on the responses of the genuine participants was monitored.  Overall, 76% made at least one error, compared with 1% in pre-tests where no one had been planted to give deliberately wrong answers.

Many of the participants argued afterwards that they conformed only because they did not want to stand out from the group (i.e. they claimed to know they were giving the wrong answer), but even when this possibility was eliminated by changing the experiment so that other group members were unable to see the answers of the participant and judge them, the error rate was significant. This suggests the beliefs themselves were influenced by simply being in the presence of others with seemingly different beliefs as well as there being strong pressures to conform. This experiment has been repeated in numerous studies since, with similar results.

Such research has direct relevance to our understanding of the type of inhumane behaviour illustrated in Mid Staffordshire. Indeed, the theme of habituation, where staff became tolerant of unacceptable standards of care, is highlighted in the 2010 Francis Report. We have to face the uncomfortable fact that we are all in some ways susceptible to the process of institutionalisation and that few of us are able to maintain our capacity to think independently and believe the evidence of our own eyes against the prevailing group opinion.

Penny Campling is a psychiatrist and psychotherapist and was a clinical director for many years. She has recently co-written a book entitled “Intelligent Kindness: reforming the culture of healthcare.”