> Once again how does venting or making jokes about patients lead to a lower standard of care?

Culture is so important that the Mid Staffs report include an entire chapter about it. You've said that venting is a way for staff to cope with a difficult job. That has already been called out as harmful: https://assets.publishing.service.gov.uk/government/uploads/...

> Aspects of a negative culture have emerged at all levels of the NHS system. These include: a lack of consideration of risks to patients, defensiveness, looking inwards not outwards, secrecy, misplaced assumptions of trust, acceptance of poor standards and, above all, a failure to put the patient first in everything done. The emergence of such attitudes in otherwise caring and conscientious people may be a mechanism to cope with immense difficulties and challenges thrown up by their working lives.

They go on to say:

> A caring culture

> In addition to safety, healthcare needs to have a culture of caring, commitment and compassion. It requires the hard lessons of a Stafford to realise that it cannot be assumed that such a culture is shared by all who provide healthcare services to patients. What are the essential ingredients of such a culture? They surely include:

> Recognition of the need to empathise with patients and other service users;

[...]

> A commitment to draw concerns about patient safety and welfare to the attention of those who can address those concerns

I'd suggest that you can't empathise with a patient if you're being unpleasant about them behind closed doors.

My context is health care provided in English MH settings, usually in-patient, usually paid for by the NHS but not necessarily in an NHS hospital or with NHS staff.

> Once again how does venting or making jokes about patients lead to a lower standard of care?

Venting is an HCP placing blame for an event on the patient. This frames future incidents and the responses to those incidents. It makes it more acceptable and more likely for staff to use restrictive practices, and it de-emphasises the skills of de-escalation.

There is wide variation in the use of "prone restraint" in England. Some hospitals do not use it at all. Others use it frequently. Prone restraint can lead to death, so it's important that we understand this variation. One of the differences, but not the only difference, is the culture.

Imagine you're detained against your will in a mental health hospital.

Nurses Ann and Bob have the legal power to get a team of people to force you to the ground, hold you in prone or supine restraint, remove items of clothing to expose your buttocks, and inject a rapid tranquillisation medication. Again, all of this is against your will.

Nurse Ann says, behind closed doors during a team meeting: "Holy crap sheepmullet's anger has been out of control all this week. They wanted Section 17 leave for Christmas[1], but that wasn't granted, and I've got to tell them later and I know they're going to kick off again. They're just so angry at everything I say to them, and I know this is going to send them off the edge."

Nurse Bob says, behind closed doors during a team meeting: "sheepmullet has applied for section 17 leave. This was not granted. I have to tell them later that it has not been granted. I know that sheepmullet was really looking forward to Christmas with their family, and that they will be very disappointed that they're staying in hospital. I've struggled to talk to sheepmullet in a way that helps them contain their anger, and I'd like some advice about how to break this bad news in the best way."

There's not much that is actionable in a complaint from Nurse Ann. The comments aren't shocking. Ann's comments are likely milder than those mentioned in the original comment I responded to. But that approach is more likely to lead to prone or supine restraint, rapid tranquillisation, and a spell of seclusion. These are significant actions and should only be done as a last resort. Prone restraint has the potential to cause death.

Nurse Bob is making use of Soft Words from SafeWards[2], which is used in a range of MH settings, including "Secure Units"[2]. We're pretty sure this approach reduces the need for restraint, rapid tranq, and seclusion.

Imagine you get to chose who looks after you: do you pick Ann or Bob?

> Even in the tech world

Look at airline safety investigation where errors, even errors that kill, are not punished but are sources of learning. This should be true of healthcare, although it isn't always. The solution is not to avoid ever making complaints, but to keep making complaints and force the regulatory bodies to change their complaint handling.

We don't know what the comments were, and obviously if they're innocuous you don't report them. But, and this is really clear from all the investigations and research we have: you need to report disfunctional culture and leaders need to listen and act on those reports.

You seem to be saying that "shocking comments" aren't really shocking, and that non-shocking comments shouldn't be reported. I'd agree that you don't need to report stuff that doesn't need to be reported, but does that need to be said?

> Once again how does venting or making jokes about patients lead to a lower standard of care?

Look at what happened at Winterbourne View. People with intellectual disability were being tortured. There was a collapse in compassion. How did that start? How did we go from a 24 bed ATU providing care to a place where multiple staff felt it was okay to punch patients or trap them underneath chairs or pour mouthwash into their eyes? That started with staff who dehumanised their patients, and that dehumanisation starts with "shocking comments" delivered behind closed doors. A culture of abuse starts with staff thinking it's okay to badmouth patients just because they're behind a closed door. "Canteen culture" - staff sharing unacceptable views behind closed doors - is a widely recognised source of toxicity.

> In fact the implication was clearly that there was a high standard

That's what the midwives at Morecambe Bay said, that this was a good unit providing high quality care with the patient at the centre of everything they do. They were wrong. It was providing such poor care that babies were needlessly dying.

That's what the managers at Mid-Staffs said. We had no way of knowing care was so poor. Everything we had told us it was okay. They were wrong, they had a lot of indicators (including complaints from patients, relatives, and staff) to show that there had been a collapse in compassion in their hospital.

[1] apologies if Christmas means nothing to you. Substitute for something else significant: child's first day at school etc.

[2] http://www.safewards.net/managers/evidence

[3] these units work mostly with people who've been imprisoned or arrested after committing a criminal offence - they work with very ill people who are more likely to be violent. https://www.centreformentalhealth.org.uk/secure-care See also forensic services: http://www.nhsconfed.org/~/media/Confederation/Files/Publica...