Institutions and their failure to care: Bureaucracy and the practice of emotion

Why do institutions fail to care? How could they become spaces that recognise and support emotional practices that caring entails? Caring institutions, which we define here narrowly as organisations, such as hospitals, asylums and workhouses, where care is proffered within a place of co-location with others, have provided services to those in need for over a thousand years. They often existed alongside community and kin care, as they do today. The growth in specialist care services that rely on highly educated and highly skilled professionals as well as expensive equipment has ensured that institutions remain important places to access particular forms of care. Despite this, recent provocations designed to encourage new imaginaries of care have placed little emphasis on institutions (Hobart and Kneese, 2020; The Care Collective, 2020; an exception here is Tronto, 2010).

That this is the case is not surprising. As well as reflecting a general turn in feminist critical theory to decentralised approaches to care practices, a robust scholarship on caring institutions has highlighted the myriad wrongs, abuses, harms and failures of care within such contexts. Caring institutions have been implicated in the removal from families and deaths of children, not least in colonial contexts; they have been sites of inhumane experimentation and individual abuses; they have been structures that enforced strict disciplines, that refused dignity to their residents (Daly, 2014; Hamlett et al., 2013; Schaffer, 2002). The scale and horror of institutional failure has been such that, at times, communities have thought them best left behind, rather than reformed, a discourse that is perhaps most visible in the deinstitutionalisation of mental health care during the second half of the 20th century (Fakhoury and Priebe, 2002; Taylor, 2015).

A less-told part of the story, however, is that few institutions commence with cruel intentions. Indeed, some explicitly originated in utopian visions of best practice, building on the (then) latest scholarship or thinking on well-being, and attempting to provide spaces dedicated to health, well-being and flourishing beyond the tread of daily life. New histories of institutional failures now seek to explore such goals and their successes, as well as the hows and whys of when aspirations become callous (Barclay, 2018; Soares, 2023). In many ways, this article situates itself within that conversation. At least in the medium term, it seems unlikely that institutions will be absent from the care landscape, and so any consideration of care requires us to attend to the role of the institution and how it is made fit for purpose, perhaps even opened up to the possibilities of ‘promiscuous care’, an abundant, generous, excessive care, as desired by The Care Collective (2020).

This article explores the capacity of institutions to care, considering how and why care fails to occur, and the ways that the nature of institutions within our contemporary neoliberal context contribute to such failures and are unable to respond adequately when failure is manifest. To explore this, the article uses a case study of one National Health Service hospital trust in England that has been the subject of the largest-ever review of maternity services. We chose this case study because of the detailed documentation that is publicly available in two reports of the Ockenden Review, published in 2020 and 2022, and the accompanying analysis and commentaries in academic journals and podcasts (Logan and Kelly, 2021; Macleod and Hodges, 2022; Small, 2023). ¹ The situation at this Hospital Trust is not unique, as emphasised by Donna Ockenden and others (Lancet Editorial Board, 2022), and we use this example to extend a conversation as to why failures of care become so routine within institutional contexts (including maternity services; see Rieger, 2010).

The Ockenden Review reports, we argue, represent the problem of a failure to care in a particular form that draws attention to clinical practice and individual behaviours and, in turn, invisibilises the operation of the institution. Moreover, while the Review recognises that care has an ‘emotional’ or ‘affective’ dimension, it struggles to envision its provision as something shaped by institutional structures. Following Bacchi (2009), we suggest that the way problems are represented shapes policy responses, and that the invisibilisation of the institution and of ‘caring for’ (Noddings, 2003) within the Review's assessment of the Hospital Trust limits the possibilities of institutional reform and so an improvement in caring practices. In this article, we reread the reports with an eye to what the evidence – provided both in excerpts throughout the reports and in a long appendix – tells us about the relationship between institutions and their capacity to provide care, especially ‘caring for’. We read this evidence against a large literature on the operation of institutions, and on care as an emotional practice, which allows us to identify patterns and silences (Tuana, 2006) within the formal reporting by the Review. We reflect on how attention to the institution as a critical context for care opens up new pathways for reforming and improving care for patients and staff.

Care and its failures

Definitions of care are multiple and contextual (Held, 2006; Kittay and Feder, 2003; Noddings, 2003; Tronto, 1993). As Tronto (1998) notes in her important contributions on the ethics of care, care is commonly used to refer to two key domains: practical or physical activities that support the sustaining, and ideally flourishing, of human life, such as might be seen in the hands-on care that nurses provide to patients or mothers to children; and a ‘mental disposition’ or set of emotional practices that often accompany care, and which for some come to qualitatively change the purpose, nature and possibilities associated with caring actions (Noddings, 2003). This distinction is important to our case study, where failures of care can be identified across these domains and where common-sense articulations of care were used by the Ockenden Review to judge the service. The Review found that the Hospital Trust failed to provide appropriate levels of medical and physical care to patients or clients, sometimes with detriment to life; it also failed to provide those services in a way that supported the psycho-social safety and well-being of its patients and notably also its staff. Thus, the institution failed to provide physical care, but also failed in making people ‘feel cared for’ – a point we shall return to below.

In 2016, Donna Ockenden was commissioned to lead an independent review of 23 cases where families had suffered harm in the course of pregnancy care. Two families whose babies had died campaigned for the review over many years, dissatisfied with previous investigations and explanations. During the course of the Ockenden Review, it became apparent that many more families were potentially affected, and the final report published in 2022 covered nearly 1500 families whose interactions with the service occurred between 2000 and 2019. The Review uncovered that failures in clinical care meant that a number of pregnant women died unnecessarily when the development of complications of pregnancy or birth was not recognised or action was slow. Failures in clinical care also contributed to stillbirths, to babies dying during or following birth, and to some surviving babies suffering avoidable brain injury. These and other adverse outcomes were not always investigated properly, many downgraded, and subject to internal rather than external scrutiny.

Many families described their experiences in interviews; vignettes were also created using health service records. The two Ockenden reports sought to make visible, and central, the experiences of families who received inadequate care. And here they referenced care in the sense of a ‘lack of compassion and kindness felt by families’ (Logan and Kelly, 2021), in addition to inadequate clinical actions and procedures. Worse than absent kindness, pregnant women experienced ‘unkind words, swearing, sarcasm, and bullying’ (2:8.91). Bereaved families and others who suffered harms did not always receive support and sometimes staff of the health service were insensitive or rude. Commonly, families were not included appropriately in investigations, which was experienced as a further lack of care.

Failures in patient care, in part, reflected a parallel absence of care for staff within the Hospital Trust itself. Chronic workforce shortages contributed to a range of practices that jeopardised the safety of pregnant women and their babies. Throughout the clinical hierarchy, in which more difficult clinical procedures were progressively the responsibility of those above, there was a lack of available support for those with less experience or lower skill level. The pervasive culture was one of stress, fear and intimidation. Bullying was rife. Midwives were reluctant to ‘escalate’ cases in this environment. For the Ockenden Review, accounts of staff were obtained through interviews and surveys, although ‘fewer staff and ex-staff contacted us than we had anticipated or hoped for’ (2:2). Staff feared being identified and some withdrew their comments prior to the publication of the reports.

The second report of the Ockenden Review resulted in over 60 ‘Local Actions for Learning’, which offered specific advice on how to improve clinical practices. These included ‘[t]he Trust must adopt a consistent and systematic approach to risk assessment at booking and throughout pregnancy to ensure women are supported effectively and referred to specialist services where required’ (2:7.113) and ‘the Trust executive team must ensure an appropriate level of dedicated time and resources are allocated within job plans for midwives, obstetricians, neonatologists and anaesthetists to undertake incident investigations’ (2:4.108). The Local Actions for Learning also covered support for staff who raise concerns and complaint handling – one of the few places where emotional practices were recognised: ‘Complaint responses should be empathetic and kind in their nature’ (2:4.121).

The second report also highlighted 15 areas where ‘Immediate and Essential Actions’ should be undertaken, which were more global in outlook. These included ‘financing a safe maternity workforce’, ‘all trusts must have oversight of the quality and performance of their maternity services’, and ‘incident investigations must be meaningful for families and staff’ (2:160–176). Again, this set of actions emphasises clinical care, but rarely the associated emotional practices, an exception being in relation to families who experience adverse events: ‘There must be robust mechanisms for identification of psychological distress, and clear pathways for women and their families to access emotional support and specialist psychological support as appropriate’ (2:175).

The second report, we suggest, can be read as being divided into two domains: the first articulated what the Review understood as the problem, largely defined in terms of clinical failures, and we would suggest saw part of its role as demonstrating ‘active listening’ to complainants; the second described the ideal responses. Thus the report situated the problem as, for example, a lack of staff and placed the solution as more staff. The intermediary step – of how the Trust would find, fund, train and (especially pertinent) keep more staff – is not explained, placed back with the institution to resolve.

The intermediary step in the report often functioned as a metaphorical ‘black box’, whereby the ‘inputs’ (the ‘problem’) and ‘outputs’ (the ideal practice) were identified but the inner workings of the box were invisible. The report alludes to, for example, ‘training’ and ‘mechanisms’, but not to their form. This was especially evident in recommendations that related to what the Review rather clinically described as ‘human factors’. All trusts ‘must mandate annual human factor training … this should include the principles of psychological safety and upholding civility in the workplace’ (2:168). The report glossary defined ‘human factors’ as ‘environmental, organisational and job factors, and human and individual characteristics, which influence behaviour at work in a way which can affect health and safety’ (2:204). Unlike some types of training for clinical care, or even bereavement support, there was no identified training that was specified by the Review to support this recommendation.

We suggest that this ‘black box’ that appears in the report and is situated between ‘problem’ and ‘solution’ is the institution, and that one of the reasons for failures of care is that the institution has been made invisible by contemporary discourses around the structure and accepted mode of functioning of institutions. To gain access to the ‘black box’ requires attention to the ways that institutions are able to produce care (or otherwise), how that is being shaped in our contemporary socio-political environment, and the relationship between institutions and the ‘human factors’ that are so essential to how people ‘feel cared for’.

Any discussion of care in an institutional context has to grapple with how it is operationalised. Feminist and similar aspirational constructions of care, certainly in the last few decades, remain committed to care as part of an inter-personal relationship (The Care Collective, 2020). Accounts of ‘promiscuous’ care or ‘radical’ care recognise that the obligation to provide care has fallen differentially across particular bodies, most notably women, but largely re-envision or remove the ‘burden’ of care by imagining greater cooperation within communities or societies at large, as well as greater resourcing from ‘caring’ states (Hobart and Kneese, 2020; The Care Collective, 2020). Attention to the professional carer has been relatively limited within future-thinking imaginaries of care, even as the weaknesses of the family as a caring institution have been acknowledged (Hooyman and Gonyea, 1995). Meanwhile, many healthcare workers are now calling for the opportunities to practise what might be termed ‘transformational care’ in contrast to ‘transactional care’, where there is time for relationships of trust to be built and for emotional practice to occur (Pavolova et al., 2023; Salisbury, 2020; Sinsky et al., 2022, noting that this call is longstanding in family practice, e.g. Gray et al., 2003, and, especially, midwifery, e.g. UK House of Commons Health Committee, 1992).

The Ockenden Review starts from a premise of naturalised institutional care. There is no suggestion that the Hospital Trust itself should not exist or that the care it provides might be best served through another structure. The Review assesses the service offered by the institution, and so the institution is the boundary of analysis. Perhaps as a result of this, the institution is effectively invisible; the Review considers individual experiences and reports, inputs and outputs, but not the wider parameters that give them shape, meaning, or purpose.

Within the report, care is operationalised through professional best practice. Failings in care, interviewees lament, reflect ‘out of date’ guidelines (2:4.31; 2:4.84); care can be restored through ‘training’, better ‘communication’ and new ‘mechanisms’. Policy becomes the lifeblood of care; institutionalised care is enabled through its bureaucracy and governance: ‘The maternity services senior leadership team must use appreciative inquiry to complete the National Maternity Self-Assessment Tool published in July 2021, to benchmark their services and governance structures against national standards and best practice guidance’ (2:4.132).

The Review struggles with a strength of institutional care that also becomes its weakness: care is provided by anonymous individuals who have a degree of interchangeability. Institutions are designed to take pressure off individualised care, provided by known persons (typically women who are family members), and to replace that with well-trained, reliable and routinised professional carers. A loss of intimacy and personal knowledge of the other is countered by the reliability and predictability of a quality of service (in theory, if not practice). The Review thus recognises that workloads are an issue, and recommends an increase in staffing, also that bureaucratic procedures are enhanced and followed, but it does not give attention to the individual providing that care or whether they have time to develop meaningful relationships with those cared for.

The ‘human factor’ offers a challenge to a bureaucratic model of care, where affective, and so effective, relationships rely on knowledge, intimacy, trust and familiarity between carer and care recipient (Tronto, 2013). The Review largely does not imagine the possibility of this form of relational care (although it does endorse a shift to a ‘continuity of carer model’ which gives much greater priority to relationships than standard care if staffing was at the right level (2:xi)). It recognises the desirability of ‘compassionate, individualised, high-quality bereavement care’, and points to a specific guidance for its provision, as well as the need for the ‘identification of psychological distress’ and ‘pathways for emotional and psychological support’. However, these forms of care are largely enabled by providing professional psychological services for those in distress. A parallel solution is offered to staff, where investment in educational and psychological support for midwives was made as a response to staff distress (2:1.38). How the institution might enable a ‘feeling of care’ that would accompany the provision of maternity services, or indeed how it would ensure its staff feel similarly cared for in everyday working life (Regier and Lane, 2013), fails to be articulated; an absence of feeling cared for is identified as a problem but is unable to be operationalised through the usual practices of a bureaucracy.

Ultimately, the problem for the institution becomes one of emotion. How could an institution make people ‘feel’ for each other and in ways that are supportive, productive, and enabling of an institution's aims? This might seem an insuperable challenge, and yet a scholarship on emotion indicates the critical role of institutions in giving shape and form to our emotional lives (Lok et al., 2017; Reddy, 2001; Vincent, 2011). Emotion takes cultural form as part of biocultural bodies (Boddice, 2023); what we feel is a product of socialisation and ‘habitus’, the social structures that shape our dispositions and capacities (Scheer, 2012). Employee feeling is directed by organisational regimes and culture, a structure of feeling that is naturalised over time as people adapt to the emotion rules of their workplace (Barclay, 2021; Hochschild, 1983). A failure to care, then, is not simply an issue of individuals and their proclivities, but of the ways that institutional structures enable and direct people to care and give care its form. The business world often points to this as a problem of ‘culture’, but as we argue below, culture takes a distinct form within institutions.

Institutions that care

Care, or a desire to provide it, is an important dynamic within many institutions, but particularly those whose guiding purpose is to provide care, such as hospitals, asylums, workhouses, and to an extent schools and other education providers. The nature, scope and impacts of institutionalisation is a topic of a significant literature (Jupille and Caporaso, 2022). Here we shall not rehearse its arguments, but rather point to some key features that we believe are especially pertinent to understanding the ability of institutions to care. These are the scale of institutions, often surviving over generations and existing beyond the individual or their leadership; their bureaucratic mode and function; and their relationship to vocational or professional fields.

Studies of institutions can be loosely grouped into two categories. The first is works by critical theorists, historians, sociologists, critical management studies, and other scholars fundamentally interested in the operation and flow of power, and for whom the institution is a key site through which power manifests and where the fact of ‘institutionalisation’ becomes central to understanding the scope and possibility of resistance within it (e.g. Mackay et al., 2010). The second category is studies of institutions by those interested in business, management and organisational studies that consider the practical management, daily operation, culture and functioning of institutions (e.g. Glynn and D’Aunno, 2023; Lawrence et al., 2013). In many of the latter studies, an ‘institution’ is often not much distinguished from a large organisation or business, and so the domain of analysis and solutions posed to problems tends not to distinguish between institutions and other forms of large organisation. We argue that to understand failures in care, this distinction is critical.

Institutions of all forms are defined by structures that are designed to produce continuity over time and generations. To achieve this, institutions must abstract themselves from the individuals who produce them, sitting outside or beyond as a form of rules or ‘law’ that gives shape and meaning to institutional practice. In modern institutions, this has been closely associated with a process of ‘bureaucratisation’, whereby power becomes concentrated in the administrative function of an organisation (Weber, 2015). Importantly, the administrative function is rarely a single individual, but rather is spread across a network of actors, each with a limited and constrained domain of work. Adaptions to the administrative function can occur, but are often decisions made by committee, and so may involve labyrinthine processes to enable change. Change is also constrained by the foundational purpose of institutions, which should guide even the most senior leaders or institutional governing bodies, and by legislation or regulators that are typically designed as barriers to corruption or to uphold a certain level of service. Within this structure, the ‘ultimate’ source of power is obscured; responsibility is shared across different levels of the institution and sometimes beyond, but rarely sits with one individual or unit. The larger the organisation the more complex the administrative function and the greater the dispersal of power, which has benefits as well as limits (Byrkieflot and du Gay, 2012).

The bureaucratic function of institutions has been widely observed as a key reason why abuses are able to emerge and why they are so challenging to resolve. Institutional administrative functions are usually designed to enable their purpose, not to limit wrongdoing. This means that when complaints are raised, especially those with some complexity, there is no middle manager with responsibility for dealing with such an issue; instead, complaints move up, down and across without possibility of resolution. Complaints are effectively silenced through such processes as even as they are ‘heard’ by individuals (who might be deeply concerned or empathetic), there is no mechanism for them to be ‘heard’ by the institution (Ahmed, 2021) and so no possibility of redress. Moreover, as individual bureaucrats have little capacity to respond to complaint, the complainer comes to be situated as ‘the problem’, the embodiment of a concern that would otherwise disappear.

In modern institutions, where procedures for complaints are now institutionalised, solutions remain hampered by institutional structures, as redress for serious wrongs typically requires institutional reform that is delimited by the dispersal of power (Martin et al., 2021). At the extreme, the bureaucratisation of institutions has been used to explain very serious wrongs, such as the Holocaust. Here myriad intermediaries, between those that gave an order and the person who ultimately carried it out, enabled genocide. Their own role was limited and the possibility of resistance (even if desired) was restricted and ineffectual – this was the banality of evil, to use Hannah Arendt's (2006) phrase, carried out by ‘desk murderers’. The Ockenden Review was highly attuned to this issue, seeing as a key theme the need to improve complaints handling.

In more everyday situations, the bureaucratisation of institutions can produce a silo effect, whereby the worker disassociates from the institution's administrative function. Individuals and groups in particular work areas might then identify with each other, emphasising professional identity (e.g. as nurses), but not with the institution itself, or at least not in its current form. Groups associated with the administrative function, such as managers or human resources, become the symbolic manifestation of the institution, and typically its ‘wrongs’, even though the workers in such roles typically feel similarly to others about the administrative function of the institution and distance themselves from it. The splitting up of the institution into ‘workers’ and ‘managers’, who symbolise an administrative function, is a particular challenge for institutional change (Powell and Davies, 2016; Rieger, 2010).

Workers who identify with their own work groups build their own cultures and indeed social norms, rules and ideas of best practice within the institution. They can then be especially resistant to ideas and approaches promoted by the administrative function, which is treated with suspicion. This effect is exacerbated within institutions where such groups of workers have distinct professional identities, such as is found within medicine, law, universities or similar domains. Professional workers often undergo rigorous training that extends beyond workplace best practice to inhering a sense of vocation, professional identity, ethics, values and shared community (Barclay, 2021; Dill, 2012; Rieger, 2010). Association with a profession is reinforced across the working life course, as individuals maintain registrations, engage in new training, participate in professional organisations or unions, and otherwise maintain and inculcate others in their vocation. Professional identities compete with institutional identities, especially when institutions are home to multiple professions (as many are – from healthcare to religious institutions to universities), and reinforce worker silos when staff feel disconnected from their institution. Worker silos that are founded on professional identities are particularly robust to critique and slow to change, and their primary identification is rarely with an individual institution; rather, the institution is typically envisioned as a vehicle for the practice of their profession.

Care practices are also shaped by definitions, expectations and ideals within professional domains and these compete with those provided by the institution and other stakeholders of institutional care (including clients and the state) and the system of rewards and punishments put in place to enforce them. The latter means that even in a situation where an institution offered a transformational vision for care, its implementation would require negotiation not just with its own staff but with the professional bodies with whom its staff identified. Conversely, transformational visions offered by particular professions, such as potentially offered by a ‘continuity of care’ model within the midwifery profession (Homer et al., 2008), run up against the institution. Change is significant, laborious and slow.

We suggest that the nature of institutions – their scale and design for continuity, their bureaucratic function, and their relationship to professional fields – is a distinctive feature of their operation that is critical to any interpretation of care practices within them. Abuses and harms or just ‘missed care’ (Jones et al., 2015) struggle to find redress within bureaucratic systems, and even where mechanisms exist for hearing them, the structure of institutions limits reform. The bureaucratic shape of an institution is hard to restructure without dramatic intervention, and effective reforms are often hard to imagine within structures where very few people, if any, have global oversight of its operation. It is much easier to tweak their current shape than to transform them.

An important consequence of this is that institutions are not amenable to the solutions often presented to other types of organisation, particularly businesses, to enhance their practices. Many solutions provided in the organisational literature for transforming institutions, and which are often presented as solutions when failures of care occur, have little purchase. For example, the importance of a strong leader outlining a transformative and inspiring strategic vision, engaging middle management to implement it, and – sometimes through sheer force of personality – enabling ‘buy in’ from the wider workforce, is often considered critical. The structure of organisations, where the top leadership is often effectively invisible to many workers, is recognised as a problem, but here lower-level leaders are assumed to fill this need. There is little recognition that in institutions where power is dispersed, the institution itself is the location of value for workers (of their love, affection and admiration) and that the embodiment of the institution by leaders is often treated with significant scepticism and mistrust (Davis et al., 2016; Grover et al., 2011). Transformative accounts of institutions that are fundamentally designed to enable continuity are not only a hard vision to sell, but a threat to the institution in which people have invested.

‘Culture change’, another popular idea for enabling transformation, runs up against similar problems. The latter is recognised in organisational literature as especially hard, because old practices and values are difficult to unwedge, and here the importance of engaging staff in a process of co-creation of new values is sometimes posited as a solution (Bate, 1995; Boonstra, 2012). However, it is rarely considered that an organisation might be made up of different professionals with their own codes of conduct, systems of best practice and values, which compete with each other and with any designed by an institution. That different groups might have their own visions for the institution – and that there is no assumption that a current management team embodies or has the right to determine the direction of an institution – is rarely discussed. Notably, while many critical theorists have explored how ‘dysfunctional’ institutions nonetheless operate, and often very successfully (Price, 2017; Seibel, 2022), that distrust, dysfunction and banal bureaucratic impediments are features, and not always bugs, is rarely addressed when responses to an institution's failure to care are proposed.

The latter discussion becomes important to an exploration of caring practice in institutions because it provides a context for how institutions can come to disrupt or destroy care and why routine solutions to care's failures struggle to find purchase. Below we explore further how these processes have impacts on care within the particular case study of maternity services presented in the Ockenden Review. That such care, as well as the management strategies that surround it, is happening in institutions, however, cannot be lost sight of. Importantly, we argue that if the institution contributes to a failure of care, so do solutions that fail to recognise that care is happening within an institutional context and not just in a private business or other type of organisation.

Institutional failings in the Ockenden Review

In the typology of organisational culture developed by Quinn and Rohrbaugh (1983) and extensively applied by Hartnell et al. (2011), most healthcare institutions would be classified as ‘hierarchical’, with the foundational assumption of stability. Hierarchical institutionalisation is justified as ‘people behave appropriately when they have clear rules and procedures, formally defined by rules and regulations’ (Hartnell et al., 2011: Figure 2) and the dominant values shown by these organisations are routinisation, formalisation and communication. As is explored below, this is a dehumanised set of assumptions, beliefs and values and from this perspective it is possible to see why enacting emotions and caring is devalued and even thwarted.

The hierarchical culture of healthcare institutions has been reinforced under New Public Management and neoliberalism, approaches to managing public services that were designed to encourage greater accountability and transparency of expenditure, but which were typically accompanied by much higher levels of bureaucracy (Connell et al., 2009). For public institutions, neoliberalism has meant an emphasis on cost-cutting and efficiency, with ‘economic-operational’ management taking hold in hospitals (Exworthy and Halford, 1999; Levy et al., 2022). These socio-political changes have exacerbated the disconnect between the rationality of providing services and the relationality of care (Tronto, 2017) and, as the Ockenden Review highlights, have come to undermine the physical and affective dimensions of care within the modern institution.

The Ockenden Review aims to describe a failure of care and to proffer some recommendations for redress; in doing so, it provides evidence of the ways that the structure of hierarchical institutions typical in healthcare – their scale, bureaucratic function, and relation to professional fields – come to limit the possibilities of care. The report provides a picture of a service where failures of care operated at multiple levels, yet where the capacity of any individual to see the full picture was occluded – the scale of the organisation limited visibility.

Descriptions of the Hospital Trust repeatedly pointed to system failures, where complaints looped backwards without resolution. Staff interviews described a Trust that had been ‘stuck, basically, for about twenty years, unable to make any progress … trying to find a way through that log jam and come out the other side of it with a set of proposals that would make services less unsustainable’ (2:1.19); one noted that the nature of reporting processes meant ‘those concerns ended up going back to those we had concerns about’ (2:1.10); another thought that ‘[w]e struggled consistently to get information’ (2:1.38), leading to a situation where ‘the same things [adverse events] were happening over and over and over again’ (2:1.38). As one staff member concluded, ‘[i]t was a system wide failure … there didn’t seem to be the guidance, there didn’t seem to be the governance, there didn’t seem to be the process of challenge’ (2:1.39).

The Board itself acknowledged their failing here, noting that they put trust in ‘confident and very strong individuals where I didn’t have any reason to question that they would come to me if they had concerns’ (2:1.46); another noted, ‘at no stage did me, and this is my fault, but at no stage did I pick up that there was such a deep-seated problem in that service’ (2:1.46). Visibility was also hampered by a growing ‘us and them’ relationship between managers and staff, a problem heightened by the merger of trusts which moved managers offsite and so reduced the opportunity for ‘corridor conversations’ that were identified as useful for promoting rapid change, and by a high turnover in leadership, which was accompanied by a constant evolution in management strategy and approach.

Problems within the system were exacerbated by its bureaucratic structure and how professional identities were situated within it. The organisation clustered into discrete areas of operation that resisted external engagement and oversight: ‘There was a lot of cliques there, a lot of [nurse] managers were cliquey, … I think that the [higher level] managers, I think they are aware of the clique and I think they have tried to separate them but they’re so deeply ingrained into the system … the management's almost scared to get rid of them’ (2:1.36). Operating within cliques promoted a protectionist orientation and limited visibility, as did the professional identities that underpinned them (Rieger, 2010). Submissions from staff to the enquiry repeatedly grouped people by identity – staff versus management; nurses versus consultants: ‘my colleagues believe senior management … have been a barrier for change’ (2:1.56); ‘there were fallings out between the Band 7s and the consultants’ (2:1.55); ‘there wouldn’t be that communication from the [nurse] coordinator to the doctors’ (2:1.55). The institution fragmented and people found refuge with those with whom they shared a professional identity.

The result was that the institution produced an environment where the possibilities of care were reduced. Respondent after respondent pointed to this: ‘[t]here are some really good people who care immensely about what they do but operating in a system that is in crisis management continually, can have significant impact on the ability to maintain passion and compassion’ (2:1.27); ‘it's not about the people on the floor doing the work, it's the whole system behind it that isn’t always as helpful as it could be and that affects those people that are trying their best’ (2:1.37). A culture of crisis reduced the possibility of ‘compassion’; workplace structures had an impact on the capacity of individuals to do ‘their best’ (2:1.37). Staff – positioned as well-intentioned but structurally restrained from practising care – experienced this tension as a form of moral injury: ‘we were all just shell-shocked … I am angry and I am hurt and I’m angry because nobody has listened and I don’t believe the change has happened quick enough and I tried to explain that’ (2:1.62).

Despite the fact that the ‘system’ was overtly addressed within respondent testimony and implicit in many of the accounts of failed processes and procedures, the solutions posed by the Ockenden Review largely fail to address systematic change. Inasmuch as they do, it is through positing a ‘refresh’ of current bureaucratic systems: updated policies, particularly in relation to clinical practice. Rather the Review, with its forensic focus on patient safety and ability to pinpoint ‘root causes’ in this domain, has a limited appreciation of (and perhaps ability to comment on) frameworks for constructing the institutional environment, for understanding how culture is reproduced, and the resulting implications for staff psychosocial safety and capacity to care.

While the role of poor workplace culture is acknowledged, this appears to be seen as reflecting interpersonal relations, including those with superiors, rather than having structural origins in the institution: ‘[i]t is imperative to ensure the “culture” within all healthcare settings is one that promotes openness, transparency and the psychological safety to escalate concerns. Yet the review team found evidence of disempowerment, with staff encouraged not to complain or raise awareness of poor practice within both personal and professional capacities’ (2:5.70). Blame was placed on personal relationships between managers and staff, not bureaucratic structures and managerial regimes.

If a bureaucratic response could be easily imagined (as it is with many clinical failures), solutions were personalised; people were adapted to the system and effectively invisibilised through removing the behaviours that might draw attention to them. In a section headed ‘Teamwork, culture and incivility’ (2:64), the Ockenden Review notes that ‘rudeness and bullying’ are detrimental to a clinician's ‘performance and/or cognitive ability’ (here acknowledging a broader NHS campaign on the impacts of incivility) (2:5.56); it recognises a need to address incivility because of impacts on productivity, while consequences for hospital staff, in terms of emotion or well-being, are at best secondary. Importantly, in this construction, incivility is an individual behaviour rather than an expression of distress or resistance within a dysfunctional system and it requires individual-level instruction and correction. At the same time and in the same part of the report, individuals are said to need more training so that they can function interchangeably, reinforcing bureaucracy as a salve to cares failures.

The problem that emerges for care is twofold. First, the Ockenden Review largely fails to conceptualise how institutions produce the conditions of care, particularly in relation to its affective or emotional dimensions; and second, in positing bureaucratic solutions to affective problems, the Review's response contributes to a dehumanisation of the practices of care, which exacerbates the very failures it is trying to address. Staff, their relationships, connections and potential for compassion, are largely refused an existence. And yet, ironically, even as staff are asked to make themselves civil and interchangeable, they are also asked to make themselves heard, to draw attention to problems, to bring notice. That such behaviour might be incompatible with invisibilising oneself within a bureaucratic regime, and that this contradiction might underpin some of the current problems with hospital culture, goes unrecognised.

Given not only the inattention to staff feeling within such solutions but also their dehumanisation, it is not surprising that burnout is widespread among healthcare professionals. Burnout is usually defined as a state of physical and mental exhaustion produced by work, with symptoms including depersonalisation. Burnout is a response to job demands (Bakker et al., 2023), as reflected in workload and time pressure, but beyond that can be traced to structural forces in the healthcare workplace that produce ‘alienating conditions’ (Iliffe and Manthorpe, 2019) that do not allow clinical empathy to be practised, while reactions such as frustration or fear must be suppressed (Anzadula and Halpern, 2021). Burnout can thus be construed as a conflict between the values of the institution and the values of the healthcare worker (Maben et al., 2007) or a lack of recognition of a person's humanity (Baldissarri and Fourie, 2023). Institutional ecosystems profoundly shape the capacity to care, through denying relationality and opportunities to care, through creating moral conflicts that have embodied effects, and by asking staff to make themselves invisible within a system. All of these reduce an individual's capacity to provide care at work and instead promote detrimental health and well-being of staff.

Institutional responses to care failures

Institutional failures in care require institutional responses, and yet, as suggested above, many of the typical solutions proffered in relation to ‘culture change’ arise from a literature on large organisations (Schneider et al., 2013) that fails to address its institutional dimensions and lacks a ‘critical’ edge (Islam and Sanderson, 2022). The solution then may appear, as it does in the case of clinical care, to turn to improved policies and procedures, to enforce care through more robust bureaucratic structures (still along New Public Management lines). The risk here is that rather than opening up spaces for care, bureaucracy further dehumanises workers, diminishing their capacity to provide care. Institutions then are ‘stuck’ in what is now a well-recognised institutional problem: bureaucracy gives shape to life but simultaneously acts to squash certain forms of ‘passion’ that are held as critical to flourishing (for discussion, see Barclay, 2021). The question then arises as to how an institution might produce space for ‘life’ or ‘passion’ within its institutional structures.

One response here might be to attend to ‘emotion work’ as a form of labour that can be observed, measured and accounted for, demystifying the ‘caring for’ of the care worker and producing conditions for its accountability. That emotional labour is expected of certain categories of employees is now well described in the ethnographic (Hochschild, 1983, 2003) and nursing literature (Theodosius, 2008), and that it can be observed is suggestive of the ways that it can also be made space for within systems. Staff can be given time and workload to care; systems can be adapted to ensure that caring practice is appropriately enabled. Institutions can also be made more accountable to care. A number of tools to measure psychosocial safety in staff and clients are now available (Zadow and Dollard, 2016) and a ‘barometer’ for a ‘culture of care’ has been developed (Rafferty et al., 2017). Their proper deployment – where measurement is followed by redress of problems – requires a new kind of accountability within organisations, involving recognising care work as well as channels for reporting concerns and complaints, listening and responding. For institutions that have been characterised by complaints that circulate but lodge nowhere, this represents another important shift, with institutions less impervious to the emotional texture of workers’ daily experience. Measurement of feeling is not enough on its own; systems must be responsive and create conditions for being ‘cared for’ to emerge.

Such ideas seek to build a space for care – both by and of staff – into an institutional context, and we suggest doing so will be necessary for any institution that wishes to address this issue (possibly motivated by a need to retain staff, which has been a pressing issue for the health sector in the UK and elsewhere Iliffe and Manthorpe, 2019). However, and perhaps more significantly, for institutions to move towards a more radical form of care – one marked by abundance, generosity and recognition of the human – will require a more profound attention to and reform of institutional systems. Institutions need to make space for ‘passion’ – not simply the emotion work of care, but the ways that care requires recognition of humans in their diversity, space for the unexpected and inconvenient, and attention to the individual as an individual, and not just an anonymous worker. Institutions need to humanise themselves. To do this, they need to address problems of scale, the dispersal of power, and the multiplicity of identity that coexists within the institution and that shapes people's loyalties and affections. We suggest that the solutions to these problems will share a concern with attention and visibility; people need to be recognised by those in power, and those in power need to be empowered and accountable to perform a form of recognition that incorporates the possibility of redress.

There are a number of ways that such a visibilising can become possible within the institution, and exploring them is beyond the scope of this article. But we would note that within the context of maternity care, as well as greater resourcing, solutions will likely require a flattening of hierarchy that places greater accountability with multidisciplinary service teams, and enables a stronger sightline between different levels of governance; a reinvestment of power and its accompanying accountability in individual employees, rather than bureaucratic structures and metrics; and an appropriate acknowledgement of professional and other identities as part of institutional culture, such that the institution builds from and with its parts, rather than directs from the top. Change will require attention to the ‘system’ – to the institution and the ways it structurally produces, or limits, the possibility of care – and not simply hoping that the same system will produce a different result.

Conclusion

Reimagining and radicalising practices of care will require attention to be given to the institution as a key site of care in the contemporary world. As such, any account of care will need to look beyond an attention to interpersonal relationships to questions of scale – how do we provide radical care to large numbers of people – and to forms of care that require high levels of specialist training and support. Understanding the institution, how it works, supports or reduces flows of power, and produces cultures and emotional regimes will be central to this project. Using a close reading of the Ockenden Review, through an academic scholarship on the function of institutions and caring practices, this article has highlighted how key features of the operation of institutions – their scale, bureaucracies, and their competing professional identities – come to interfere in the capacity of individuals and groups to enable people to feel cared for, so any solutions that seek to enhance care require attending to the institution and the way it shapes the life of the institution. The example offered by the Ockenden Review, however, suggests that solutions will first require creating space for care in the institution, likely using the same bureaucratic structures that act as its lifeblood, but also a new visibility and space for individuals, their needs, relationships, and which recognises the humanity of the person, not just an abstracted service user or worker. New forms of accountability will be important here, with emotional practice recognised and valued, and reciprocity in terms of being cared for by the institution. Caring ‘for’ in the institution will involve more room for the human to flourish.