Most people think of large hospitals, asylums or even prisons as ‘institutions’. Still others might bring to mind children’s homes or universities. What all of these examples have in common is buildings and so most people think of institutions as being enclosed by walls – by bricks and mortar but that’s not really what the word institution means. Actually an institution is anything governed by rules and conventions. That’s why we also talk about the institution of marriage or religion or of monarchy. It is the presence of rules that defines the institution – not the presence or absence of buildings.
Institutional abuse then is the abuse that comes from the rules that govern the situation, the institution, the environment.
Routines and conventions can be just as abusive as individuals even though they are not meant to be and nobody would want them to be. Let’s consider a hypothetical example….
It is 6am in the care home and the night shift are approaching the end of their shift. Their last task of the night is to help some of the more dependent residents to rise, bathe and dress. They have around half a dozen named individuals to ‘get up’ before the day staff arrive at 7:15am.
Once they’re up they are taken to the lounge where the television is playing 24 hour news. This is appropriate because ‘everyone likes to watch the news’.
At 7:15 the handover begins and lasts until 7:30 when the night staff go home. The day staff have a cup of tea and the work of the morning is allocated. This lasts until around 8am when the residents in the lounge are also given a cup of tea. At 8.30 am they are helped on and off the toilet. By this time the other, less dependent residents have been helped out of bed and are also sitting in the lounge. Medication is given out along with breakfast at the morning ‘drugs round’. At 11am everyone gets another cup of tea (everyone likes tea) and then toileted. By noon the staff are ready for another drink themselves. All the residents are enjoying themselves watching daytime TV in the lounge.
This routine of tea, toilet, TV drugs and food continues day in, day out with set times for everything and no consideration for individual choices. Such a routine dehumanises the residents even though nobody actually wants that and it was never the intention. The abuse is the unintended consequence of the routine.
Of course institutions need rules in order to survive and nobody is suggesting otherwise. Care homes and hospitals can’t function without reasonable routines. Neither can domiciliary care services or outpatients departments. The trick is to ensure that the rules and routines do not discriminate, do not deny individuality and do not ignore the genuine and reasonable needs of the service-users.
Consider for example a menu routine involving pork on Tuesdays. Without an alternative this would discriminate against the dietary needs of people from several religious groups and, of course, vegetarians and vegans.
Systems controlling the need for security from outsiders might inadvertently have the effect of preventing those inside from leaving the building.
Routines involving televised Sunday services played in a communal lounge may be very inappropriate for non-Christian residents unless there is sufficient flexibility to provide them with an alternative way to spend that time.
The problem in identifying institutional abuses is that they are usually unconscious. People don’t plan to be abusive when they set up their systems and routines and so this type of abuse often goes unnoticed.
One way to identify your own institutional abuses is to take note of your justifications. If, when questioned about a particular practice or routine, your automatic justification is something like “That’s how we’ve always done it” then it’s worth asking why. This doesn’t necessarily mean that there’s a problem. Very often the things we’ve always done work extremely well – that’s why we continue doing them. They are effective and not abusive in the slightest. But there’s no harm in asking yourself the question.
Additionally ask yourself if there’s any flexibility in the system. Is there a reasonable alternative for people who need it? Whose best interests does this routine serve, the service-user, the staff or the relative?
Above all remember that tradition is just another way to say ‘someone else’s rules’ and ‘best interests’ isn’t usually the same as ‘what we’ve always done’ or ‘what the relative demands’.
About the Safeguarding series
This blog series first appeared on Stuart’s personal blog early in 2010. It has been reposted here as part of a process of ‘rationalisation’ in which work from several blogs has been removed and reposted on only two.