Why is it important and how can an unhelpful culture be identified?
Organisational culture is ‘how we do things round here’. It represents the collective values and beliefs of the people who work in the organisation and is influenced by its history, its primary task, key individuals, management strategy, external constraints and circumstances. It can be observed in how the organisation presents itself and the values behind it can be discerned through the behaviour and attitudes of individuals. Organisational culture runs deep and may not be explicit or even always consciously determined.
Often organisations are adept at ‘doing the right things’, ticking the boxes and setting out their values. What is less obvious is whether the hearts and minds of the people are fully behind the organisation – whether there is alignment around the values and whether the culture is one in which the right sorts of values can flourish and take root. In the NHS we are looking for organisational cultures that put patients first, promote trust, respect and equality and are sufficiently open and transparent such that staff feel able to challenge each other robustly, regardless of status, without fear and are encouraged to come forward when difficulties arise. The recently published report by Sir Robert Francis, following the Freedom to Speak Up Review1, puts organisational culture to the foreground as a key determinant in what creates safe health care systems. He noted specifically the need for a culture of openness and learning where all staff feel able to voice concerns. His evidence showed that the issue of bullying and a coercive culture was a frequent concern for the staff who gave evidence.
Merely stating that the organisation is committed to a set of values along the lines described doesn’t mean that they are the lived experience of the staff and patients. Francis also noted a disparity between espoused policies and the level of support given to staff. Many NHS trusts do have good programmes in place to embed values from board level to front line staff; induction, inset days, staff focus groups, regular communication, staff training and appraisal are all used to impart what the organisation stands for, what it aspires to and what it expects of its staff and these can be evaluated fairly reliably. What we are looking for is an organisational culture where what is explicitly stated tallies with what staff think and feel and that what lies behind the rhetoric is a genuine desire to live out the values rather than simply to pass inspections.
Unspoken rules and unconscious behaviour
At a surface level it is relatively easy to describe an organisation’s culture and it can be observed overtly in terms of the mission statement and what goes on the website, and more implicitly in the staff behaviours that they explicitly seek to inculcate. At its deeper level however, organisational culture is sometimes difficult to discern and even more difficult to change, precisely because it is hidden and may rely on unspoken rules. Many of these unspoken rules may exist without the conscious knowledge of the membership. Examples of this might be, ‘we don’t tell on our colleagues’; ‘we can’t challenge senior medical staff’, or perhaps there is a mutually understood sense of an in-group and an out-group. Schein describes theses as ‘tacit assumptions’, they are often unconscious and don’t show up in staff surveys or casual conversations, but can de-rail the best rational plans and strategy, they can be the source of paradox, resistance to change and conflict and can result in behaviours such as bullying and harassment, a high level of grievance, unexplained absence and high staff turnover. Francis advocates a zero tolerance approach to bullying. Understanding why bullying is happening – what may be behind it – is also vital.
A significant determinant of such unconscious behaviour is anxiety. Anxieties can stem from concerns about job status, pay, security, all of which affect self-worth. Anxiety is also associated with the particular job that people do, their role – and in the NHS many tasks are complex, difficult and involve intimate contact with patients or involve hearing about distressing things. There are also new requirements to merge and integrate services; this necessitates making new relationship across institutional boundaries and securing agreement in a competitive environment. There are currently unprecedented pressures on the NHS to make savings at the same time as improving services. All such pressures activate the unconscious aspects of organisational culture and irrational behaviour, counter to the values of the organisation, can follow. The implications of the Francis report are that staff need access to mediation, counselling, coaching and mentoring. We would strongly support this with the proviso that individual measures do not detract from the need to consider the cultural/ systemic implications when things go wrong.
Organisations need to be reliable containers for the emotions of their staff members; to create a context in which it is possible for staff to acknowledge the impact that the work is having and to feel listened to when their working situation becomes stressful or at worst, intolerable. They should provide opportunities for staff to feel valued and supported in the work that they do and, particularly for clinicians, promote a context where the complexities of clinical work can be openly grappled with, rather than closing down discussions or seeking premature solutions.
It is a truism that organisational culture starts with the board. A board that models open communication, trust and respect for its members, which pays attention to the quality of its working relationships and values these attributes is likely to promote behaviours that exemplify them in the workforce. Francis also refers to the importance of the involvement of the board of directors being closely involved in monitoring the organisation’s culture, supporting senior managers particularly in handling concerns.
So how can we identify an organisational culture that is likely to promote the values of today’s NHS? Paying attention to the following 5 points can help.
- Do employees at all levels know what the values of the organisation are, do they believe in them and believe that the organisation is truly committed rather than just engaging in ‘corporate-speak’? Staff should be able to evidence ways in which values were being expressed in the behaviour of managers and senior staff, team leaders and front line staff. This requires digging down through individual conversations – where there is high degree of distrust and where tacit assumptions prevail, staff are not likely to be open about their fears and anxieties.
- Is there a culture of reflective practice? We know that the work that both clinical and non-clinical healthcare staff have to do can have a profound emotional impact at a personal level and a great deal of emotional effort in healthcare goes into managing feelings – one’s own and those of patients and relatives. If staff are not able to give expression to this it can have a seriously detrimental impact. At its mildest staff become overwhelmed and may deal with this by being short tempered or going off sick, at its worst it can find expression in abusive behaviour or turning a blind eye to unacceptable practices. Being encouraged and able to speak about their experience, preferably in a structured way in supervision or in a group can allow staff to understand and contain their own emotional responses. A culture that values reflection practice would prioritise clinical supervision and explicitly support staff at all levels. Senior managers would have coaching available to support them in their roles. Sir Robert Francis stresses the importance of staff having time to explore issues and share good practice. We would suggest that this also includes some opportunity to debrief about the emotional experience of the work.
- Is trust evident throughout the organisation from board level to front line staff? This would be demonstrated by staff describing their presentations to the board as open discussions to interested colleagues rather than a ‘grilling’. It would be apparent in team meetings where difficult clinical material can be grappled with collectively, where everyone’s opinion could be heard. Teams will experience their colleagues and managers as supportive, loyal, ‘having their backs’. Individuals would report feeling that their views count and are valued. Trust requires attention paid to the quality of relationships. It should not be acceptable for senior staff to ‘snap’ at junior colleagues. Disciplinary differences need to be understood and respected for true cooperation and collaboration. There is a human tendency to ‘split off’ bad things and associate them with another group/team/race etc. In healthcare splitting off difficult feelings or behaviour and locating them in another group is often a way of dealing with what is complex and challenging about the work. It is as though staff are saying ‘we’re ok, it’s that other team/ hospital where all the poor care happens’. Unless staff can be helped to take a collective responsibility and recognise that we are all part of the health system, patient care will inevitably suffer.
- Related to the notion of trust is whether or not it is acceptable to get things wrong and learn from mistakes. It must be ok for staff to say they don’t know something and to be able to ask. This relies on a culture of containment as described above, where staff feel able to give their perspective without fear of looking stupid or not knowing. Do staff feel able to challenge their senior colleagues? If not why not, what is the fear behind this?
- Clarity of roles and task. Is the organisational structure one that is designed around the task it is intended to support? Too often team structures have grown up around individual personalities and avoidance of long-standing differences, which makes collaboration and integration of services very difficult. Historic mergers between services (or even whole trusts) that have never been accomplished completely can result in unclear lines of accountability and responsibility. Are staff clear about their role, its limits, their accountability and their responsibilities? Whenever staff do not feel fully authorised in their roles or where there is a lack of clarity they may resort to anxiety-driven behaviour. Staff need to be given honest and direct feedback about the impact of their behaviour on others. This is neither easy to do nor easy to hear and organisations may need help in establishing robust reflexive systems.
It will be evident from the above that while the indications of a culture that can be detrimental or one that could sabotage good intentions may be observed in the behaviour of individuals or from individual narratives, we are talking about a systemic phenomenon. Francis identified the need for a system-wide approach to addressing the issue, including systems of feedback. Unacceptable behaviour, staff burnout, near misses, ‘never incidents’ are symptoms of a cultural failure and should be considered as indicators of such. Of course there may be examples of individual failings at the centre of some tragic cases, but more often than not there is a systemic failure. Staff do not come into the NHS to be negligent, brutal or uncaring to patients. Something happens to some of them, they become inculcated. Identifying the aspects of an organisation’s culture that has the potential to lead harmful behaviour is crucial. What follows from Francis’ recommendations is that NHS organisations are encouraged and supported to develop a reflexive ethos where the nature of ‘how we do things round here’ can be thought about in depth, openly and honestly.
1Freedom to speak up review report. An independent review into creating an open and honest reporting culture in the NHS. Sir Robert Francis February 2015. freedomtospeakup.org.uk