Risk, rationality and learning for compassionate care; The link between management practices and the ‘lifeworld’ of nursing

SummaryThe nursing care experiences of older people in the United Kingdom, has been much reported in the national and international press. Reasons for that poor quality of care in hospitals often focus on the ‘culture’ of organisations, as well as focusing on individual failings. However, discussions about culture change are partial explanations without a deeper analysis of how cultures and leadership operates in socio-political contexts which characterise nurses' ‘habitus’ and ‘lifeworlds’. Therefore the solutions may not address wider determinants of care such as risk governance, managerialism, instrumental rationality and of course staffing and skill mix. Instead, organisations may be exhorted to change their cultures, without addressing these wider determinants and thus poor care practices may continue to occur. If targets are abolished, this may still leave a layer of managerialist thinking. This impacts on education because students, who are ‘working and learning’, experience occupational socialisation through immersion in the lifeworlds of their clinical colleagues. What is required is much less manageralism in the care of older people. Instead, there is a need for clinical leadership, based on critical reflective understanding of the occupational socialisation of nurses operating in a context of risk and rationality and organisational objectives; collegiate political and moral action by health professionals and society on behalf of the older person, and support for front line staff who require more autonomy and control over care practices.