Trust in care : a personal reflection

I noticed in my calendar this morning that Monday is International Peace Day. It’s a day designed to promote peace among nations and peoples. The UN established the day and its website describes the day by stating that ‘peace is recognized as both an innate state of being, and a dynamic evolutionary process wherein constructive growth can occur and the children of this and future generations may gain hope for a better world to inherit.’

A bit wordy but in essence peace is both internal and relational. Reading the description reminded me of a phrase from the work of one of my favourites, the contemporary American novelist and short-story writer Veronica Roth, who wrote that:

“In order to have peace, we must first have trust.”

I will leave world peace to the Nobel prize winners but there is a truth in the linking of peace and trust which is inescapable. Whether in the realm of international politics, in the interactions of lovers, in the contracts of care or during a pandemic there is a profound interconnection between a sense of peace and ease and the extent to which trust is present.

But the problem is that if there cannot be peace and what comes with it without trust then there has been very little trust both before and during the pandemic in the realm of social care.

Where else would you get the extent of mistrust as in some of the contractual terms and practices between local authorities and social care providers. Explicitly what does it say of trust when electronic call monitoring systems originally designed to keep lone workers safe are used in homecare services to effectively electronically tag workers, to pay providers only for their contact time and to penalise for late arrivals or only to pay for a proportion of attendance. As one colleague put it – it is almost like saying to a nurse in a hospital you only get paid for the time you are at a patient’s bed but not your walking between them. There is little trust in the way we contract and provide care at home and housing support in Scotland. Without trust there can be no maturity of relationship.

Where else but in social care in the community would we treat workers with so little respect and maturity that we clock them in and out like some sort of Victorian factory, failing to give them autonomy and the capacity to make professional decisions? So, if they come across someone who is distressed by loneliness and simply wants company they have no capacity to sit and have a cuppa which restores. Why do we not have a system that instead of clock-watching care enables a worker to design their day around the needs of the supported person  rather than the demands of the system? Instead we have a system  of mistrust designed to drive down costs as much as possible.

This lack of trust was endemic during the last few months not least in relation to additional financial support for social care providers where in some local authorities the support and collaboration has been remarkable but in far too many the level of forensic examination of applications for financial support for things like PPE, extra staffing and additional costs, has been equivalent to trying to get money out of the Royal Mint. Without trust there can be no growth in relationship.

In all the talk in the last 24 hours about a second wave of Coronavirus I think that we need to reflect on the nature of trust both in the last few months and as we move forward. For perhaps the evidence of lack of trust and therefore absence of peace can be seen at its sharpest during some of our responses during the pandemic.

Much has been and no doubt will be written about the way in which as a society we failed to protect the most vulnerable in our care homes; the prioritisation of the NHS, confused Guidance, misuse of DNACPR forms, the absence of testing till late in the day and so on. But where a trust deficit has been perhaps seen most acutely is in the degree to which we have responded to the issue of allowing families in to see their loved ones in care homes.

This morning one of the main stories on the BBC website along with news of a second wave was from the English social care minister talking about visiting into care homes and making it very clear that all visits would require to be strictly supervised. This is all about trust. There is no trust when you have to police the love and care of family for their loved one. There is no trust when you have to have care wardens dressed in PPE to remove the privacy of individuals and disproportionally limit their rights of exchange. There is no trust when it is assumed that more harm will come from family rather than, at least for the last two weeks, the risks of a failed and broken testing regime designed to protect staff and residents alike.

It is time to start trusting rather than on the edge of a second wave to retreat back into positions which put up the walls of defensiveness. It is time for all to start to trust the professionalism and dedication of care home staff and providers rather than assume ignorance, lack of professionalism and ability. I have heard this week of one nurse manager who after 40 years of dedicated professionalism has resigned because in essence there is a lack of trust in her professionalism which has kept people safe from Covid from those who know nothing of what a care home is and does. Without trust there can be no community of care.

Trust is that most elusive and intangible of human emotions and characteristics. It is, however a fundamental for human relationship and community cohesion. It is an essential requirement for social care. Trust is diminished by lack of knowledge, by fear and the absence of relationship. It is fostered and grows by being alongside, by asking questions rather than knowing all the answers, and by taking proportionate risk.

I think as well as all the work we are doing in directly fighting the virus we also need to do the necessary work to build trust collectively as politician and commentator, carer and family, community and provider.

The psychologist Dr Andrea Bonior argued that there are some six requirements for building trust – I suspect they have a place in these days on the edge of a second wave:

1. Say what you mean and mean what you say – In the noise of conflicting priorities there is a need for clarity and clear communication. We often hear what we want to hear rather than that which is said. I hope in the weeks ahead as we face new challenge we can be clear and concise, truthful and honest.

2. Be vulnerable – Vulnerability is often used to describe that which is fragile and broken, limited and unwhole, but rather, I believe, our vulnerability should be seen as part and parcel of our humanity. It only becomes a weakness when someone uses that vulnerability for their own negative ends, it is a strength when we live through that vulnerability to be authentically who we are. So, in the days and weeks ahead let us not pretend to be who we are not, to know what we do not have the knowledge of, but rather to own our limitations and lack of certitude.

3. Remember the role of respect – Respect comes from an ability to understand the other and to see the value and essence of who they are. It is also rooted in a mature understanding of our own self. So, in facing the next few weeks I hope we can as professionals and colleagues come out from positions of defensiveness to recognise the ability in the other, the knowledge and expertise in that which we do not know, and to be honest in admitting our own frailties.

4. Give the benefit of the doubt – There are times in human relationships when we simply have to go into the unknown trusting that the other will not hurt or harm us. This is perhaps the hardest thing to do especially if there have been reasons for a lack of trust in the past. When pressure comes it is of the ultimate importance to be able to take a risk that the other will be true to their word, will adhere to what they say and walk their talk.

5. Express your feelings functionally, especially when it’s tough – it may not surprise many that there is a real emotional illiteracy in much of society and those who work in and around social care are no stranger to that lack of maturity. To hide emotions to the extent to which they overwhelm and overcome is not a sign of strength or ability but rather the reverse. One of the insights that I have gained from the last six months is that it is only by the honest display of feelings and emotions in all their raw pain and reality, that we can meet the challenges of a virus which can overwhelm and of emotions of grief and loss which can become so all consuming.

6. Take a risk  – I wrote last week about risk – but it is important to recognise that risk is not a solo activity but a mutual journey. Trusting the other that they are able to take a risk but one grounded in a mutual concern is the essence of being together in all human relationships. In facing challenges there are always moments and times when we venture into the unknown and the fearful, it is at such times and moments that we need to have the certainty that our risk-taking is upheld by the regard and support of others – we all need to know that there is someone there to have our back.

I hope as we move into the next stage of this pandemic, into days which will have their times of darkness and fear, that we seek to build the trust that gives us peace; that we work together to respect the knowledge and professionalism of the other, and that critically we work as hard as we can to continue to foster connection and contact between care home residents and the co-carers who are their families.

There will be many pressures in both community and care homes, upon our staff and families, but these will not be overcome by retreating into fear and blame, but only through trust and developing relationship. The future of social care in Scotland whether in community or care home can only be one built on trust and then perhaps we might have the peace we all seek.

Donald Macaskill