Dementia Care

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18 Australian Journal of Dementia Care June/July 2016 Vol 5 No 3
• recurrent falls without cause
• presence of pressure ulcers
• resident becoming acutely ill, or a long-
term condition becoming worse.
All, most or some of these conditions
can occur spontaneously without any hint
of neglect, depending on the complexity
of the person’s illness. Equally, they could
be caused by neglect. The defining factor
for abuse is the action taken to prevent
these complications developing.
Obstacles to a positive culture
There is a range of obstacles to
developing and maintaining a positive,
open culture. Group-think is one
example. In essence, according to Janis
and Mann (1977), group-think is a
psychological phenomenon in which
people strive for consensus within a
group. People opt to set aside their own
opinions and remain quiet, preferring to
keep the peace rather than disrupt the
uniformity. They may not want to look
foolish or appear to be difficult. It is
thought to occur when the group members
have a lot in common, are perhaps from
the same staff group, and where there is a
powerful dominant leader.
Seven main symptoms of group-think
were identified by Janis and Mann:
1. Group ignores obvious signs of concern
and is overly optimistic about the ease
with which things can be put right.
2. Group too easily explains away
concerns or discredits those who have
raised them.
3. Group believes what it is doing is
morally correct and does not consider the
wider ethical consequences.
4. Group has negative stereotypes of
rivals outside the group who it considers
may be a threat (often incorrectly).
5. Members who disagree with the
opinions or actions of the group are
labelled as disloyal.
6. Members falsely perceive that
everyone agrees with the group’s
decision and silence is seen as consent.
7. Some group members self-select for
themselves the role of protecting the
group from adverse information.
If these seven characteristics are
considered in the context of the findings
of the serious case review of Orchid View
(Georgiou 2014), group-think was evident
both within the team at the UK care home
and senior managers in the organisation.
According to Janis and Mann leaders
can avoid group-think by making the
group aware of its causes, by being
neutral and by encouraging an
atmosphere of open inquiry. They should
give high priority to airing objections and
doubts and readily accept criticism.
Additionally, groups should always
consider unpopular alternatives,
embracing the role of devil’s advocate if
appropriate, and it may be helpful to
divide the group into separate bodies to
enable all options to be considered.
In reality, implementing these actions
can be challenging, particularly if there
are groups or individuals trying to
undermine the leader. And, in any
situation, leaders are limited by their
personal sphere of influence and their
own professional and moral beliefs,
ethics and duties. For example, the
managers at Orchid View were
ineffective but they could not force senior
managers to examine the concerns more
rigorously in 2010 or 2011. Leaders
should focus on the things over which
they do have control, however large or
small, and they can help to avoid group-
think in their care homes by applying
some practical principles (see box at left).
Conclusion
Leaders should be assertive, proactive
and approachable. They already have
much valuable information at their
fingertips but the key is to start
considering it all from a safeguarding
perspective. By being open, honest and
prepared to learn from the past, they will
be supporting the provision of a resilient
care environment that is able to adapt.
All staff can be encouraged to ask
themselves reflective questions such as
“Am I working to meet the resident’s
needs or because ‘we always do it this
way?”, “Am I offering care in accordance
with best evidence?,” and “Who is the
most important person in my work, my
colleagues, boss or the residents?”
It is important to remember that an
organisation’s culture is constantly
evolving and even a high-quality care
home can experience a shift from good to
poor care very quickly. Staff at all levels
should be ever conscious of signs
suggesting that the care is deteriorating.
A learning organisation is one in which a
leader supports staff to think about and
honestly analyse why mistakes occurred,
to learn frommistakes and so be in a
position to anticipate and avoid situations
where harm could occur in the future.
References
Brooker D, La Fontaine J, De Vries K, Porter T
(2011) How can I tell you what’s going on here?
Association for Dementia Studies, University of
Worcester.
Georgiou N (2014) Orchid View serious case
review. West Sussex Adult Safeguarding Board.
Heath H, Phair L (2015) The Sit&See Tool: an
evaluation of implementation and use.
(downloadable).
Janis JL, Mann L (1977) Decision making: a
psychological analysis of conflict, choice and
commitment . New York: Free Press.
Lupton C, Croft-White C (2013) Respect and
protect: the experience of older people and staff
in care homes and hospitals: PANICOA
(Prevention of Abuse and Neglect in the
Institutional Care of Older Adults) Report.
London: Comic Relief.
Phair L, Manthorpe J (2011) Health care and
adult safeguarding: an audit informing the
relationship of the UK vetting and barring
scheme with the NHS. Journal of Adult
Protection 13(5) 251-258.
Phair L (2015) Adult safeguarding: a care
leader’s guide . London: Hawker Publications.
This article was first published in the UK
Journal of Dementia Care 24(3) 30-31.
Tips for a positive culture
• Leaders and staff should build good
relationships so that concerns can be
raised. Leaders should identify key staff
members and how they influence others.
• Staff should be encouraged to
consider concerns from the resident’s
perspective, questioning the 'why' of
care repeatedly until answers are found.
Leaders should work with staff,
encouraging proactive supervision and
personal development.
• All staff should listen to the voices of
residents and families openly, including
the small concerns, and consider them
all carefully. Staff should try to keep in
close contact with families and actively
involve them in relevant decision-
making.
• Leaders should walk around the home
at different times of the day and night,
looking at environments and day-to-day
happenings through the eyes of the
residents and families. Is the home
clean, noisy, hot, cold or even
malodorous? Does it feel happy?
• Managers should seek evidence of
care, for example from medication
reviews, fluid and repositioning charts
and hospital admissions information.
• Managers should consider introducing
a care and compassion observation tool
such as Sit&See (details at
, which can
contribute to positively changing care
cultures in a broad range of organisations
(Heath & Phair 2015).
• Leaders, managers and staff should try
to see inspectors and regulators as
professionals with whom they share a
focus on the well-being of residents.