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Integrity; to be worthy of trust.

Can you imagine a young child not trusting their parent? The term trust and love are very closely entwined, aren't they? That wonderful feeling of unconditional trust that a newborn baby offers their mother, that a toddler being hurled in the air screams joyfully at their father creates an incredible feeling in the parent or caregiver, as much as in the child. Being trustworthy, is an amazing feeling that cannot be replicated by false promises. Over time,

children learn their parents are fallible, they grow to gradually see their shortcomings and recognise their mistakes, but are usually able to forgive them, because they know they tried their very best to be good parents. Those very human parents were not perfect, and that is OK; none of us are. The serious problem occurs when someone who wields power or authority misuses that trust.

As health or social care professionals, we are privileged to receive the trust of those we work with and that is something we cannot take lightly. Some of our partners are the most vulnerable in society, others are people we meet at a particularly vulnerable time. Acting in a way that undermines trust leads to a poorer experience for people who use services. If we do not see integrity and honour as something that underpins positive outcomes then care will be worse.

One only needs to look to energy price increases in the UK and the impact on poorer households to see cause and effect of a lack of corporate and political integrity . Britain’s two biggest energy companies are making profits of £4.5 million per hour whilst 1 person in the UK dies every hour due to living in a cold home. It is not a global issue - France has restricted fuel increases to 4% whilst the UK sees a 53% rise. Poor households are suffering because of the propaganda that this is not the fault of those that make decisions. For balance, MPs get £3,500 for energy bills on their second homes. Across Europe, only Bulgaria and Romania have a higher percentage of children living in poverty or at risk of social exclusion.

So, how does that translate into our practice? When does our integrity and honesty affect the outcomes for people using health or social care services? Perhaps importantly, how does that affect us personally? I can't list all the times it matters or all the times there is a negative effect caused by a loss of trust between and professional and someone using services; its very easy to reflect and think about your own practice and how you work to see the damage dishonesty causes. It may not surprise you that in 2019, a survey carried out by CV-Library showed the least trusted professionals were politicians and the amongst the ten most trusted professionals were doctors, nurses and paramedics. Knowing you are trusted is a good feeling. I've long wondered whether we call NHS hospital provider organisations trusts because, generally, patients trust healthcare professionals or whether it was because the organisation wanted to sell a message of trust; neither is a bad answer.

Not trusting others is an isolating experience. For a manager, not trusting the staff team is likely to see them behave in less trustworthy ways and that will have an impact on the way they work and deliver care.

Not trusting those who are providing care or treatment must be quite frightening;

  • Imagine if you felt your GP was dismissive of abdominal bloating and pain that turned out to be ovarian cancer, that was quite advanced by the time you were diagnosed? How could you trust them to support you through quite grueling treatment?

  • Imagine if you hadn't checked a relative claiming to have Lasting Power of Attorney actually had it and a frail elderly patient was subject to inappropriate treatment on the word of someone not acting in their best interest.

  • Imagine if you had missed off a set of observations on a child in an emergency department because they appeared to be asleep, but didn't mention your lapse so the fact the patient was actually developing sepsis went unrecognised. How would the parents trust the hospital staff throughout the admission?

I've recently been engaging with a group called Hysteroscopy Action, a campaign group calling for greater recognition of the pain and trauma that many women suffer when undergoing outpatient hysteroscopy. Some of the stories are very sad, not only because they experienced severe pain and but because they felt so let down and dismissed by healthcare professionals. The Royal College of Obstetricians and Gynecologists' guidance is very clear - that all pain relief options should be discussed with women, along with the risks and benefits of each. The College says that women should be given the choice of a local or general anaesthetic, particularly where there are factors likely to make a hysteroscopy more difficult. That isn't always what happens in practice though.

The Campaign Against Painful Hysteroscopy patient group surveyed 860 women who had had the procedure at an English NHS hospital. Of those women, 750 said they were left distressed, tearful or shaken by the procedure, with around 466 of them saying that feeling remained for longer than a day. Many of the women said their painful hysteroscopies damaged their trust in healthcare professionals, had made cervical smears more painful and had a negative impact on sexual relationships.

The survey also found 660 of the women were not made aware the procedure could be done under general anaesthetic, epidural or sedation, raising concerns hospitals are not giving women appropriate information. Some of the women surveyed likened their hysteroscopies to “torture” and described doctors carrying on with the procedure even though they were screaming in pain.

Where is the integrity that is so important to build trust? Withholdings information means that that woman's' decisions and consent to procedures is not actually consent; it is coercion. Dismissing someone's pain with false reassurance that 'it will be over soon', particularly if they have asked for the procedure to be stopped is not demonstrating professional integrity. Those same women might not return for another hysteroscopy when symptoms recur and that might mean endometrial cancers are not diagnosed until they are advanced beyond a point where curative treatment is possible. That's not a good thing for the patient or the healthcare professionals.

One woman said, "I had a Hysteroscopy procedure without any knowledge or advice prior to the procedure. It was made 1000 times worse by the consultant ignoring my pleas to stop when I asked. There were 4 other medical people in the room and later on when I complained suddenly two people disappeared from the complaint and the two others couldn’t remember what happened!". Is this really listening to patients? At what point does continuing when you have been asked to stop become assault?

Thinking specifically about hysteroscopy, but also about other outpatient procedures, how well do you monitor the patient experience and pain levels? Is this part of the feedback that patients are asked for or do the staff report the level of pain? If high pain levels are reported, what action has been taken to ensure that information for patients is accurate, that it reflects a reality based on current evidence and that all options are discussed and offered without coercion? For hysteroscopy specifically, is there a pre-procedure assessment that considers factors more likely to lead to higher pain experience or failure to complete the procedure in an outpatient setting? Do staff supporting procedures feel confident to insist it is stopped if a patient requests this? Has that ever happened and if not, why not?

Health and social care professionals are often called upon to do tasks that many would consider 'unpleasant'. I am pretty sure there are very few people who like clearing up dried diarrhoea, vomit or infected leg wounds. If the person you are helping is distressed, it can be even harder and can truly call on all our skills to maintain our professional integrity. If we consider it from a different perspective, seeing the person not the fleas or encrusted faeces under fingernails, then we may begin to see that it is one of the greatest of privilege's to be trusted sufficiently to be allowed to help someone who is embarrassed, uncomfortable and acutely aware of their appearance and smell.

If anyone watches videos circulating on social media they will have undoubtedly seen a prominent politician smirking when apologising for parties that should not have happened. Imagine if a patient or resident saw a health or social care professional grimacing, rolling their eyes or smirking when they had been entrusted with someone's distress. It is our integrity that allows us to see apparently insignificant, unpleasant or dull tasks as a way to build relationships, as an opportunity for assessment of mood, skin integrity, mobility, pain and much more. Nobody should be irritated by an 'accident' or thinking 'just a shower'; that shower can, and should, be personalised care at its very best. It should be supporting a message of wellness, of being cared for and feeling comfortable. It is an opportunity for the people receiving care to show the care providers that they are respected and trusted. Feedback doesn't come much better than someone singing in the bath or smiling with their teeth in.

How often do you reflect on the importance of high quality basic care?

How often do you just stop and use your senses to see, hear and smell what quality of care is being offered in your service, or part of a service?

How often do you feedback to those providing 'day to day' care about the quality of their work? Often something as simple as, "It smells nice in here this morning" or "Mr. Jones looks very smart today". If you build that low level, but important, feedback into your management routine and notice when small things are done well, the staff will trust you to understand what they are doing. If you show that small things matter, they will become more important in the minds of the staff team and the positive reinforcement will see Mr. Jones looking smart every day.

Is that integrity? I think so, it builds trust.

What happens when you get something wrong? My mother always used to say, "Least said, soonest mended", but I agree with Launcelot: in Shakespeare's The Merchant of Venice, "Truth will always out". I remember all too well when one of my friends dropped a baby whilst bathing it on her first ward placement. She was distraught and the infant's mother spent the afternoon pacifying the student nurse rather than being angry with her. My friend had owned up and apologised straight away; she showed genuine remorse. That's all it took.

Similarly when working in regulation, I have seen providers move from threatening judicial reviews and court action to making coffee (and serving it with cake) simply because I acknowledged we got something wrong and apologised to staff.

When you are thinking about the responses to mistakes, defensiveness and a failure to take responsibility are likely to cost far more in both human and financial terms than simply owning up and apologising. The Regulations require providers to adhere to the Duty of Candour when incidents and mistakes reach a certain threshold. Wise providers and wise professionals respond openly and honestly well before that threshold is reached.

Integrity goes beyond simply telling the truth. How do you demonstrate integrity in your professional life?

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