research organisational culture nhs

Measuring and Assessing Healthcare Organisational Culture in the England's National Health Service: A Snapshot of Current Tools and Tool Use

Affiliations.

• 1 School of Health and Life Sciences, Teesside University, Middlesbrough TS1 3BX, UK. [email protected].
• 2 School of Health and Life Sciences, Teesside University, Middlesbrough TS1 3BX, UK. [email protected].
• 3 Teesside Centre for Evidence-Informed Practice: A JBI Centre of Excellence Middlesbrough TS1 3BX, UK. [email protected].
• 4 NHS Calderdale Clinical Commissioning Group, Halifax HX3 5AX, UK. [email protected].
• 5 Cardiac Intensive Care, South Tees NHS Foundation Trust, Middlesbrough TS4 3BW, UK. [email protected].
• PMID: 31683839
• PMCID: PMC6955975
• DOI: 10.3390/healthcare7040127

Healthcare Organisational Culture (OC) is a major contributing factor in serious failings in healthcare delivery. Despite an increased awareness of the impact that OC is having on patient care, there is no universally accepted way to measure culture in practice. This study was undertaken to provide a snapshot as to how the English National Health Service (NHS) is currently measuring culture. Although the study is based in England, the findings have potential to influence the measurement of healthcare OC internationally. An online survey was sent to 234 NHS hospital trusts, with a response rate of 35%. Respondents who completed the online survey, on behalf of their representative organisations, were senior clinical governance leaders. The findings demonstrate that the majority of organisations, that responded, were actively measuring culture. Significantly, a wide variety of tools were in use, with variable levels of satisfaction and success. The majority of tools had a focus on patient safety, not on understanding the determining factors which impact upon healthcare OC. This paper reports the tools currently used by the respondents. It highlights that there are deficits in these tools that need to be addressed, so that organisations can interpret their own culture in a standardised, evidence-based way.

Keywords: NHS; clinical governance; defining culture; healthcare culture; measuring culture; organisational culture; patient safety culture; patient safety measurement.

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• v.7; Jan-Dec 2020

Developing a Workplace-Based Learning Culture in the NHS: Aspirations and Challenges

Suzanne gawne.

1 East Lancashire Hospitals NHS Trust, Blackburn, UK

Rebecca Fish

2 Lancaster Medical School, Lancaster University, UK

Laura Machin

Background:.

The delivery of patient care in the United Kingdom is under increasing financial pressure. The need to continuously improve service delivery while making financial savings is challenging. Alongside this, National Health Service (NHS) Trusts must provide a suitable educational environment that meets the needs of all learners while meeting performance standards and targets set by external regulating authorities. This research addresses the gap in literature concerning educational culture in the NHS.

This case study examines the delivery of postgraduate medical education in the workplace. Semi-structured interviews were conducted with 6 lead educators in the Medical Division of a North West NHS Trust to glean their insights into what works and what needs to change.

A thematic analysis of the transcripts revealed a number of factors that facilitated and hindered educational opportunities for doctors in training, including the role of leadership, the demands of external regulatory authorities, and the pressures on frontline staff to deliver safe, personal, and effective care.

Conclusion:

Opportunities for developing a collaborative approach between educational and clinical leaders and the individuals delivering education in the workplace to enhance the educational environment are discussed. Finally, an evaluatory toolkit based on the themes emerging from the data is proposed, as a resource for other health care organisations to help improve the delivery of workplace-based medical education.

Introduction

Health care providers must demonstrate that they are continually improving and streamlining service delivery and meeting targets, while not compromising the educational environment for doctors in training. The faculty guide produced by the UK National Association of Clinical Tutors was introduced to stimulate discussion on how to deliver work-based training while providing a high-quality service with safe patient care. 1 The guide acknowledges the role of workplace culture in ensuring that health care workers feel valued as members of their multiprofessional team; and advises that learning is maximised when all members of the clinical team contribute collectively to ‘ observing performance, advising, teaching, giving feedback and encouraging discussion ’. 1 (p2) Guidance from the General Medical Council 2 encourages a similar collaborative approach for ensuring quality education in the workplace.

However, there remains a dearth of literature considering educational culture within the National Health Service (NHS), in particular examining the delivery of medical education while providing safe effective patient care. 3 - 5 For doctors in training, it has been shown that their ability to understand information is more readily developed when explained within the relevant clinical context. 6 - 8 Yet, internationally, barriers to workplace learning have been identified, such as heavy workload, 9 lack of respect for trainees, 10 and unsupportive management, 11 as well as dealing with unforeseen events and difficult circumstances. 12 It is therefore essential that insights around workplace learning within the wider context of learning culture and educational leadership are gained from UK settings to contribute to the growing body of literature in this field.

In this article, we examine the delivery of medical education within a Medical Division in a North West of England Hospital Trust. We identify factors that facilitate and hinder education when patient care is paramount. Our findings hold relevance for other NHS Trusts balancing the delivery of safe and effective care and meeting clinical targets, whilst providing an educational environment that meets the needs of doctors in training.

Semi-structured interviews were conducted to enable the interviewer (first author, S.G.) to probe and challenge opinions and thoughts, to gain a deeper understanding of the workplace educational culture. Ethical approval was obtained from Edge Hill University Faculty of Health and Social Care Research Ethics Committee, with additional approval from the Research and Development Unit at the Trust where the research took place.

Participants were purposively recruited from the Medical Directorate of a large NHS Foundation Trust in the North West of England. Each participant was provided with an information sheet stating that participation was voluntary and that their interview would be recorded and transcribed with their permission. They were informed that their data would be anonymised on transcription, and their identity would be kept confidential. A pilot interview was conducted and transcribed as a way to inform future interview questions. The data from the pilot were not included in the data set reported here.

The research questions for the study were to identify the models of medical education that were operationalised in the workplace and to explore how effective they were perceived to be by staff. An initial interview guide was developed based on the work by Markiewicz and West 13 who suggest key characteristics for effective team working, including team identity and objectives, role clarity, processes, and leadership. These characteristics were used as areas of enquiry when investigating the structure and delivery of medical education within the specialty. The interview guide included questions such as the following:

• Are you able to identify the leaders for medical education in the workplace?
• Are there clear objectives for the provision of medical education in the workplace?
• Do you think the educational environment in the workplace is where it should be?
• What are the barriers? What is working well?

Interviews lasted between 30 and 60 minutes and were conducted in a private area of the participant’s workplace.

Interviewer

The interviewer and first author was a consultant with a role in medical education at the research site during this time. The research team recognised the potential issues with interviewing colleagues and possibility of bias, however concluded that the benefits of insider knowledge outweighed the risks. Trowler 14 discusses the benefits of an ‘insider’ researcher being ‘culturally literate’ to produce meaningful accounts, leading to a better chance of impacting the field. Being part of the Trust and with experience of medical education in the Trust advantaged the study; the interviewer had the knowledge to structure the interview and ensure it remained focused on the issues at hand. The case study design of this research precludes requirement for objectivity.

Sample group

Purposive sampling was undertaken by interviewing a selection of people who were in or had recently been in educational leadership roles within the Division of Medicine. Participants were invited to take part via direct e-mail. Although many potential informants did not reply to the e-mail and others did not have time to be involved in the research, 6 participants agreed to be interviewed: 2 educational supervisors, 3 educational leads, and a Trust Director. Four participants were men and 2 women. The research team decided that this purposive sample of key personnel was sufficient for the case study design of the project.

As this work was designed to be reported in case study form, and the sample was purposive involving key personnel, this influenced and determined sample size and analysis; therefore, saturation was not achieved. The team met to discuss the analysis and visited the broad themes repeatedly in an iterative process to code and modify groupings of themes and develop subthemes with each reading of the transcripts. 15 This resulted in subsequent revision of the generated themes on a number of occasions until the data had been rigorously explored and consensus was met. Three ‘umbrella’ themes were identified in the data: delivery of education in the workplace, leadership in medical education, and learning culture, which we will discuss in the next section along with their subthemes (see Table 1 ).

Themes and subthemes.

The following section will explore each analytical theme, providing representative quotes for illustration.

Of the 3 global themes that were identified in the data, the first global theme – delivery of education in the workplace – encompassed a number of subthemes that focused on the barriers to delivering quality education. The second global theme – leadership in medical education – focused on the relevance of leadership to these barriers. The third global theme – learning culture – explored aspirations for developing an integrated culture of education. For each subtheme, we provide representative quotes from the transcripts.

Major theme: delivery of education in the workplace

This theme encompassed the perceived barriers to the delivery of education day-to-day.

Supervisor selection

Participants suggested that not all consultants have an interest in education, and recommended reserving lead educational roles for those who are more engaged. They suggested that the role of educational supervisor should not necessarily be expected of all consultants as is tradition:

I would have a smaller number of consultants with more trainees, each adequately timed. Some people who have a bigger interest in medical education could take on more trainees and do a better job. (P1)

Other participants acknowledged the difficulty in expecting all consultants to deliver education, when combined with high-pressure clinical commitments:

Where it is very busy it is hard to get everyone to deliver education unless they are interested in doing that. Some of them are just interested in doing their ward round quickly. (P6)

Despite all participants advocating that everyone in the workplace should be contributing to a culture that promotes education, some interviewees suggested that perhaps the more formal aspects of supervision should be reserved for those with an interest in it and who perform better based on feedback from learners. In return, participants argued there should be more recognition for the educational role on behalf of senior leaders.

Valuing educators and trainees

All participants reported that educators felt undervalued in their role. There was a general feeling that colleagues were ‘ worn down ’ (P4), had low morale, and lacked motivation to improve things, as one participant explained:

If I’m honest I think that there is no shortage of people waiting to tell you how rubbish you are. (P6)

Indeed, some participants noted that trainees are occasionally not valued, for example:

Sometimes I look at trainees and wonder why on earth they put up with all this! (P4) They are our future colleagues, and sometimes they are seen as just filling a gap in the rota. (P2)

All participants discussed the importance of respecting trainees and of appreciating what they had to offer:

A lot of it comes down to how you view and treat the trainees. And how you respect them. It’s about nurturing the talent. Actually, these are really special people and if we nurture them they will fly. (P2)

Participants commented on how trainees should be recognised for their achievements while valuing their talent and helping them to fulfil their potential. The tone of the discussions centred around individualising education for trainees; participants emphasised the importance of getting to know trainees and acknowledge their individual needs and strengths: ‘ Give them responsibility! Let them learn! ’ (P4). Participants stressed that when trainees are valued and considered part of the team, the hospital benefits - trainees are more likely to consider future training and substantive posts, which in turn can help improve the motivation and morale of supervisors to better the educational climate of the workplace.

Some participants reported that the current workforce was under-resourced to deal with the levels of service required while also giving time to educate doctors in training. Participants claimed there simply was insufficient people in the workplace to deliver this level of input, for example:

We try to do our best as consultants. We discuss this issue every time in our governance meeting. And everyone is trying to do their best. We are a very busy unit and it’s not always available. So really, just very rarely we do not give education if we are very busy and we are under pressure to discharge the patients as soon as possible. (P5)

However, there was a general acceptance among participants that improving patient care would improve the educational climate and vice versa:

I think that the two do marry up – those that are providing the best education also provide the best clinical care. (P1)

Further to this, some participants suggested that the specialties that struggled with the educational climate were also challenged with providing patient care, and also found staff recruitment problematic.

Job planning

When participants discussed pressures on their time, the topic of job planning arose. Most participants felt that their job plan did not accurately represent what they did and that the process of job planning was not robust:

It could be job planned. If they can just take into account teaching delivery during the ward round then we need more time. To be honest, we can’t do proper teaching delivery with the amount of work we have to do during the morning. (P5)

This participant proposed that a reduced clinical load was necessary so that job planning could include time for educational responsibilities:

We should job plan. If it’s training, instead of seeing 10 patients, you see 7 patients. Lists need job planning. Because money comes from the trainees and it’s part of our core business. (P4)

This was connected to the notion that hospital Trusts should ‘ make it rewarding ’ (P4) to have trainees, rather than an expectation.

Major theme: leadership in medical education

This theme encompassed discussion about the delivery of education in terms of forms of leadership and how this influenced the educational culture of the organisation in different ways.

Leadership engagement

Some participants perceived that senior clinical managers were uninterested in the delivery of education and the impact that pressures of service delivery had on the experience for learners:

The perception that the senior managers within medicine give around education is that they’re not interested. And actually, perception is an awful lot of what happens in education. There are lots of things that cannot be recorded, cannot be measured, it comes down to little things that maintain people’s motivation. And so people may think, well actually if the leadership can’t be bothered why should I? (P1)

Clinical leadership structures were sometimes presented as disengaged from the delivery of education in the workplace. In addition, despite participants claiming to try and bring attention to the importance of education, this was not perceived to have been acted upon.

Some of the participants commented that educationalists feel they have no ‘power’ with middle management to make changes and that senior management should address this:

I think the Medical Director, or someone with equal credibility, should be saying to these Divisional Directors, ‘Postgraduate education is just as important as patient safety. Put it at the top of your agenda. And let’s see something happening about it’. (P3)

The issue of ‘power’ was raised by the participants as a barrier to being able to deliver medical education, with some commenting that the barrier seemed to lie within middle management. There seemed to be a general consensus that there was support for medical education from ‘the top’ and a willingness from ‘the bottom’, but that somewhere in the middle there were problems with trying to make change. The power disparity was perceived to lie in favour of clinical management, who were not always aligned to the strategy for delivery of education.

Measures and feedback

Participants felt that feedback and ‘intel’ from surveys were not always understood by clinical teams, as this quote shows:

I actually don’t know why they are collecting numbers. To see how much time we put in maybe? To see whether the money should flow to the right people? I’ve no idea! (P3)

However, positive feedback was well received, for example:

. . . just recently feedback that I think we are doing well. We are improving. We are in all areas of the teaching in the green area, for the ward rounds and support for the trainees, we are doing well I think. (P5)

There was some discussion about the importance of constructive feedback, and some participants recommended that this be given in the form of a framework:

Doctors are competitive people – they don’t want to be below the level. I think [giving constructive feedback], yes it does raise standards. Give them a framework about what we need you to deliver as a minimum and then build on it. And I think that’s different from the feedback [we got] that was just negative. (P2)

All participants claimed that everyone within a trust should acknowledge and be realistic about areas for improvement that can be addressed. This theme highlights the importance of communicating the reasons for collecting metrics, as participants suggested that current methods of dissemination of feedback may be misunderstood or indeed not reach their target audience. However, this must be undertaken in a supportive manner.

Clinical targets

A common view by all was that the priority for attaining clinical targets on behalf of mangers took precedence over any requirements to deliver education:

There are huge pressures around the 4 hour waits . . . They are more of a priority, as if we are having issues around beds, we will not get where we need to be as a Trust. So day-to-day, that is a measure we need to achieve. (P1)

Participants also mentioned the time pressures that they are under:

My clinics are all overbooked. It would certainly help improve the teaching and learning experience if I could have less on a clinic when there are trainees there but I wouldn’t be allowed by management. (P3)

Participants claimed that clinical targets are more easily measurable and have attracted bigger sanctions if they are not met and therefore take priority over education.

Major theme: learning culture

There was much discussion about the need to develop a learning culture throughout the organisation – that it should be integral to everything and not a separate entity.

Integrating teaching into working practices

There was a concern that the delivery of medical education was not integrated into working practices. There was agreement among all participants that medical education should be continuous and perpetual, and should not be a separate entity to providing patient care, for example:

There are educational opportunities that take place all the time. And I think it just often needs a complete change in attitude. It shouldn’t be, ‘Right I’m doing a business round today, I’m not going to teach’, it’s a fundamental part of everything we do. (P1)

Another participant reflected on their own practice, demonstrating how small changes in working can result in education becoming second nature:

It just takes a different brain space. And there is a little bit of investing to do. Because if you just give that little bit of investment, then the next time you are on the ward round, actually all of those things will have happened because the trainees will understand why. So, I do think there is a little bit of a culture change that is required. (P2)

All participants highlighted the importance of integrating teaching and learning opportunities into the working day so that they become integral to clinical practice. This participant described the significance of the responsibilities involved with combining teaching with clinical work:

[We need to be] passionate, interested, giving feedback in a constructive way, creating that environment so that [the trainees] feel comfortable. There’s something comfortable about raising concerns and making mistakes and admitting to them. The human stuff about being with someone and learning – it’s constructive and it’s relevant and meaningful. A lot of it is intuitive. (P2)

Shared vision for education

Some participants discussed the organisational culture, stating that there needs to be a shared vision for education across the Division of Medicine:

I think it needs to come from the very top of the organisation. You just need the right people in the right places to say this matters. This matters. Do it! (P4)

All participants therefore expressed a need for a change in leadership culture when considering the delivery of education in the workplace, arguing that it needs to be considered as much of a priority as achieving clinical targets.

The findings from this study describe a system lacking in cohesiveness, where staff felt unsupported to deliver workplace-based medical education. There appeared to be a resistance to moving to a culture whereby education was intrinsic to working practice, and this was often attributed to a lack of time. This study has shown that there are many factors that hinder the development of an educational or learning culture, many of which are based on the attitudes and values of management and clinical and non-clinical frontline staff. The literature features a number of suggestions about how to address these barriers, including putting aside time and resources for team building and work-based learning. 10 , 16 - 19 Of particular note is Clarke’s 20 work which presents a comprehensive overview of possible solutions to these barriers, including recognising the role of the learner.

We argue that the development of a learning culture is key here. We would define learning culture as a supportive environment within which all staff members can talk freely about concerns and how to solve them, without fear of blame or punishment. A supportive learning environment is safe, fosters collaboration, values the contributions of individuals, and is based on mutual respect.

Fostering a supportive environment, one that ‘ motivates learning through cooperation, considers individuals’ needs, and encourages participation in problem solving ’, 21 is one of the key roles in educational leadership. We argue that leadership throughout the organisation can influence this type of culture; a leader who acknowledges good work and considers the suggestions of employees is key to making this difference. Good leadership encourages employees to collaborate with other team members, and enables employees to provide the best care for patients while learning from errors. 16 , 22 , 23 Therefore, it is clear that supportive, collaborative leadership is likely to enhance learning culture while dissuading punitive culture.

In the present study, leadership was an issue – there was a perception that middle managers had more ‘power’ than educational leads, and the actions of supervisors were subject to managers’ approvals. There was a general sense of feeling undervalued and stressed due to tension with clinical commitments, and feeling disengaged from management with no shared vision. It seems therefore that the perceived dominant leadership behaviours within the division were more transactional in nature and that collaborative leadership was required to facilitate change. There was a palpable ‘them and us’ attitude from those interviewed as identified by Rose 24 in his report on leadership within the NHS. His observation of doctors and nurses positioning themselves in opposition to management is evident here, but in contrast it would seem that the doctors in this study felt that managers placed themselves in opposition to them. This seemed to stem from a perceived difference in values between educationalists and clinical managers, which resulted in a lack of common ground.

The participants described variable attitudes to education among medical and non-clinical staff and therefore a lack of a shared vision for educational delivery. Developing a culture of education integral to service delivery requires engagement from all stakeholders and collaboration between the clinical and educational leadership frameworks. People must feel valued and supported. Ideas and solutions must come from the frontline, and to do this they must be listened to and acted upon. 4 We argue that Trusts must develop a culture that appreciates the importance of the educational environment and one that promotes opportunities for learning in addition to patient outcomes and targets. Undertaking the necessary number of workplace-based assessments and educational meetings is mandatory, but more emphasis must be placed on the value of training, and this requires educational leaders. The work undertaken by Alimo-Metcalfe and Alban-Metcalfe 25 recognises the importance of leadership in this balance and suggests the two should ‘augment’ each other: ‘ Valuing staff but not clarifying objectives and priorities is not effective; neither is showing concern while not dealing openly with performance problems and giving high-quality behavioural feedback ’. 25 (p53) They conclude that the most important role of leaders in the NHS is engaging staff in developing and achieving a shared vision in a supportive environment.

Taking this into account, and in agreement with Stoller, 26 we therefore argue that a focus on leadership is key to a change in educational culture. In this respect, James 27 discusses the need for NHS Trusts to move towards collaborative leadership. She suggests that effective leadership in the NHS requires people in both formal and informal roles working collaboratively across organisations and professional boundaries, at different levels within the organisation. The focus should move away from individual and personal leadership skills to ‘ organisational relations, connectedness, interventions and changing organisational practices and processes ’ 27 (p6) and importantly, ‘ the key is learning with others, in and for the specific organisational context ’. 27 (p13) Rose 24 (p30) made a number of recommendations in his review of leadership in the NHS, including the need for improved leadership training and opportunities for all NHS employers. Changes in leadership approach can be achieved using training, as demonstrated by Steinert et al. 28 They reviewed the literature to consider the impact faculty development schemes (promoting leadership in medical education) have on individuals and the organisation, finding consistently positive changes in faculty leadership capability and leadership styles as a result of training. 28

McKimm and Swanwick 3 (p434) specifically discuss educational leadership and its place within NHS organisations:

If we are to develop a healthcare workforce capable of delivering high-quality services, then we will need to develop excellence in healthcare education, and this in turn will require educational leaders at all levels who can manage as well as lead and who can work effectively and collaboratively across boundaries.

They discuss how little theory and research there is in relation to leadership in the context of clinical education. In addition, Sholl et al 4 have identified a lack of literature pertaining to the delivery of medical education while delivering safe effective patient care.

McKimm (2004, cited in McKimm and Swanwick 3 ) interviewed 100 leaders in medical and health care education and identified common issues and challenges for educational leaders. Common to both studies is that those interviewed identified the difficulties of working in a rapidly changing NHS and the tensions between ‘ the dual demands of higher education and the NHS – a “ crowded stage ” with multiple task masters ’. 3 (p433)

Acknowledging the possible limitations due to the status of the interviewer within the research site, as well as focusing on a small sample of participants within a single NHS Trust, we argue that this study highlights important and relevant issues relating to the delivery of education and how this relates to leadership structures. Along with others, 4 we recommend further research that evaluates health care educational interventions to better understand what works for whom, under what circumstances and why, and how this can contribute to a change in culture of a workplace. We have also identified the need for future research that explores the perceived distinction between service and teaching, which specifically focuses on challenging these perceptions. Finally, we call for further research to compare NHS education leadership with models in other health care providers.

In response to the gap in literature considering the barriers to the delivery of workplace-based education in the NHS, we have drawn on faculty staff’s perspectives to show the aspirations and barriers involved with shaping a learning culture. We have argued that leadership is key to addressing many of these barriers 12 and propose further research focusing on leadership and educational change.

Once armed with an overview of issues impacting the delivery of education and a supportive learning environment, interventions can be developed to address them. To this end, we propose a toolkit ( Table 2 ) that can support NHS Trusts to identify areas to address within their workplace, with suggestions on how to tackle them. This toolkit was created by the research team as a response to the themes arising from the analysis and should be used as a supplement to Health Education England’s Supervision Standards for Postgraduate Doctors in Training. 29

Evaluatory toolkit.

Abbreviations: GMC, General Medical Council; HEE, Health Education England; NACT, National Association of Clinical Tutors.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the East Lancashire Hospitals NHS Trust.

Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Author Contributions: SG – designed the study, submitted ethics application, peformed primary literature search, performed primary data analysis, drafted and edited paper. RF – secondary literature search, contributed to data analysis, redrafted and edited paper. LM – contributed to literature review and data analysis, contributed to redrafting and editing paper

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• NHS culture change is...

NHS culture change is difficult, not impossible—but essential, says health ombudsman

• Related content
• Peer review

A toxic culture of defensiveness and hostility pervades the NHS, and despite many patient safety reviews nothing has fundamentally changed, Rob Behrens tells Abi Rimmer

Early on in his career as a civil servant, Rob Behrens, now the parliamentary and health service ombudsman, was sent by the UK government to South Africa, to work on the transformation from apartheid to democracy. “People in Britain used to say what they had to do was hard. I would come back from South Africa and say, ‘You don’t know you’re born.’”

It’s an anecdote he uses when talking about culture change in the NHS. Although change might be difficult, it is not impossible, and it is something that needs to happen, says Behrens, whose role is to adjudicate independently on complaints that have not been resolved by the NHS in England and UK government departments.

“There is huge professionalism and commitment throughout the NHS. It’s been through the mill in a way that no other institution has—because of covid, strikes, and shortages of staff,” he says. “But unless we call everyone together to have a conversation about the emerging problems around the suboptimal culture in the NHS, then we will miss a big opportunity.”

Behrens was appointed to his current role in 2017, having previously worked investigating allegations of public service failure in the legal and higher education sectors. During his six years as parliamentary and health service ombudsman, a non-governmental role, he has seen many investigations and reviews into poor care in the NHS. He has, however, seen little change.

“We’ve had a lot of inquiries into leadership, distressing events, and organisational cultures but the fact is nothing has fundamentally changed,” Behrens says. “I understand that everyone has a massively busy job, that ministers, managers, and clinicians are doing the best that they can. But that doesn’t alter the fact that there are things that are fundamentally wrong that need to be tackled.”

Depressingly little learning

It’s not just his own learning that Behrens is reflecting on. He says that Bill Kirkup, a public health doctor with a specialty in obstetrics who led reviews into maternity services at the University Hospitals of Morecambe Bay NHS Foundation Trust (published in 2015) and East Kent Hospitals University NHS Foundation Trust (2022), had similar observations. 1 2

“When he reported on East Kent, Bill Kirkup said that what depressed him was how little learning there had been from the first time he looked at these matters,” Behrens says. “Secondly, he said this is multifaceted—it’s not just about managers and clinicians, it’s about tribalism among clinicians themselves.

“Thirdly, it’s a failure to listen to patients and their families. That adds up to a toxic culture, which we need to talk about so that we get the one thing that makes an organisation effective: a disposition to learn rather than just to move on.”

Staff are victims too

As well as describing the culture in some parts of the NHS as toxic, Behrens says it is suboptimal, hostile, and defensive. “This leads to a perception that organisational reputation and professional reputation are more important than patient safety. And that is very dangerous.”

It is not just patients who suffer from such a culture, staff are victims, too, he says. “It’s not that they’re sitting there twiddling their thumbs. This is an enormously difficult climate in which to work and to tackle difficult problems.”

Medical education has a role to play in improving this culture, Behrens says, especially when it comes to relationships between doctors and patients. He has heard doctors say that their education was based on the premise that they had to stand by their decisions and not “back off just because people don’t like them.”

“First of all, that says that medical education is very important to the disposition of people, even before they get into senior positions,” Behrens says. “Secondly, it says there’s an implied arrogance that results from that education that stops communication between doctors and their patients. It’s not just about what you do in the NHS, it’s also about the education of people before they get there.”

He says there is now a “golden opportunity” to think more radically about staff development and to link it to accountability and performance. “We should be spending more on the professional development of clinicians and managers in the NHS in a way that enables them to respond to the need to change the culture of their organisation. I think that’s very important.”

Focusing on managers, Behrens stops short of calling for their regulation, but he does support calls for more accountability. “The impression that one gets is that people move from job to job as senior managers without their performance being scrutinised. That needs to be carefully looked at.”

Leaders at all levels

While it would be easy to lay the blame for cultural problems in the NHS at the door of politicians or leaders of national NHS organisations, Behrens says it is not so simple.

“You have to have leaders at all levels throughout the NHS. You can’t just say this is about ministers and trust boards, it goes right the way through. I know from the visits I have made [to organisations] that if you have a powerful, compassionate person leading a ward, for example, that makes a significant difference to the morale and the disposition of people working there.”

The power of good leadership is a point that he emphasises repeatedly. “People say culture changes from the top. Well, that’s true, but you can’t change the culture unless you have buy-in from people,” Behrens says.

He adds, “The key thing about leadership is empowering the people who work for you to do the things that need to be done. You can’t do it on your own. You can’t be a general without an army. You have to make sure that your people are with you, whether it’s at a ministerial level, at NHS England level, or at a GP surgery level.”

“Bunker-ism”

Within his own world of ombudsmen, Behrens has introduced peer review, something he thinks the NHS could benefit from. “We now have, through the International Ombudsman Institute, a group of validated reviewers who are ombudsmen in other countries who, if they are asked, come for a short period of time to review one of their sister institutions and then write a report on what they found.

“It doesn’t solve the problem, but it provides a perspective of learning and drawing on the expertise of your colleagues. I don’t always see that in the NHS because there’s an element of bunker-ism about it.”

Behrens, who is coming to the end of his time in the role, has called for a thorough, independent review of NHS leadership, accountability, and culture. He reissued this call in the wake of the case of Lucy Letby, the neonatal nurse convicted this summer of the murder of seven babies at the Countess of Chester Hospital, but he says the culture of fear and defensiveness that the case highlighted is not isolated to one organisation.

“We have to be less defensive, and we have to be more collaborative. It’s not easy, but it’s not impossible. Surely, after Chester, after [other NHS patient safety scandals] Birmingham, Bristol, Shrewsbury, East Kent, Essex, there needs to be a systemic reflection on what this means for the culture of the NHS.

“It doesn’t matter what you call it, but the thinking has to take place. The debate has to take place.”

• ↵ Kirkup B. The report of the Morecambe Bay investigation. 2015. https://assets.publishing.service.gov.uk/media/5a7f3d7240f0b62305b85efb/47487_MBI_Accessible_v0.1.pdf

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Organisational culture: problem-sensing and comfort seeking

You can view this chapter as as PDF here .

Publication date: 17 April 2023 Last reviewed: 17 April 2023

In this chapter:

• Key messages

Introduction 

Reluctance and eagerness to know .

• Variations in ability to use routine data to monitor quality and safety and make improvements  
• Differences in the ability to access and use "soft intelligence"
• Orientations towards openness 
• Conclusions

Back in 2004, Bill Moyes, who was at the time executive chair of the foundation trust regulator Monitor, said: "There is no such thing as a perfect organisation. The best we can ever hope for is that an organisation is self-aware, recognises its issues, and deals with them effectively".  This remains as true today as it was nearly 20 years ago.  The complexity of large organisations and even greater complexity of working within systems challenges organisations to be self-aware. The evidence of what is going well, what can be improved and what requires urgent attention is readily available in organisations that use soft intelligence effectively. There will always be the temptation to take comfort in getting most things right rather than being disconcerted by the significant minority of things that go wrong. There will always be a danger in regarding compliance as an end in itself rather than as useful, but limited, intelligence on organisational performance. In this section Mary Dixon-Woods and Graham Martin contrast problem-sensing with comfort- seeking, confront structural complacency and a lack of eagerness to use hard and soft intelligence, and discuss the crucial importance of openness. It would be surprising if there were many who would disagree with the content of this chapter, but the challenge is to embrace openness and make real a learning health system in which structural secrecy is identified and challenged at all levels.

Key messages :

• Comfort-seeking is undesirable behaviour characterised by seeking reassurance, by taking undue confidence from the data available, and by the inability or unwillingness to seek out information that might challenge the sense that all is well.
• Problem-sensing involves actively seeking out weaknesses in systems relating to quality and safety, typically using multiple techniques and sources of organisational intelligence.
• Problem-sensing behaviours also involve actively seeking out data or other forms of organisational intelligence that offer challenge, disrupting any incipient risk of complacency.
• Organisations and systems need to be able to distinguish between: quality issues that can be attributed to the individual performance of healthcare staff; what can be achieved through process improvement; and what represents defects in the design and resourcing of systems.
• Culturally, problem-sensing encourages staff to engage in active noticing of where there might be defects, speaking up about them, and ensuring that systems are in place to make improvements.
• As with the collection of 'harder' data, though, it is important not to mistake activity for action. Simply undertaking listening activities or unannounced visits is no substitute for the hard work of analysing and responding to the issues they unearth.
• The willingness of those at the 'sharp end' to speak and of those at the 'blunt end' (senior leadership) to listen exist in a reciprocal relationship.
• We should not overestimate the power of leaders or of 'transformational leadership' in influencing behaviour across complex, disparate and dispersed organisations.
• The most important role of boards and senior leaders in nurturing positive cultures may be in collating knowledge about variations in performance, behaviour and culture across their organisations, and supporting local leaders, located within units with their own subcultures, in their efforts to improve openness.

Unwarranted variations and deficits in patient safety and quality of care continue to present a major source of harm and distress for patients, families and staff, as well as consuming a growing proportion of the NHS budget on payments for negligence claims. 1 2 3 At their most extreme, these problems result, with depressing frequency, in organisational catastrophes – including, but not limited to, the Bristol Royal Infirmary and Gosport War Memorial Hospital failures in the 1990s, Mid Staffordshire NHS Foundation Trust in the 2000s, and, in the recent past, the Morecambe Bay, Cwm Taf, Shrewsbury and Telford, and East Kent maternity units. Some vulnerable groups are especially badly impacted by poor quality care. The Learning Disabilities Mortality Review Programme, 4 for example, has revealed a grim pattern of premature death for people with learning disability. Though each of these organisational degradations and failures in care is distinctive, they demonstrate many shared features. They include discounting of warning signs, poor management systems, failure to listen or act on patient and staff concerns, fragmentation of knowledge about problems and vacuums of responsibility for addressing them, cultures of secrecy and protectionism, and fragmentation of knowledge about problems and responsibility for addressing them. 5 It is clear that healthcare systems are vulnerable to what Diane Vaughan, in her account of the Challenger disaster, terms "structural secrecy". This describes how "patterns of information, organisational structure, processes, transactions, and the structure of regulatory relations systematically undermine the attempt to know and interpret situations." 6  In this chapter, we discuss a crucial contribution to structural secrecy: behaviours that can undermine the capacity to recognise and act on sub-optimal care. These behaviours may be found at all levels of the health system – from individuals and teams all the way upwards through organisational leadership and the regulatory and policy level.  Based on a very large study of culture and behaviour in the English NHS, these behaviours can be characterised on a spectrum from "comfort-seeking" to "problem-sensing". 5 Problem-sensing involves actively seeking out weaknesses in systems relating to quality and safety, typically using multiple techniques and sources of organisation intelligence. Comfort-seeking, on the other hand, is characterised by seeking reassurance, by taking undue confidence from the data available, and by the inability or unwillingness to seek out information that might challenge the sense that all is well.

Problem-sensing and comfort-seeking behaviours to some extent reflect variations in dispositions towards wanting to know. Tendencies towards complacency, over-optimism, and even self-deception reflect patterns found in disasters outside healthcare – including, memorably, the financial crisis of the late 2000s. 7  Within healthcare, these kinds of orientations are highly consequential. At Mid Staffordshire, for example, many of the behaviours described by Sir Robert Francis 8 fell firmly in the category of comfort-seeking. Senior leadership at the trust demonstrated comfort-seeking behaviours that appeared to be rooted in hubris, including the belief that it was compliant with quality and service standards despite numerous internal indicators that it was not. As in the Challenger disaster 6 and other failures in aerospace and the oil industry, 9 staff at the trust with specialised technical expertise were marginalised from the trust’s decision-making structures. Over 900 incident reports submitted by staff in Mid Staffordshire on understaffing and other safety concerns were neglected. Experienced doctors and nurses were pressurised to collude in creating favourable accounts of the Trust, for example by getting patients through the emergency department on time—or making it appear that they did—regardless of the consequences for quality of care. More recently, the Kirkup report into maternity and neonatal services at East Kent found that "the Trust wrongly took comfort from the fact that the great majority of births in East Kent ended with no damage to either mother or baby." 10 Problem-sensing behaviours, on the other hand, involve caution about being self-congratulatory. 5 They also involve actively seeking out data that offer challenge, disrupting any incipient risk of complacency. 11 Equally importantly, when they do uncover problems, problem-sensing behaviours involve the use of strategies that go beyond merely sanctioning staff at the sharp end of care delivery, 12 instead making more systemic and holistic efforts to strengthen their organisations and teams.

Variations in ability to use routine data to monitor quality and safety and make improvements 

As well as cultural dispositions, problem-sensing and comfort-seeking behaviours also vary according to team, organisational, and institutional capacity to use routine data as the basis of monitoring safety and quality of systems and ability that data as the basis of action. High quality data collection and analysis is needed to support managers and clinicians in their work and to facilitate co-production of health with patients. 13 Good measurement provides the information that organisations need to monitor quality and safety and take action where needed, 5   and it supports innovation and evaluation of service change, which improves the allocation of finite resources and flow through the system. 14    Despite a long history of performance measurement in the NHS, 15 and the many data sources available, several challenges remain in monitoring quality and safety in health systems and translating insights from measurement into beneficial use. One issue is that, despite their ubiquity, the results of many performance management schemes are mixed: they are susceptible to multiple unintended consequences. 16 17 18   Even when launched with an explicit emphasis on improvement, they may become regarded by staff at the sharp end more as blame allocation devices than supports for practice. 19 For organisations with a tendency towards comfort-seeking, measurement aimed performance management may too easily incentivise exactly the behaviours that contribute to structural secrecy. Serious blind spots can arise when organisations are preoccupied with demonstrating compliance with external expectations. 5 Future performance management efforts should be subject to careful design and evaluation. At a minimum, they should not be regarded as providing a fast-track to improvement, and the threats they may pose to learning should be acknowledged more fully. A second set of problems in monitoring safety and quality is to some extent located in an institutional context that is still maturing. Despite recent efforts to improve monitoring and measurement 20 that have sought to go beyond crude indicators, and to emphasise the complexities and multidimensionality of safety, much remains to be done to support the NHS in high quality measurement for the multiple purposes for which it is needed. Safety in particular has remained difficult to measure in part because of the absence of a unifying construct and associated valid indicators, 21 and because methods of effective, reliable surveillance have been slow to develop. 22 Though the number of quality indicators currently available is now enormous, many are inconsistently defined, poorly operationalised, or may not address the priorities of patients or staff. 23 24 Data collection endeavours for many monitoring and improvement efforts are often very time-intensive and may involve long delays so that valuable information is received too late. 25  Even for those with a problem-sensing disposition, these are key challenges. For those inclined more towards comfort-seeking, these more technical problems provide too many opportunities to avoid confronting discomfiting knowledge. The future may involve more automated data collection, collation and processing techniques that take advantage of emerging artificial intelligence techniques to learn adaptively and offer real-time predictive analytics. But for the moment, the hype exceeds the reality. 26 Much more needs to be done to recognise the value of high quality data collection, analysis and interpretation at every level of the NHS. 14 Also important is the recognition that better data by itself is only part of the solution – and indeed the quest for more data can sometimes thwart the goals of improvement. 27 The ability to use data to make sound diagnoses of problems and use those diagnoses as the basis of action requires more attention. For example, organisations and systems need to be able to distinguish between what quality issues can be attributed to the individual performance of healthcare staff, what can be achieved through process improvement, and what represents defects in the design and resourcing of systems.

Differences in the ability to access and use "soft intelligence" 

In addition to being able to gather, analyse and act on metrics, achieving quality and safety requires attention to what is not measured: forms of soft intelligence 28 that may not be easily surfaced and are often highly fugitive in character. Comfort-seeking behaviours may result in organisations neglecting or being highly selective in how they access and use soft intelligence. Problem-sensing behaviours, on the other hand, are characterised by going beyond mandated measures, and using multiple techniques for gaining access to softer forms of intelligence. Such techniques should always include active and participatory forms of listening to patients and staff, but may include a range of other methods, such as informal, perhaps unannounced visits to clinical areas; use "mystery shopper" style data gathering, shadowing of staff, swapping roles for a short period, and use of clinical simulation as a diagnostic method. Culturally, problem-sensing encourages staff to engage in active noticing of where there might be defects, speaking up about them, and ensuring that systems are in place to make improvements. 29 While sometimes discomfiting, this less routinely gathered knowledge enables fresh and penetrating insights.  Accessing softer forms of intelligence requires care and sensitivity, including intentional efforts to hear and make sense of the views and concerns of people at the sharp end of care. Often these are nascent, partial and may not be fully formed as safety concerns. 30 But they also represent the signals that, experience in healthcare and other industries suggests, can be crucial in identifying and heading off emerging disasters. 31 As with the collection of "harder" data, though, it is important not to mistake activity for action. Simply undertaking listening activities or unannounced visits is no substitute for the hard work of analysing and responding to the issues they unearth, and it can even undermine efforts to learn and improve if perceived as an exercise in inspection or a meaningless performative gesture. 32 33

Orientations towards openness

The ability to access and make use of intelligence, soft or hard, is not dependent solely on the attitudes and behaviours of leaders and board members. Rather, it is also crucially reliant on the broader culture and systems of the organisation, particularly the extent to which their values, norms, behaviours and institutional capacities are oriented towards openness and learning. 34 Past tragedies in healthcare have been attributed in part to a reluctance on the part of a wide range of people to raise concerns about quality and safety. At Mid Staffordshire, for example, many staff at the sharp end of care felt unable to speak up about the issues they saw. It was due to the tenacity of a determined few – including advocacy by patient groups – that the problems were finally recognised. 8 The willingness and ability of those at the sharp end to speak and the willingness and ability of those at the "blunt end" of senior leadership to listen exist in a somewhat reciprocal relationship. 35 The efforts of boards and other senior leaders to foster openness, and the extent to which they model good behaviour, make proactive use of data for improvement, and listen and act on soft intelligence, are crucial in setting the organisational tone, for better or worse. But we should not overestimate the power of leaders or of "transformational leadership" in influencing behaviour across complex, disparate and dispersed organisations. The cultures of healthcare organisations are often multiple, and may be patterned along specialty, occupational groupings, professional hierarchies, and service lines. 36 Consequently, the most important role of boards and senior leaders to nurturing positive cultures may be in authentically seeking and collating knowledge about variations in performance, behaviour and culture across their organisations, and supporting local leaders, located within units with their own subcultures, in their efforts to improve openness.

Conclusions  

The complexity of healthcare organisations makes them highly prone to structural secrecy, and the consequences have been seen, tragically, in multiple disasters of quality and safety of care over the last two decades, in the UK and elsewhere. Organisations vary in their ability to capture intelligence and use it as a basis for improvement, and the contribution of comfort-seeking behaviours to organisational malaise need to be recognised and addressed. One way of addressing these challenges may in the opportunities presented by the concept of a learning health system: 13 one that constantly integrates quality monitoring, quality improvement, research, operations, staff and patient engagement. 37 Embracing this concept at organisation and at system level may help to routinise the use of data and insight from a variety of sources in the improvement of care – not least patients and carers themselves. Again, however, capacity to become a learning organisation will vary, and so institutional action at the level of the whole NHS system is also important. The principles of positive deviance are likely to be especially helpful in the move towards learning at system level. Effective learning in health systems requires both learning from failures 38 and from success. 39 40 Encouraging examples are now beginning to appear, 41 42 suggesting the potential value of the approach – but how to replicate and scale positive deviance remains an important question. 39 System-level actors – including national bodies, integrated care systems, regulators and improvement agencies – are likely to have an important contribution to make – not least because coordinating system-level activity in a way that enables individual organisations to realise problem-sensing behaviours. At system level, it is important that  "priority thickets" of goals that may conflict, compete or fail to cohere 5 are avoided if the potential of learning health systems is to be fulfilled, and the safety of patients advanced.

Available in the PDF version . 

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The OD practitioner and culture change: Provocations for organisations and systems

27 September 2021

Culture, the patterns of beliefs and behaviours in our organisations and systems, when aligned to strategy, is a powerful force. Organisation development (OD) professionals and academics have explored the concept of culture for decades, suggesting many ways of influencing and improving it. Culture change has a core theme in OD practice in the NHS, particularly in the years since the Francis Report recommended fundamental change in culture is needed across the NHS.

Culture is subjective. Organisations and systems are made up of many interconnected cultures. Teams have their own cultures. Regions have theirs. When we talk about culture in this resource it is shorthand for the multiple, sometimes complimentary, and at other times opposing, cultures that exist at all levels of the NHS.

We challenge the myths that culture is a single thing that can be changed by policy; that culture change takes a long time; and that culture cannot be changed. We believe culture change is possible, it can be immediate, and it happens through the conversations between people. While it can be helpful, and often necessary, to undertake a formal and structured approach to culture change, we offer a complimentary approach that says we can all change culture, all the time. This process begins by asking good questions.

This resource is built around ten culture provocations and ‘what if?’ statements that invite you to examine and challenge your views and practices. They have been developed by Stefan Cantore from foundations of research, through the lens of the challenge of changing culture in the NHS in 2021. Stefan is a senior university teacher in organisation development and management learning at the University of Sheffield Management School .

At the end of the provocations is a set of ten questions we encourage you to answer as a way of planning your next steps.

Good conversations that start with great questions lead to powerful action.

How to use this resource

Each of the ten provocations begins with a ‘what if?’ statement, followed by an idea challenge intended to help us look at culture through fresh eyes. 

Provocations stimulate a reaction, sparking new questions and inquiries about our assumptions and practices. They disturb our thinking and unsettle us so that we become open to considering alternative perspectives.

We invite you to stay with the feelings and thoughts that come with these provocations. For some OD practitioners the ideas themselves might be familiar and prompt a milder response than for others. However, we can all do with re-examining our beliefs and practices so hopefully there is some challenge for everyone.

Stick with the ‘what if?’ questions. If they irritate you, then they are doing their job. Use them as an opener for your own analysis about the idea of organisational culture and how your OD practice might develop in response. Give yourself the time to chew them over. Perhaps use them as a starting point for a conversation with colleagues. We would also encourage you to create your own ‘what if?’ questions.

If you feel some energy around a particular provocation, you can explore deeper and dive into the topic in more detail. Each provocation also features practice challenges and ‘why not?’ suggestions. These are initial ideas about practical actions you might take.

Provocation 1: What if we don’t have an agreed definition of organisational culture?

Idea challenge

A Google search into the term organisational culture and a dip into academic literature will show that there is no one definition of the concept. Therefore, we need to do our own individual and collaborative thinking to come up with an understanding of the concept that fits well with us. Ed Schein (2004) identifies more than 11 categorie s used to describe culture, let alone the number of definitions. These range from observed repeated behaviour patterns, shared language, articulated values, rules of interaction, embedded skills, habits of thinking, metaphors, and symbols.

Schein goes on to suggest that while all of these might be relevant, the concept of culture brings with it the implication of what he calls ‘structural stability’ (Schein 2004, p. 15). This apparent stability offers a group a sense of meaning and predictability, both of which contribute to a sense of psychological safety. Furthermore, culture, as Schein sees it, is often something of which groups are largely unaware and shapes all their activities. When taken together, culture can be seen as a continuous patterning of behaviours and deep-seated beliefs that integrate our experiences and help us make sense of the environment in which we live and work.

Getting clarity on what we mean by the word culture in organisational contexts is a challenge, it can mean different things to different people. It is often used when we wish to create a group through our descriptions of their behaviours and attitudes. In using the label culture, we also create boundaries between those who belong to the culture we are describing and those who behave differently. Using labels is an act of power and differentiation. Because of the generality of the term, we also tend to pick up specific stereotypical behaviours that for us illustrate the nature of the group dynamics we observe.

Cultural identification in this way becomes a process of continuing social construction. As we discuss the behaviours and attitudes of groups, as we perceive them, so they become more real to us. We then tend to have our biases confirmed about the reality of the culture. So, if we perceive culture as a reality, how then might we define it? 

Reviewing definitions of organisational culture offers not one meaning but a cluster:

1. Routinised ways of doing and thinking about things that are shared by the majority of organisational members. This incorporates methods of production, skills, work roles and habits of managerial behaviour.

2. Unique configuration of norms, values and beliefs apparently shared across members. These are reinforced in both the stories told and the strategies adopted by the organisation (strategy is then an enactment of culture).

3. Culture is not what an organisation has but what it is. Culture is a metaphor, a way of describing how people create order and organise for a purpose. In effect, then, every part of the organisation is its culture. You cannot tease out values from strategy, technology, or job roles since all combine to form a culture, a whole organisation. 

4. A set of interdependent values and ways of behaving that are common in the organisation and tend to perpetuate themselves over an extended period.

5. Culture is a means of socialising and exercising control over organisational members.

These are a small sample of definitions; many more are available. Take some time now to craft your own definitions and then reflect on your own ideas.

Perhaps it is also worth asking if we see organisational culture as a positive construct. Often culture is blamed for failure, it allows a whole group to be demonised. What if culture became a more positive construct for us? What if we framed culture as a means by which people co-create relationships and value in the lives they lead? Why not spend some time reflecting on how you tend to view culture in the context of your practice? Why not play with different ideas and images of culture and see what happens? Note your reaction to each idea and consider why some are more appealing to you than others. 

What is your reaction to the ambiguity and breadth of the idea of organisational culture?

How does it impact you as you think about the implications for your practice?

What spaces do you have to explore the idea/s with others? Can you create some new ones?

• Search organisational culture on Google and read some of the definitions you find?
• Jot down some reflections. Which ones particularly resonate for you? Which ones seem odd and don’t really work for you? Why do you think this is the case?
• Share your insights with a colleague and see what they think?

Provocation 2: What if our OD approach to organisational culture is itself a reflection of the organisational culture we work in?

We inhabit work environments that shape, albeit subconsciously, our behaviours and thinking as OD practitioners. The consequence is that when talking about organisational culture and working out how to change it, we are drawn to using the same language and behaviour patterns adopted by the organisation we work for. So, we find ourselves, almost inevitably, drawn into the patterns of culture transformation programmes, key performance indicators (KPIs), culture change tools, staff engagement strategies etc. We are also influenced by preconceptions and the interpretations of past experiences we carry with us and project on to our present context. In summary, OD practitioners need to acknowledge the range of influences on our cultural diagnoses and change strategies.

Cultural language and behaviour patterns are intended, as Schein (2004) 45  points out, to maintain some collective sense of structural stability. This comes across in his definition of organisational culture:

‘A pattern of shared basic assumptions that was learned by the group as it solved its problems of external adaptation and internal integration, that has worked well enough to be considered valid, and therefore, to be taught to new members as the correct way to perceive, think and feel in relation to those problems.’ (2004 p7).

Schein elaborates on this when he explores the purpose of organisational culture:

• It has a function in enabling productive working with other organisations, systems, and individuals.
• The processes are a means of socialising members to behavioural and attitudinal patterns.
• Maintenance and development of the culture, or patterns, happens over time. This gives a sense of stability and reduces anxiety.
• Culture encourages communication in a variety of ways with the purpose of ensuring cultural relevance to perceived contexts and organisational purpose. This implies that culture and its management is related to the control of group members.

The patterns that we encounter in OD practice arguably exist to support current mindsets and work routines, to reduce anxiety about what might happen next and maintain individual and group identities. If we accept this is the case, then such patterns may also be our patterns. Patterns which   shape us and which we also contribute to shaping. While we aim to hold a stance of separateness from any organisation in order, for example to undertake OD diagnostics, can it be that even the sense and desire for separateness is an organisational pattern which ultimately is deceptive? Perhaps we cannot fully extract ourselves from patterns that have been a collective response to uncertainty. We are an integral part of the culture, whether we notice it or not.

It may even be that we miss organisational culture and tend to focus on the managerial culture of our peers, its language, and norms of behaviour. To an extent then, the organisation perhaps remains a mystery to us. The lens we use, a managerial worldview, can obstruct our vision of the whole.

As OD practitioners, we usually belong to the managerial community and culture, so the approaches chosen can, and often do, reflect the unacknowledged desire and imperative for stability within that sub-culture, and in its relationships with other sub-cultures in the organisation.

It is possible that we may also be creating and sustaining a distinct OD sub-culture in our organisations that contributes to the mix. If this is the case then the irony is that while OD promotes organisation development, the actual drive in any OD function, whether conscious or otherwise, may be to sustain the status quo; the very reverse of what it may be asking other groups to do.

If this is the case, then we need to take time to reflect on the patterns our OD practice may have adopted that mirror organisational patterns. This isn’t easy to do, and external facilitation and supervision could be helpful. Of course, it could be that any external enabler is also shaped in their thinking by a similar OD culture to our own.

• What is your reaction?
• Do you see points at which your practice is shaped by the organisational or sub-culture of which you are a participant?
• What are the implications?
• Does this resonate with you?
• If so, how do you personally handle the paradox of organisational culture change with the seemingly irresistible forces, sustaining old patterns of thinking and behaving?
• What can you do to surface the patterns that underpin your own assumptions about organisational culture in your own context?
• Do you have insight into why these might figure so prominently in your own understanding?
• How do your assumptions/beliefs shape your organisational culture practice?
• What resistance to change in your own practice do you notice? What sense do you make of it?
• introduce some different language and ideas about culture into a workshop you are facilitating?  Notice the reactions and invite people to think/talk through their patterns of talking about culture
• review the language in some recent reports published by your organisation? What assumptions are leaders making about organisational culture?
• re-write some of your workshop materials to reflect a different way of thinking and talking about organisational culture? Reflect on how that makes you feel.

Provocation 3: What if organisational culture is made through relationships between people and the work they do?

Organisational cultures are being created and redesigned through relationships between people and the work they do. These relationships alter as people come and go and as the work they do changes.

While this dynamic process continues in both organisation-wide cultures and group or professional cultures, the nature of the work itself can be overlooked. How does the type of work and the meaning attributed to it affect how people relate to one another and thus co-create culture?

Exploring the work of Eric Trist, one of the founders of OD alongside colleagues at the Tavistock Institute, may offer some insight into this provocation. Based on his research in the 1950s he developed the idea of sociotechnical systems, which is defined by Ropohl (1999) 47  as:

‘The reciprocal interrelationship between humans and machines and to foster the program of shaping both the technical and the social conditions of work in such a way that efficiency and humanity would not contradict each other any longer.’ (p.186)

The theory behind this approach was based on the idea of joint optimisation of the technical aspects of work alongside the human contribution. There was a need to enable the social system to work in harmony with the technical system (broadly defined) for there to be both productivity and wellbeing.

The link is then made to organisational culture:

‘The pattern of work organisation - the way in which those who carried out the necessary tasks are related to each other - was analysed in terms of the quality of work roles, the kinds of task groups, the prevailing work culture, the nature of inter-group relations, and the character of the managing system.’ (Trist, Higgin, Murray, and Pollock, (1963) p.289) 48 .

Insights that flow from Trist’s work include:

• the interdependency of the social and technical
• social systems that are designed to be highly fragmented require a lot of external control
• change is best accomplished by involving those affected
• the design of work affects the level of stress
• managers tend to pay more attention to the technical rather than social innovation in spite of its importance
• organisations are poor at learning from experiments
• organisational culture affects the ease with which new ways of working can be introduced
• teams that lack social unity and technical ability will experience problems in self-regulation.

Perhaps this sounds familiar, and some have a definite OD ring about them. What is significant though is to note the emphasis on the design of the work itself. Is this any area of OD practice that is under-developed in modern organisations? Where does responsibility for the design of work rest and who is engaged with considering the social implications? In healthcare organisations, quality improvement, safety governance, workforce planning and each professional group has a role in designing the work, although perhaps they do not see that this is what they are doing. So, the question is: where is the influence of OD in this rich mix of work designers? Is it there at all and if so, what contribution is it making?

Relatively new players in the field are those who specialise in organisation design. Finding a clear definition of what this involves remains a challenge. The European Organisation Design Forum suggest that it is: ‘a systematic and holistic approach to aligning and fitting together all parts of an organisation to achieve its defined strategic intent.’

The CIPD 49 opens this definition further:

‘Organisation design is the review of what an organisation wants and needs, an analysis of the gap between its current state and where it wants to be in future, and the design of organisational practices that will bridge that gap. It’s a fundamental, wide-reaching, future-focused activity that often requires a review of the entire organisation and its context to decide what does and doesn’t work. It will therefore usually involve a holistic review of everything from systems, structures, people practices, rewards, performance measures, policies, processes, culture and the wider environment.’

They see organisation development following on from the design to ensure that the people dimension is fully attended to.

Where does organisation design sit in your context? What is its impact and how does it relate to the practice of organisation development? To add further complexity, the popularity of agile and lean concepts adds to the challenge the OD practitioner has in working with the interfaces between design and development.

What connection do you make in your OD practice between the characteristics of the work people are engaged with, the organisational culture and emerging integrated care system (ICS) cultures?

What does the language of the work and the organisational culture tell you about the cultural patterns and legacy being handed down to the next generation of the workforce?

What do you notice about your own language and the materials you create as an OD practitioner? How do these offer difference to prevailing cultures?

• talk to colleagues from different groups and professions about what is important to them about their work? Ask how the work affects how they relate to other groups of people in the organisation and the wider ICS
• talk to OD peers about how the work you do affects how you experience your organisation’s cultures and inter-personal dynamics?
• reflect on your insights? How is this shifting your understanding of the relationship between work and organisational culture?

Provocation 4: What if we practised as though culture is a living, constantly developing process?

If we accept that organisational culture is a dynamic, living process this opens new ways of thinking and intervening. It offers the possibility that we can continually co-design organisational culture. This practice of ‘culturing’ or ‘culture crafting’ highlights the idea of culture not as a noun, with fixed characteristics, but a verb with a sense of collectively and actively shaping and re-shaping relationships, symbols and behaviour patterns.

Culturing as a practice enables us to work with groups, organisations and systems in proactively shaping cultures. It has the potential to help us do the following:

• Enable inclusion

As we take on board that culture is constructed and reconstructed between and through our interactions, so we can actively decide together to include a wider range of voices and perspectives in co-designing than we might otherwise consider. The power dynamics that once seemed so fixed are weakened and changed as we talk about what has happened and explore what might happen. This radical inclusion opens new learning for us individually and collectively. Of course, we can find ourselves seeking safety in old patterns of behaving, but these become potentially less appealing as we acknowledge what is happening.

• Acknowledge needs

All of us do have needs for belonging and safety. Traditionally, much of organisational culture has focused on enabling this for the members, but what about those people who are outside? Arguably they too have needs that are as legitimate as anyone else’s. Culturing invites us to surface the needs we feel we have and bring them explicitly into the co-design process. This requires a collaborative, trusting environment. Such an environment supports great conversations where relationships begin to flourish. This forms the foundation for trust.

• Discuss assumptions and beliefs

When we give space and time to considering the ‘artefacts,’ or outward expressions of culture, the visible and felt evidence of what goes on from day to day, we also could look carefully at the assumptions and beliefs that underpin our ways of working. People do things for good reason, but usually we do not give ourselves permission to consider together why we might adopt certain practices or behaviours. They just become the way things are done.

By opening conversations about the practices there is an opportunity to discuss the underlying beliefs. This needs not to be rushed, but once the discussion starts it can lead us to considering new ways of doing things. In this way, the culture starts to shift for us. At the beginning of a co-design process we can make early choices, not just about the ways of working, but also agreeing that talking about these things is fundamental to the ongoing design process. Co-designing is, in part, about culture creating and re-creating.

• Choose language that enables co-designing

In complex systems, like ICSs, people bring their own languages. By this we mean not just the words and the many acronyms that they have developed over many years in their organisation, but also the specific and nuanced meanings they attach to the words. Culturing invites us to explore language explicitly and the contribution it makes to how we work. Language is both an artefact and an expression of core beliefs. Making explicit choices about language enables us to shape our lived experiences.

• Recognise and work with difference

By becoming more culturally aware it becomes much more likely that we will be able to recognise both the artefacts and develop some skill in listening for the assumptions to which they give expression. Given that in system work we will always be encountering many cultures, it is helpful if we can notice difference and feel confident in engaging with it. Such confidence then enables us to act particularly, regarding what we might consider to be the external environment that ultimately shapes the culture for work. We also develop a sense of what can be left alone and what aspects of culture are important to surface.

• Become culturally proactive

Arguably, one of the principal reasons why culture is considered stable and difficult to change is because theorists and practitioners have treated it as such. The idea that we might co-design cultures in the way described in this chapter is new to many. It does though challenge us to become, through practice, proactive in working with culture and move away from what can be a very pessimistic sense of helplessness. That sense of helplessness is itself an artefact of culture and worth exploring if you feel it. Ultimately, culturing is about acting to intentionally make and remake the cultural context in which work happens.

• Develop a spirit of inquiry and learning

There is much to be uncovered in the practice of culturing. It calls us to inquire into the whys of organising. We may not always be comfortable with what we uncover, but nonetheless such inquiry opens the possibility for new insights and deep learning. Because culture can be perceived to be quite intangible, such inquiry is often best undertaken within a group context. This gives opportunity to test out perceptions, share new learning, and grow together in confidence.

• Help shape system leadership

One manifestation of culture is the manifest behaviour of those in leadership roles across the system. Culturing gives permission to engage in conversations about the impacts of behaviour on how the system works. Leadership here includes those who have any role in how services are experienced. This means those traditionally perceived as clients or customers. The conversation encouraged by culturing opens up the possibility of entirely new thinking about what the system is intended to accomplish and how the different roles support or detract from success, however that is defined.

Behind the practices rest several assumptions about the mindset we adopt:

• Those involved in the work are people of goodwill. They are not involved to deliberately frustrate the process. They bring, as we all do, a set of biases and intentions that may make culturing a challenging journey, but they are still people who have in common a shared humanity.
• Proactive culturing will see changes in mindsets and final outcomes. This implies holding a future orientation. Culturing does not encourage retrospection on past successes but, in its language and focus, invites all involved to look at what the future may bring as new approaches to relating and working begin to emerge.
• Encouraging honest and open communication will bear fruit, particularly in the potential to continually explore the nature of cultures as they develop between us. This will at times call for courage to speak about things that often go unspoken. We might feel the risk of rejection and alienation, but without facing, and voicing, these fears, a potentially unhelpful cultural pattern grows.
• Culturing and learning go together. As we work together in creating new cultures, we are learning about how to develop new organisations and systems.
• The external environment is amenable to change through the actions of culturing in one part of the system. Sometimes we can hold a view that while we might change cultures in our group, this effort will be futile because the rest of the system remains unchanged and just forces us back into our old ways of behaving.

Holding these beliefs is not always easy. Our feelings and thoughts change. Working with people with whom you can share your concerns, doubts, thinking, and learning as you engage in culturing is a very helpful practice 53 .

The following five practices could be a good starting point to explore to culture craft:

Inclusivity

When forming and re-forming groups, find ways of making membership and participation as inclusive as possible.

Acknowledging needs

Giving time and space for people to express what is important to them helps build trust and safety.

Hosting conversations and asking questions

The framing of interesting questions about culture and patterns of behaviour can support people to learn for themselves about what is helping or hindering them with collectively developing new ways of working.

Exploring language

Taking time to explore how people are using words and acronyms will highlight how they use language to create their shared social reality.

Noticing artefacts

Inviting people to walk around the physical spaces that form the system. Discuss what the different spaces, signposts, pictures and design features communicate about the existing culture. What could be changed and what might that communicate?

• review your work plans for the next couple of months and identify which activities could potentially directly contribute to culture-crafting, both in your organisation and the ICS?
• set out some intentions and practical steps that you can take to culture-craft?
• work with an interested team in the organisation to explore how they might act to culture-craft? Support them to implement an action plan and then gather to reflect on the impact and learning about a month later
• try the process with your own team?
• try the process with a group drawn from across the ICS.

Provocation 5: What if the NHS People Plan 2020/21 and the Our People Promise are, in totality, an organisational culture agenda?

A recent trend in NHS organisations is to categorise culture and culture change or transformation as one strand of a development agenda. This might formally be located within HR, the people function or an OD directorate. In doing so it comes with its own plans, action lists and KPIs. In a hierarchical bureaucracy, where policies and procedures dominate alongside authority, accountability and chains of command, then this is understandable.

What if this transactional understanding of organisational culture is no longer helpful nor effective? If the NHS People Plan and the Our People Promise in their totality are about developing both organisational and system culture, how will OD practitioners respond and act? Rather than viewing culture as part of the organisation, what if culture is the organisation system? How then is the culture-crafting process undertaken?

Organisational culture themes are evident throughout the NHS People Plan 2020/21 and Our People Promise. The documents incorporate ideas around compassion, inclusivity, psychological safety, belonging, working differently, autonomy, equality, digital transformation, voice, learning and teamwork. The list could on. Taken together it is reasonable to conclude that separating out culture from the lived experience of working in the NHS, according to the authors of the plan, is likely to be frustrating. In other words, organisational culture is the organisation and not simply one aspect of it.

Putting the effort and time into exploring ideas around organisational culture can deepen our own insights and practices.

McCalman and Potter (2015) 55 put forward their own reasons why it is worth doing this:

• Culture constitutes society. To understand a culture, or at least to seek to do so is to be able to better understand its inhabitants.
• Culture is the organisation (as opposed to being one aspect of an organisation).
• People are expressive beings and culture represents both the process of human expression and the outcomes.
• Similarly, on a smaller scale, organisations are organising processes with outcomes that represent something of what their leadership considers to be of value both to themselves and their context.

They go on to argue:

• If we truly wish to understand the people in organisations, we can best do so by engaging with the culture.
• If we wish to facilitate change in organisations profoundly then we need to also engage with supporting the change of culture.
• We need to increase our appreciation of the value of organising effort and cultural environmental fit of a culture (put more simply enhance our perceptions/reality of an organisations commercial and/or social success and value…. or otherwise). This point links with the idea that organisational cultures contribute to the broader culture of society and function within it.

Different perspectives on organisational culture can spark in us fresh thoughts. Try reflecting on the following three perspectives and ask how they match or differ from how you see culture:

• Three-dimensional view.
• Culture as an integrated and clear meaning system within an organisation.
• Culture as distinct set of sub-cultures linked by common themes.
• Culture as fragmented with an agreement to agree on a particular view of reality to enable a working consensus (this can appear like integration when it is not).

(Meyerson and Martin, 1987) 56

2.     A web (multi-perspectives)

The web entraps us in a sense of having significance from which we cannot escape. It does this by:

• sustaining a central organisational paradigm that acts as a centrifugal force that weaves themes together as interconnected strands of control
• maintaining performative elements to sustain the ‘threads’ of the web including stories, symbols, power structures, organisational structures, rituals and routines and control systems

This frame offers a way of seeing organisational culture from a range of perspectives. (Geertz,1973) 57 .

3 . Culture as a sense-making device

Sense-making happens as we construct reality through the attribution of meaning to symbols.

These symbols can be:

• expressions
• anything made by us
• ideas and philosophies.

Sense-making can be considered a ‘conversational and narrative process through which people create and maintain an inter-subjective world.’ (Balogun and Johnson 2004:524) 58 .

‘Shared means, shared understandings and shared sense-making are all different ways of describing culture. In talking about culture, we are really talking about a process of reality construction that allows people to see and understand particular events, actions, objects, utterances or situations in distinctive ways.’ (Morgan, 1997:138) 59

‘Constructed reality means the world we know and understand is our invention.’ (Ford, 1999: 481).

Now spend time re-reading the NHS People Plan 2020/21 and Our People Promise. What are you seeing now that you did not notice before? What culture is being crafted through the themes, language and narratives? How do you feel called to respond in your practice?

By giving space for inquiry and learning together it becomes possible to start seeing the complexities and dynamics of organisational culture through a new set of lenses. Organisational structures tend to divide domains functionally into finance, operations, quality, planning and HR/people and so on. Culture often finds itself located in the people box. For a systemic approach to culture to take root, all the individual functions will need to incorporate an awareness of how they shape culture and contribute to the whole experience of an organisational culture. Once aware choices become possible around intentional culture-crafting for leaders, actions can follow with support and feedback. 

• Arrange to meet with as many heads of organisational functions as you can?
• Ask them for their views on organisational culture. What contribution do they think their role and function can make to culture-crafting?
• Find out from them what learning and development support will help them contribute to culture change?
• Discover how culture-crafting actions can be routinely incorporated into annual operational plans?

Provocation 6: What if the global pandemic is a systemic culture change process?

 OD is classically defined as:

‘.…a system-wide application and transfer of behavioural science knowledge to the planned development and reinforcement of the strategies, structures and processes that lead to organisation effectiveness.’ (Cummings and Worley, 2009 p2).

While there is much that can, and should, be critiqued about this definition and others like it, it needs to be noted that the primary organising unit is the organisation (called ‘the system’ in this definition). However, it is helpful not to lose sight of the reference to systems in the definition. The authors make no attempt to define what they view as the system and its boundaries although they seem to be assuming the organisation is a closed system which everyone can see, understand and to a great extent control. But what if the organisation is more of an open system with a wide range of interdependencies that connect it with the wider world in which it operates?  

This is also reflected in the Do OD definition of organisation development:

‘OD enables people to transform systems. It is the application of behavioural science to organisational and system issues to align strategy and capability. It enhances the effectiveness of systems through interventions that enhance people’s collective capability to achieve shared goals.’

The belief in the organisation as having a firm boundary, and particularly that it has one unified and manageable culture, permeates much of the academic and practitioner literature in this and the last century. But is it sufficient? What if one among many lessons being learned through human responses to the pandemic is that unless we consider our interdependencies at a local and a global level, humankind is unlikely to survive long? This means that systemic patterns of behaving really do matter and are shaping organisational cultures in ways that we are only just beginning to grasp. So, what if organisational culture is not the lens to look through to understand how people behave? What if we were to explore the dynamics between people and processes (whether technical or relational) and consider the complexity and multiplicity of influences outside of the definitions of organisation we currently work with?

If the way organisations interact in systems changes behaviours and cultures, then it is worth giving some attention to the nature of systems. For the OD practitioner in a very interconnected world, it is important to understand these dynamics and the way in which systems themselves may be amenable to being co-designed by participants.

Many are familiar with the saying: ‘Every system is perfectly designed to get the results it gets.’ It suggests a starting assumption that, regardless of how complicated or seemingly random behaviour may appear in a system, there is at the heart a purpose or, more accurately, purposes, that shape the way it works. This offers OD practitioners a lens through which to see a system of purpose. Using the word purpose suggests a fixed statement, so it may be more helpful to understand systems as continually exploring purpose or ‘purposing.’ It is a clumsy word but nonetheless gives a good sense of a dynamic practice at play within systems.   

The practice of purposing is the intentional asking of questions that help exposed people in systems to shared inquiry. It does this by first encouraging active reflection on why systems have formed themselves to be systems and, second, to help people in those systems continuously redefine the purposes that they believe they are called to enact.

The first dimension of purposing enables people to engage with:

• the personal sense of meaning they ascribe to work and collaboration in the context in which they exist day by day
• differing perspectives and meaning ascribed to working by colleagues with who they have interaction (such as team members)
• disconnected approaches that often manifest themselves between stated purposes and enacted purposes
• mindsets around purpose that have become routinised.

The second dimension opens:

• conversations about what purposes may be emerging through the experience of living and working in the system
• potential shifts in acting that help with aligning expressed or desired purposes with attitudes and behaviours
• grounded and critical reflecting on what is happening between different elements in the system.

Taken together, the practice of purposing offers new ways of thinking about developing systems and their cultures moment by moment.

Purposing enables systems to begin to move away from relatively fixed narratives that are often just an amalgam of organisational mission statements. Very rarely is space given in conversation to exploring the purpose of a system. The narrative always moves swiftly toward fixing system ‘problems’ and perceived challenges. The dominant political voices move to place their own perspective and agenda to the forefront, while other less prominent voices are ignored. Often such lesser voices are those who rely heavily on the system, like patients or customers.

Purposing is therefore part of the development process for a system. It has an immediacy that enables, through inquiry and conversation, the opening of new purposes and questions. Building capacity for purposing therefore needs to figure as a shared process across the system.

In doing this, purposing opens potentially difficult issues and tensions. For the health of the system these are to be welcomed. Without such issues having space to breathe, what will happen is a continuation of past habits of relating and performing. Purposing enables people to look at the reality of lived experience together and the culture they are co-creating.

Just as the pandemic may be prompting some thoughts in us about our individual purpose going forward, it encourages whole systems to practise purposing around the way each element relates and the necessary outcomes. This can perhaps be most vividly seen in health systems around the globe that have had to shift culturally to enact a new set of purposes for the time of crisis. OD practitioners now have some opportunities to support ongoing purposing in local systems that will together help shape the whole culture of healthcare into the future 65 .

Take time to reflect on what you have observed recently regarding new patterns of behaving. Perhaps these include examples of less formal control of teams; more collaborative working across ICSs; rapid decision-making; leaders taking greater initiative and ownership for actions; greater recognition of the interconnections between public health behavioural initiatives and demand/pressure on health services. Perhaps rapid vaccine development along with regulatory approval is also an example of shifts in attitudes and behaviours across many boundaries?

It could be too early to draw conclusions, but it is worth thinking through from an OD practice perspective how sense–making and culture-crafting can be enabled across complex systems like an ICS.

• Meet with your peers in neighbouring organisations to learn about their own understanding of organisational culture and how they enable change?
• Explore areas of shared concern across the ICS and consider what actions you can take in your own organisations to grow a system culture?
• Take some actions and review impact together?

Provocation 7: What if organisational culture is all about control?

Arguably, the role of organisation is to control. To control strategy and finances and ultimately to ensure that all processes are controlled in accordance with the wishes of the owners/shareholders. Is control of this type still feasible or is control illusionary in complex systems? Do all the KPIs presented in board reports reflect the reality of organisational culture, or are they constructed in a way to satisfy the hope of the owners (or political representatives) that everything is under control?

What part does control play in your organisation’s culture?

Do you agree or disagree? Why?

If we think organisational culture is all about control, then we need to ask ourselves some fundamental questions. The first is how do we make and perform cultures, including how is control performed?

Schein (2004), suggests that we make and re-make culture through three elements:

These are the expressive consequences of actions ground in values and assumptions. It can be material like a building, conceptual like capitalism, process like organisational procedures, and rituals like award ceremonies.

Social principles and standards collectively considered to have worth. These are expressions of assumptions and underlying theories in use. Choices are available to leaders about which values framework they wish to promote. People can participate in supporting these values even if they do not match entirely their own framework. Values can guide operating cultures and behavioural norms.

• Assumptions

Taken-for-granted beliefs about reality or human nature.

We then need to think through how these elements mix to form cultures. One option is to consider the idea of cultural themes; a construct usually found in anthropological literature. These themes are either firm rules or soft guidelines (patterns and habits of behaving and speaking) that set out what is an appropriate way to think, talk, communicate, behave and demonstrate knowledge or identity in the multiple spaces that make up an organisational culture. So how might we recognise a cultural theme?

• Several assumptions and values that are pre-existing before the theme is identified.
• Enough people share one or more assumptions.
• They are pervasive across sub-cultures.
• They are so pervasive they are usually difficult to identify.
• They are deeply embedded in power and political relations.

An example of a cultural theme could be that management development is a waste of time with no real benefit.

So how do cultural themes act as a means of control?

McCalman and Potter 67 suggest the answer is a construct they describe as cultural hegemony: ‘…a system of cultural themes that have no counterweight and thus morph into what is effectively a system of themes that stand over and suffocate any new form of cultural expression.’ (2015: 74) Introducing a new or counterweight theme in an organisation may stimulate defensive reactions and even aggressive outbursts against the proposers. Cultural hegemony is the process where those with power in organisations (usually a very small minority) act to maintain their own interests over the weaker majority.  

OD practitioners will most likely encounter cultural control mechanisms as soon as they attempt to offer an alternative cultural theme or highlight the existing themes.

What part does the desire to control play in your OD practice?

This question recognises the inherent tensions and paradoxes in organisational culture around power and control. For example, we speak of empowerment but only want people to operate in the empowering limits that we define. What type of empowerment is that in reality?

Organisations talk of trusting their staff but then put in place monitoring mechanisms that demonstrate a lack of confidence, or trust.

Is it uncomfortable or disturbing to consider these paradoxes? How might colleagues in your team or organisations feel about discussing them?

If organisational cultures are ultimately about finding ways to control the behaviours of people, then what is the role of OD?

• Spend time with colleagues discussing how control impacts on your individual and collective working lives?
• Work with OD peers to explore the paradox of a culture of empowerment and control?
• Find a team of people who are interested in working through the practical implications of working with such a paradox?
• Reflect on your conversations and see if there are any other cultural paradoxes that you notice? What is the impact of these on how you and others behave?

Provocation 8: What if no organisational culture interventions ever work (at least not in the way we thought they might)?

Given the perspective on culture we have adopted, fully evaluating organisational culture change/development work is probably close to impossible. We can try and take a scientific approach by collecting numerical data (which is always a proxy for something that can’t be measured by numbers) and attempt to maintain an objective perspective. We are invariably left unsatisfied at the result.  If we get close to the process of evaluation, then further frustration results because we know that the act of measuring itself is a culture change intervention. In any case, outside influences in the wider system usually have an unmeasurable impact on the change process.

When this is combined with the range of power interests vested in ensuring either a successful or unsuccessful intervention (at least regarding how it is described in the public arena) it is quite easy to see that determining what works or otherwise is very difficult indeed.

Just because evaluating culture change may be difficult it does not mean it is not worth attempting. The process of evaluation will itself impact on the culture change. It is not a neutral activity but one that shapes the language and mindsets around culture in the organisation. Therefore, it seems wise to consider the process as ongoing and contributing to the development of new ways of acting and thinking. If we do so, then the focus shifts towards learning from what is happening rather than expecting some form of definite conclusion at a pre-determined point in time. So, what steps might help in giving a learning focus?:

• Clarify the intended culture change as much as you are able through developing a shared frame of reference. Use open questions to allow wider engagement in the process and encourages fresh perspectives:
• Why do we need culture change?
• What would success look like?
• How will we know if we are moving toward the required culture?
• Are key stakeholders aligned about the need for change?
• What beliefs exist about how to achieve the desired culture?
• It is worth recognising the ambiguity and challenge of the process that will call for a change in mindset when contrasted with other evaluations?:
• Allow the process to be adaptive and emergent.
• Use any data collected in real time to support learning in the moment.
• Co-design ways of engaging with as many people as possible in the learning rather than confining conversations about data to a small group of people.
• Identify as many different methods as possible for collecting views and stories that illustrate experiences.
• Take opportunities for learning pauses to step back from what you have immersed yourself in. Sense-make with others.
• Work collaboratively around what it is that you wish to measure and how you plan to do this:
• Appreciate that measures shift attention and in doing so will also affect some sort of change in the culture. People can also respond to measures by gaming them and creating a range of dynamics that will similarly affect culture in some way.  
• Co-design a mix of methods that will offer a range of perspectives. Some you will wish to use frequently, like mini surveys, others, like group conversations, may be less frequent but are nonetheless valuable.
• Develop a plan for how you will use collected material and inquiry processes to shape the ongoing development of the culture.

Adapted from Stawiski, S. (2018) How to know if your culture change strategy is working. White paper: centre for creative leadership. 69

One option open to the OD practitioner is to use appreciative inquiry (AI) as an evaluation process. It has the advantages of collecting rich stories of culture and culture change alongside a future orientation. Finding ways to inquire about culture change in complex systems offers plenty of opportunities to be creative. AI encourages collaborative inquiry focused on what works in any system. The intention is to discover what is excellent and life-sustaining and then agree together how these attributes can be amplified. The system is therefore encouraged to grow in the direction of its strengths. The process is underpinned by a philosophical stance that proposes the following:

• Reality in a social system is subjective.
• The moment we begin an inquiry or even ask a question we initiate change and movement.
• In choosing our questions for inquiry we already change our systems.
• Human systems move in the direction of their images of the future.
• Momentum for change develops through social bonding.

AI processes typically follow five sequential stages:

• Working with people from across the system to explore the theme for an inquiry. This broad topic then acts as the guide to developing questions and processes. For example, life-enhancing organisational culture might be the choice where cultural development is a priority.
• The discover stage enables people to tell their stories of when the system worked at its best in the past. This surfaces information about what makes the system work well and builds social bonds.
• The dream stage invites small groups to co-create their collective image of the future if the best of their past experiences happened all the time. This generative image opens possibilities for a better future.
• The design stage enables group conversations around how best to make the generative image become a reality. It is more like a conventional change process.
• The final destiny stage explores with individuals how they are going to take the next steps to their desired future

(Adapted from Lewis, Passmore, and Cantore, 2016) 70

The stages can be covered in a day or over six months, and the number of people involved can be flexed to meet different circumstances. The process offers opportunities to co-design specific evaluatory/change processes. The choices are for people in the system to make. In this way, it can become a highly collaborative process with the benefits seen immediately through the social bonding and sharing of narratives from the start. Of course, like any inquiry process it is not possible to define the endpoint. AI is not a controllable managerial process, but rather one that invites people to shape their own collective futures based on active evaluation of previous experiences.

If you accept this ‘what if,’ then how will this impact on your planning of organisational culture interventions? How will it shape your implementation and ongoing evaluation? How comfortable are you with the range of perceptions and judgements this type of work can evoke in people?

• Have some conversations with leaders of your organisation about how they evaluate the success or failure of your work?
• Find ways of encouraging a spirit of learning to support engagement with culture change processes when things don’t go to plan?
• Research the idea of action research, which brings action and reflection on impact together, and consider how you could adopt the approach in your work?

Provocation 9: What if all OD interventions influence culture?

Our way of thinking and the language we use are closely connected. Each shapes the other. One pattern of thinking and speaking we have been accustomed to is the separation of OD interventions into categories: leadership development, coaching, team development, and organisational culture change. This categorisation offers us a shorthand way of describing the type of work that OD practitioners typically get involved in. What if this way of thinking about OD work misses the interconnections between the different types of intervention? What if they all form part of the process of re-shaping and re-designing relational work patterns and power? What if each type of activity intentionally, or unintentionally, prompts cultural shifts?

This is a difficult question to explore and quite possibly there is no correct answer. All OD interventions are in a specific place and time. Given that they focus on development of people and systems any interaction in such a complex context is likely to prompt a shift, albeit slight at times, in cultural dynamics and consequently people’s experience. How are we ever to know which action has which impact? One route is to prioritise learning within OD practice. In doing so we open ourselves up to considering questions like this one, both as individuals and collectively.

What can you do to strengthen your learning as a practitioner?

Developing a spirit of inquiry

Getting into the habit of framing questions about your practice and the contexts within which you work and live is a helpful way of initiating opportunities to learn. Questions that interest us stimulate energy to explore and investigate. Allow the energy to help you read, visit places, engage in conversations, watch films, and listen to podcasts. As you inquire, allow new questions to emerge. In this way, the process of learning continues to develop and strengthen.

Time spent reflecting on your experiences of leading for learning is never wasted time. It can help to have a framework to work through, so perhaps begin by identifying an experience where you felt you initiated some learning. Write down the details of what happened. Then ask yourself the following questions:

• What was the context?
• Who else was involved, if anyone?
• What happened?
• What were the outcomes?
• What have you learned through the event?

Questions like these enable you to mine for the richness of the learning. Gillie Bolton (2018) 73 has written a very helpful book on how to use writing to support professional development. See the end of the chapter for details.

Definitions of coaching are varied but, in the context of this discussion, coaching can be considered a conversational process to intentionally support learning. Work with a coach happens on a one-on-one basis, with the coach asking questions that help the individual make sense of experiences and deepen their reflections on practice. Barry Oshry (2007) 74 has developed a model of coaching that focuses on helping individuals see the role they and others play in complex systems.

Listening out for learning stories

Working in a complex system means that there are plenty of diverse perspectives on learning among the people involved. It is worth giving time to hear what people are saying about the journeys they have made. These provide insights into both the experience of people and the language and metaphors used by people in relation to learn.

Finding other people who have made a similar journey to your own can be very helpful in sustaining your learning over time. Hearing their stories of the ups and downs of working in complex systems can open new avenues for inquiry, as well as practical support and encouragement to continue the journey. Becoming a mentor to others can also stimulate personal learning, as you find yourself needing to reflect on what you have discovered when you seek to communicate it to another person.

Of course, learning as an individual is just one strand, the other is to support collective learning processes. The selection of which processes to adopt depends on context and preference. Options include:

Action learning

This is a facilitated small-group process originally developed for managers by Reg Revans (1982) 75 . It works just as well with people who have roles in different parts of a complex system. The idea is that members of the group meet every two or three months to present practical issues they face in their work. Through a process of questioning by group members, individuals gain insight into actions they can take to make progress. Back at work, individuals act and then report back to the group what happened and what they learned from acting and the process itself. This cycle of action and reflection underpins the learning work of the group. This rich mix of activities encourages high levels of engagement in learning as people actively support one another.

Participatory action research

Participatory action research (PAR) is not a defined methodology but a set of approaches to inquiry that are based on some explicit social values, including the need to:

• enable the participation of all people
• acknowledge the equality of all people’s worth
• actively seek the wider good of society
• encourage the expression of people’s full potential.

Consequently, it assumes that:

• Those affected by the problem under investigation should be involved in the process of inquiry.
• Participants involved in the inquiry engage in collecting data and reflect on the information to transform their understanding of the nature of the issue under investigation.
• The new set of understandings are then used to inform and implement action plans that are then collectively evaluated.

The aim is to support people to learn about their world, to make sense of their lives and develop new and creative ways of looking at things (Heron & Reason,2006) 76 . Through meeting together to agree upon inquiry questions and actions, people, after taking action, can reflect on their experience. Through this cycle of inquiry and action, people learn how to act to change the systems in which they work.

How does holistic OD practice look for you in your context? What are the encouragements and what are the hindrances in taking this approach?

Key to OD practice is the use of self. Do you understand yourself to be an OD intervention? Your presence, showing up in all contexts, modelling values and behaviours that others catch from you, all of these offer cultural interventions. What will help you sustain this approach in your context?

• Take time with your team to map the interconnections between all your work streams?
• Identify culturally related themes and explore their implications for the work you do collectively? Are there any you would wish to change and develop?
• Gather some feedback from colleagues around how your presence, language and action contributes to organisational culture?

Provocation 10: What if organisational culture is best discovered on the boundaries?

The idea here is that organisational cultures are not a unified whole, but rather composed of a set of micro-cultures each overlain and continuously interacting at boundaries. Can OD practitioners, by exploring and working at these boundaries, discover more about the nature of the patterns of relating between micro-cultures and their impact on the whole organisational context?

This idea also asks us to consider the nature of the boundaries. Are they perceived as very fixed, with people talking about ‘silos,’ or do they have a degree of fluidity? Do the boundaries extend outside of organisational boundaries and, if they do, what does this mean for understanding how organisational cultures are shaped by external patterns of relating?

In work we are familiar with boundary distinctions as part of formal organisation. Jobs are often defined by their role description. This entails a set of points about the responsibilities and duties of a role within a specific organisational context, and a wider industry or system environment.

What is the relationship between a role and boundaries? Often a role will be designed and structured in a functional correspondence to tasks and activities. These tasks may be defined by their skill level and level of expertise. This kind of identification is similar to the nucleus of a cell, it encodes what it performs. The longer we stay within a boundary as a practitioner, the more likely we are to become habituated into a specific set of routines and behaviours: what is often called competence. We can understand the functioning of a role along different dimensions. Often, efficiency and productivity are standard concepts, but there are many others. The longer someone practices a specific task, the better they will get, according to the 10,000-hours rule of expertise (Hambrick et al. 2014) 81 . Practising builds experience, knowledge, memory, decision heuristics, and muscle memory. This is the benefit of boundaries; they lead to refinement.

The downsides of fixed boundaries are familiar to us in organisational life. There is the well-known silo effect (Tett, 2015) 82 . The dysfunctions of bureaucracy and formal departmental boundaries lead to a long list of dysfunctions of a mechanical organisation: lack of integration; dehumanising work environment; operating procedures crowding out exploration and adaptation; efficiency preferred over effectiveness; and competition between individuals, teams, and departments within the same organisation. When there is a sense of a holistic boundary at one level, says the organisation, the boundaries at layers beneath this, the individual, team, and project, are seen to be in service to the high level. This is the basic idea of hierarchy of functions and identity. The argument against relying on silos is one of alternatives and possibilities and the psychosocial experience of being imprisoned. The fixed boundary leads to exploitation of resources, not exploration of possible uses of resources.

Boundaries can then lead to practices and behaviours that are out of shape, old, disused, and decaying. Without new growth and new inputs of energy and resources, living things gradually die. This is the kind of boundary that OD practitioners often encounter and struggle with. We therefore come to the tension within human organisations between fixed boundaries and flexible boundaries. Clearly, some boundaries are more fixed than others. It is conversations between those on either side of the boundary that lead to more fluidity. How do you identify fixed boundaries at work and how can you help make them more fluid?

One potential answer to this question is to test out what might happen if we design roles to be fluid rather than fixed? To do this, a discussion of roles needs to get beyond individual tasks and responsibilities to consider roles as relationships. Roles do not only define what the role incumbent does, but also what others they interact with should also do. This is a theatre analogy of organisations: everyone plays their part on the stage. The duties of work roles within service settings often involve doing things to, or with, service users. For example, this might be to ensure patient safety or enhance student experience. This has implications for the role of those other actors. In role theory, the idea of the role set is a powerful idea because it places any individual role into a web of relationships. Each role defines and shapes other roles with which it comes into contact. Roles are effectively mutually constitutive: there can be no ‘teacher’ without a ‘student,’ no ‘doctor’ without a ‘patient,’ and no ‘leader’ without a ‘follower.’

This process of defining mutual service positions through a service encounter naturally creates a service boundary. At each boundary there is a potential for it to be ‘hard’ with one person or group defining boundaries, or more fluid where there is a shared understanding of the roles each party plays. Just as this happens in a micro sense in each service encounter, so it happens at an organisational and system level. OD practitioners can offer expertise in helping people see the boundaries, explore, and learn from them. 83

Beverly and Etienne Wenger-Trayner (2015) 84 suggest OD practitioners must consider boundaries as learning assets rather than as obstacles or things we need to somehow remove. By seeing boundaries as assets, we recognise the challenge of crossing boundaries of all kinds, especially given the tensions or contradictions between different practices as sources of accountability. The same authors offer the following helpful set of questions when thinking of boundaries as assets:

• What kinds of boundary activity, joint project, visit, mutual storytelling, or learning partnership can serve as a productive encounter for negotiating and exploring a boundary?
• How can boundaries be used to trigger a reflection process about the projects on either side?
• What kind of boundary objects (documents, templates, materials) and activities can support this boundary-oriented learning approach and create points of focus for engaging multiple perspective?
• Who can act as brokers to articulate regimes of competence across boundaries?

Standing on a boundary and looking across in different directions is a way to understand competing learning perspectives. It also offers OD practitioners clues and insights into the dynamics of organisational culture that otherwise might be missed when the perspective often taken is a top down one from the board.

• collectively map with colleagues the boundaries that impact on your team?
• identify how you might work with the boundaries that you perceive exist?
• find a multi-professional team with whom you can discuss the boundaries they perceive to exist and how it impacts on them?

discuss with OD colleagues what might happen if OD practitioners intentionally focused on enabling learning at the boundaries as integral to both organisational and ICS culture development?

Stefan’s work prompted us to think about the following ten questions for you to consider as you plan the next steps of your culture change journey:

• What are your own clear beliefs about culture change and how has this changed?
• What are the contextual conditions shaping your organisation / system right now?
• What assumptions do you make about change in your organisation and how do you know?
• What are the stories about culture change told in your organisation that could be re-framed into a new narrative?
• What is the immediate trigger for culture change?
• What does organisation development look and feel like in your organisation now?
• What OD theories and models have shaped your past culture change efforts and are they appropriate for the future?
• What practical tools and people resources do you have to support you in this work?
• What is the story about culture change that needs to be disrupted?
• What is the next most important conversation you need to have?

(Adapted from Angus, Dumain and Taylor-Pitt, 2017)

Further reading on culture change

• Inclusive culture: North East London NHS Foundation Trust Find out how one NHS trust improved its culture by putting people first, engaging with staff and ensuring its recruitment process was inclusive.
• Implementing a just and learning culture Read how Mersey Care NHS Foundation Trust implemented a just and learning culture and the impact it has had on its workforce.
• Improving staff engagement, the Chesterfield way Explore how Chesterfield Royal Hospital NHS Foundation Trust improved its NHS Staff Survey results through a programme of staff engagement using Listening into action .

Culture tools and approaches 

• NHS England’s Culture and leadership programme provides a practical, evidence-based approach to help you understand how colleagues working within your organisation or system perceive the current culture, and guides you to create and implement a collective leadership strategy.
• The King’s Fund have a tool to help organisations assess their culture , identifying the ways in which it is working well, as well as the areas that need to change.
• Members of our NHS Do OD community have recommended Affina OD and People Centred Insights  for assessing organisational culture.

Interesting reads, video and online resources

• The book Organizational change explained features a chapter by Do OD’s Paul Taylor-Pitt and Karen Dumain with Kelly Angus on changing culture in the NHS (you can read the chapter for free as part of the Google Books preview).
• Working on organisational culture in COVID-19 - a blog post by Tom Kenward on using the NHS England and Improvement’s culture and leadership toolkit.
• Mee Yan Cheung Judge’s Just in case podcast series features conversations with leading OD thinkers. Bob Marshak has recorded one on the Hidden dynamics of organisational change .
• This presentation on the challenge of culture change in the NHS from the Health Services Research UK 2020 conference explores, through three linked presentations, the problems and opportunities associated with changing healthcare organisation cultures.
• The HSJ published an article on managing cultural change in a crisis .
• This article from the BMJ looks at how notions of culture relate to service performance, quality, safety, and improvement.
• Access Hofstedes model of organisation culture .

We are keen to hear from you

Share your good practice examples of changing culture or let us know how you’ve used the provocations in your own culture work by getting in touch with us at [email protected].

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Being fair 2 – improving organisational culture in the NHS

Date published: 30th March 2023

Being fair 2 aims to promote the value of a person-centred workplace that is compassionate, safe and fair.

A just and learning culture is the balance of fairness, justice, learning – and taking responsibility for actions. It is not about seeking to blame the individuals involved when care in the NHS goes wrong, nor the absence of responsibility and accountability.

Since the publication of Being fair in July 2019, and with ongoing work across the NHS, it is apparent that organisations still require support to improve the culture for those working within the health system to tackle issues of incivility, bullying and harassment.

Our second Being fair report sets out the benefits to an organisation of adopting a more reflective approach to learning from incidents and supporting staff.

Download the Being fair 2 report here

The key messages from the report are:

• There is a clear link between culture, workforce and patient safety.
• A poor culture is costly : The cost of non-clinical, work-related stress claims closed over a ten-year period (2010-2020) was in excess of £14 million.
• Minority groups are disproportionately impacted by formal disciplinary processes : Our Practitioner Performance Advice service found that ethnic minority groups had 1.7 times the rate of cases per 1000 and were significantly more likely to have a case with the service compared with white practitioners. Redressing disproportionate rates of disciplinary action between ethnic minority and white staff across the healthcare system is essential to foster a just system that supports staff to learn from incidents. This is in line with other recent findings.
• A diverse and inclusive working environment is beneficial for productivity and staff retention : When staff feel valued, able to speak up and psychologically safe this can have a positive impact on teamwork, staff wellbeing, efficiency and lead to higher standards of patient care.

There is already a wealth of resources and guidance available across the system to support organisations to drive improvements in culture. This report makes reference to key guidance and best practice throughout. It also provides a ‘Just and learning culture charter’ that we invite organisations to consider adopting.

Organisational culture is everyone’s business. Everyone within healthcare has an important role to play, across all professional groups and at all levels. We hope this report acts as a toolkit for organisations looking to adopt a just culture when managing incidents and supporting staff.

We are grateful to a wide range of organisations who have contributed to this report including the Care Quality Commission, British Medical Association, Royal College of Nursing, Health and Care Professions Council, The National Guardian’s Office, NHS England, the General Medical Council and others.

At NHS Resolution, we provide expertise to the NHS to resolve concerns and disputes fairly, share learning for improvement and to help preserve resources for patient care. Our work and the work of others across the system has identified that issues of incivility, bullying and harassment are prevalent across the NHS. This has a negative impact on staff recruitment, retention and overall wellbeing. We hope this document highlights not only the importance of this issue but encourages organisations to take an evidence-based approach to improving organisational culture. We will continue to work with key partners to ensure the best practice referenced throughout the report is implemented. Dr Denise Chaffer, Director of Safety and Learning, NHS Resolution

Being Fair 2 uses Practitioner Performance Advice’s experience and expertise to strengthen its recommendations. Our findings show that practitioners from ethnic minority groups and those who qualify outside the UK are statistically more likely to have a case with us compared to white practitioners who qualify in the UK. This is an important contribution to the discussion and highlights the need to redress disproportionate rates of disciplinary action through agreed frameworks that support a consistent approach for everyone. The report also highlights the significant link between organisational culture and individual behaviours, emphasising how fairness and open cultures of continuous quality improvement can improve staff wellbeing and patient safety. This link is explored as part of the advice that we provide and is also a key driver for our Compassionate Conversations programme, which aims to support honest conversations on practitioner performance. Vicky Voller, Director of Advice and Appeals, NHS Resolution

Recent years have seen a growing evidence base linking organisational culture, and the behaviours it enables or incentivises, and patient care. One aspect of this is whether organisations and individual managers respond when things don’t go as planned. Initiatives such as the ‘Just culture’ movement seek to emphasise learning not blame when things go wrong. The use of accountability nudges at the point of incident have helped to reduce biased decisions to disproportionately investigate ethnic minority groups when incidents occur. This revised version of the original Being fair report will build on that work which has already helped to significantly reduce the numbers of disciplinary cases in the NHS and reduce the relative likelihood of ethnic minority staff entering the disciplinary process. The resultant emphasis on learning not blame inevitably benefits patient care. Roger Kline OBE, Research Fellow at Middlesex University Business School and one of the report authors

I welcome NHS Resolution’s Being fair 2 report, promoting a person-centred workplace that is compassionate, safe and fair. This is important given the recent news of the decrease in workers’ confidence to speak up in this year’s NHS Staff Survey results. No one should feel they cannot speak up to protect their patients or their colleagues. As highlighted in the report, ensuring effective speaking up arrangements are truly embedded and at the heart of any healthcare organisation is key to improving workplace culture. While Freedom to Speak Up guardians are an additional route for workers to speak up, they cannot improve the speaking up culture on their own and organisations must take a proactive approach to foster a culture where all workers feel safe to speak up and feel heard. Dr Jayne Chidgey-Clark, National Guardian for the NHS

In line with Being fair 2 , we’re clear that a just culture – that balances fairness, learning and accountability – is key to ensuring safe, effective and kind care for people who use services. Everyone working in healthcare has a responsibility to foster these positive working cultures. That includes being open and candid with the people in your care about all aspects of care and treatment, including when any mistakes or harm have taken place. This means lessons can be learnt quickly to protect people from harm in the future. Our Code also encourages each nurse, midwife, and nursing associate to speak up if they see something they feel isn’t right – all professionals should be able to without fear of being discriminated, excluded, victimised, bullied or undermined. Anne Trotter, Assistant Director of Professional Practice, Nursing and Midwifery Council

We know that the right organisational culture is crucial to safety and, as demonstrated in recent reports such the Ockenden review, the impact workforce wellbeing has on patient safety is also becoming increasingly evident. How an organisation responds to bullying and harassment can have a massive impact on individuals and the quality of care provided, as well as other important factors like staff recruitment and retention. CQC’s strategy is clear that learning and improvement must be the primary response to all safety concerns and in order to achieve this, staff should be able to report concerns openly and honestly, confident that they won’t be blamed and that their voices will be listened to and acted on. Being fair 2, and the just and learning culture charter that accompanies it, will help organisations promote a workplace that is compassionate, safe and fair – benefitting both their staff and the patients they care for. Dr Sean O’Kelly, Chief Inspector of Healthcare, Care Quality Commission

We welcome NHS Resolution’s Being fair 2 report which highlights the need to focus on the wellbeing and retention of healthcare staff; reduce stress and incidents of bullying, harassment or assaults; and to work together to instil fair, learning cultures in the workplace. The data is clear, we must do more to turn the tide of talented registrants leaving the NHS. Creating compassionate leadership and safe, supportive working environments are absolutely vital, not only to the welfare of doctors, but also to the future of the NHS and to the safety of patients. We’re taking firm steps to achieve long-lasting change and support the wider health system to overcome barriers to change. We have accelerated our commitment to eliminate disproportionate complaints from employers about ethnic minority doctors by 2026, and to eradicate disadvantage and discrimination in medical education and training by 2031. Additionally, we continue to deliver our Welcome to UK practice workshops. And we’ve developed the Professional Behaviours and Patient Safety training programme which discusses ways of responding to unprofessional behaviours, because everyone is entitled to be treated with courtesy and dignity in the workplace. Taking practical steps to improve doctors’ working environments will not only improve their wellbeing, but will help retain their skills and experience. If doctors are happier in their working environments, and they are allowed to thrive, they will achieve better results, which will support patient safety. Anna Rowland, Assistant Director of Policy and Business Transformation, General Medical Council

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Nhs Racism Report Roger Kline

Search the website, racism remains embedded in nhs organisational culture - study.

6 February 2024

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New MDX-backed report shows the health service is still falling short in tackling discrimination

NHS leaders are urged to listen to, and act on, the concerns of their black and minority ethnic staff following the launch of a new report today (6/2) by Middlesex University academics and human rights charity Brap that found racial prejudice remains embedded in the health service despite initiatives to remove it.

The 66-page report,  Too Hot To Handle: An Investigation Into Racism In The NHS,  shines a light on the problem and the failure of healthcare organisations to provide a safe and effective means for listening to and dealing with concerns raised by BME staff. The study, co-authored by Roger Kline, Research Fellow in the University’s Business School, and Prof Joy Warmington, Middlesex University Visiting Professor of Education and Brap Chief Executive Officer, found there was a culture of avoidance, defensiveness, or minimization of the issue from their employer if they did so. The report’s findings were partly based on a survey of more than 1,300 NHS staff, who were asked if they experienced racism and what form it took. Among the results, the survey found:

• 71% of UK-trained staff complained of race discrimination.
• 63% said their performance or behavior was subjected to a greater degree of scrutiny than that of white colleagues.
• Over half (52.5%) said they had not been offered development opportunities.
• Over half (53.2%) said they heard a colleague or patient make an assumption about someone based on their race or nationality.
• 49% said they had been denied promotion opportunities.
• A third said colleagues spoke to them rudely or in a different way to other colleagues.
• Almost a quarter were left without support when patients were racist towards them.

Many respondents said they were reluctant to challenge experiences of racism, with the most common reason (75.7% in the survey) that they did not believe anything would change. Staff who did not raise concerns were worried about being seen as a troublemaker, or worried about repercussions from their line manager or other organisational leaders. Of those who raised concerns, only about 5% said their problem was dealt with satisfactorily.

“Our report found that BME staff still face serious challenges in raising complaints of racism and this has an impact on staff morale, progression and recruitment, and potentially on patient care if staff feel under-valued and badly treated,” said Mr Kline. “In the NHS, where a quarter of staff have BME heritage and a significant proportion of patients do too, this is not a marginal issue and nor is it a new one.” The investigation was prompted by several recent NHS employment tribunal race discrimination cases, most notably that won by senior nurse Michelle Cox which highlighted the shortcomings of how the health service in England handles incidents of racism. It draws on lessons from those tribunals as well as evidence from the survey which aimed to understand both personal experiences of racism and the institutional responses that followed when allegations of discrimination were raised. Pulling this evidence together, the researchers found extensive correlation between the survey responses and findings that emerged from the tribunals they examined and other recent literature they reviewed. “Our report shows that the NHS is not addressing racism effectively, and that many organisations respond by challenging or ignoring allegations of racism rather than taking them seriously,” said Prof Warmington. “BME staff are still anxious about raising concerns, worried about the consequences if they do, and see little or no action if they do raise concerns.” This latest report comes 10 years after The Snowy White Peaks of the NHS, a landmark study by Mr Kline which found that BME staff were largely excluded from senior positions in the NHS, especially in London. “Too little has improved or changed since my report a decade ago,” he said. “There has been some progress but overall the NHS needs to get a grip on this issue.” Drawing on their research and the wider literature, the researchers make recommendations to NHS Trust boards and human resources departments. Healthcare organisations need to adopt a culture where racism is spoken about routinely and understood as being maintained by organisational culture. Trust boards can create an early reporting system that flags up opportunities for intervention. Increasingly, NHS organisations are adopting ‘behavioral standards’ which govern values and employee behavior and this also provides an opportunity for employers to introduce expectations of behaviour with regards to ‘race’ and the consequences for breaching them.

The report argues that NHS employers need to be proactive and preventative, not relying on individual staff to raise concerns but instead be problem sensing and curious.

The research coincides with a series of webinars launched by Middlesex University Business School to explore key concepts of leadership, culture, and treatment of staff and patients in the NHS. The issues being covered in the webinars are a prelude to a Doctorate in Business Administration course being launched in September 2024 which will focus on leadership and culture in healthcare.

Read the full report:  Too Hot To Handle: An Investigation Into Racism In The NHS.

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• http://orcid.org/0000-0002-1762-7606 Kate Kirk
• University of Leicester , Leicester , UK
• Correspondence to Dr Kate Kirk, University of Leicester, Leicester, UK; kate.kirk{at}leicester.ac.uk

https://doi.org/10.1136/bmjqs-2024-017236

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• Patient safety
• Health services research

The COVID-19 pandemic shone a light on the work and needs of the healthcare workforce like never before, resulting in an increased focus of workforce well-being research, policy and within mainstream media. Despite this recent attention, the relevance of workforce well-being for healthcare delivery and efficiency is not a new phenomenon. The National Health Service (NHS) in England employs around 1.4 million people, 1 and as such provides a prominent case study for these issues. A landmark report in 2009 by Dr Steve Boorman (commissioned by the English Department of Health 2 ) reviewed the health and well-being of the NHS workforce in England. The report highlighted issues with poor well-being, sickness and the likely relationship between workforce well-being and patient outcomes. Recommendations were outlined to reduce staff sickness and improve experiences of work, with cost savings predicted at £500 million per year if sickness was reduced by a third. Dr Boorman’s report was one of the first calls for change and many have since followed.

Forward to 2024 and the NHS workforce is experiencing unprecedented demand with systemic stress, burnout and sickness alongside the psychological legacy of the pandemic. 3 Sickness rates in the NHS are higher than in the rest of the economy. 4 In 2023, around 42% of staff felt unwell in the last 12 months as a direct result of workplace stress and just under 55% had come to work in the last 3 months despite not feeling well enough to do their duties, known as ‘presenteeism’. It is important to note that for this most recent round of the NHS Staff Survey, 5 48% of staff completed the survey; some argue this in itself speaks loudly to how staff in the NHS feel, given that 52% did not complete it. 6 Recent analysis by the International Public Policy Observatory, via The University of East Anglia and RAND Europe, estimated the cost of poor mental health and well-being to NHS England might amount to £12.1 billion per year. 7

Workforce well-being issues are fundamental for retention and the delivery of quality healthcare, yet can be labelled as ‘soft’ and easily overlooked compared with more technical aspects of healthcare management. This is regardless of the evidence showing that where staff well-being is prioritised, patients are safer. Despite these observations in the academic literature, the prioritisation and management of workforce well-being in practice are complex. In line with this complexity, in this issue of BMJ Quality and Safety , Taylor et al 8 used a fitting realist lens to synthesise literature on the causes of psychological ill-health and interventions designed to support the workforce. Their study focusses specifically on nurses, midwives and paramedics as these groups make up around 30% of the total NHS workforce and over half of the clinical workforce. The realist analyses drew on initial theory development from 8 key reports and 159 sources. The authors identified 26 context–mechanism–outcome configurations: 16 explaining causes of psychological ill-health and the other 10 helping to explain why well-being interventions have not worked to mitigate psychological ill-health. These were synthesised into five key findings:

A blame culture makes psychological well-being difficult to promote.

System needs frequently over-ride staff psychological well-being.

Implementing and upholding values at work often have unintended personal consequences for staff.

Interventions designed to support well-being are usually focused on the individual and fail to recognise cumulative chronic stressors.

Identifying and implementing interventions is challenging.

Through their analysis, the authors identified several tensions between the realities of healthcare delivery that seem incompatible with and affect the psychological ill-health of the workforce. Therefore, they call for an urgent need to restore the balance in four key areas and prioritise multilevel systems approaches that consider the conflicting demands between meeting service delivery requirements, and protecting the workforce:

Psychological harm to frontline healthcare workers should be anticipated and planned for.

Listening and learning cultures should be balanced with the need for professional accountability.

Interventions that are reactive in nature (usually in response to traumatic events) must be balanced with proactive preventative interventions.

An individual focus where feeling blamed for their own psychological ill-health must be balanced with an organisational focus to address systematic issues—A systems approach to staff psychological well-being is needed, which balances individual responsibility for psychological ill-health with organisational responsibility, interventions and bundles of support.

The unique contribution of the study relates, in part, to the use of a realist methodology, which has facilitated insights into the complexity of healthcare environment context(s). As the authors note, previous studies have failed to explore this sufficiently and have often focused on individual professional groups. Studying across groups and subsequently across contexts stands to gain a deeper exploration of cross-disciplinary challenges.

Emotional ‘cost’ of care and mechanisms ofsupport

Psychological ill-health is a product of cumulative stress as well as exposure to individual traumatic events. The emotional complexity of healthcare delivery is intensely stressful and rarely acknowledged or recognised, 9 even though heightened emotional experiences affect clinical decision-making and play an integral part in care delivery and patient safety. 10

This labour is not without cost to the individual, one of many unintended personal costs of upholding and implementing values as shown by Taylor et al . Certain types of emotional labour (namely ‘deep acting’, where staff try to manipulate true feelings to conform to the ‘expected’ emotional display) are related to burnout, poor well-being and intention to leave. 13 This can result in secondary trauma, ‘moral injury’, suppressing guilt, frustration and grief as staff are unable to deliver care which aligns with their professional values. 14 In a study undertaken during the COVID-19 pandemic, healthcare workers were twice as likely as the general population to experience post-traumatic stress disorder, and one in five met the threshold for conditions such as anxiety and depression. 15

In practice though, strategies to address psychological well-being often focus on strengthening an individual’s resilience and are usually designed to respond to acute trauma (eg, trauma-focused peer support known as ‘TRiM’) rather than considering cumulative stress and moral injury. Many argue that placing the emphasis on individual resilience as an inherent quality is further damaging to staff and ignores organisational responsibility, 16 particularly at a time when the workforce is already showing great resilience. Concurrently, as shown by Taylor et al , the absence of a structured approach to workforce well-being means implementation is challenging. Front-line staff often struggle to access interventions in a meaningful way. Organisational challenges and culture prevent staff, particularly more junior staff, from accessing support. 17 Taylor et al call for whole-system approaches to improving well-being, with organisation-wide interventions and bundles of support, which are preventative as well as reactive; a request echoed in the wider literature. 3

Staff well-being as the foundation to improve patient safety

We know that over time, as staff suppress their true emotion (deep acting), they experience compassion fatigue and can become numb to the suffering of others, described by Taylor et al as a ‘buffer’ against secondary trauma. Ultimately and unsurprisingly, staff with better well-being are more likely to deliver compassionate care. 4 18

Psychological well-being is also intrinsic to clinical safety outcomes. This is evident in two ways. First, staff who are well deliver safer care and are less likely to make clinical errors. 19 20 Second, when staff are well, they are less likely to be absent. Staff who are off sick from work contribute to depleted staffing which is fundamental for patient safety. In nursing, for example, when staffing is reduced and/or skill mix is poor, patients are more likely to die 21 and any resulting care left ‘undone’ results in poor patient experience. Patients in hospitals with highest patient to lowest nurse ratios have 26% higher mortality (95% CI: 12% to 49%) 22 with more recent research echoing the same. In addition, the nurses left behind are twice as likely to be dissatisfied with their jobs, to show high burnout levels, and to report low or deteriorating quality of care in their hospitals, 21 continuing the cycle.

Although the impact of the experience of the workforce, their emotion and psychological well-being on patient safety is evident, these issues are often considered separately in healthcare management. Taylor et al highlight the lack of attention by regulatory bodies and NHS organisations to consider wider workforce issues when managing clinical error with catastrophic outcomes for those staff involved (secondary trauma and suicidal ideation). Similarly, wider ‘solutions’ to patient safety culture in academic literature can also fail to (explicitly) acknowledge, how critical an adequate and well workforce is to their likely success. The same considerations can be applied to many initiatives that stand to improve care. For example, most attempts to improve patient experience, care quality and increase efficiency in healthcare practice all require the workforce at their core but this acknowledgement is not always obvious. Based on growing evidence showing the relevance of psychological well-being for patient safety, it seems unlikely that safety culture and other initiatives that begin without an adequate and psychological well workforce will produce the desired results or ability to sustain them.

Where next?

There is a growing body of literature confirming the relationship between workforce well-being and patient experience and outcomes. Economic evaluations have outlined potential cost savings into the billions. 7 Concurrently, there are a range of interventions shown to improve the well-being of the workforce and staff’s experiences of delivering care. Yet poor well-being, sickness and retention issues persist and are significantly impacting the NHS’s ability to deliver safe care, and similarly in other countries. Psychological ill-health is, as Taylor et al argue, highly prevalent across the workforce. Although their paper draws attention to the challenges faced by nurses, midwives and paramedics due to their dominance in the clinical field, there is likely to be transferability to other staff groups. This opens up future research opportunities which include other allied health professionals alongside ‘non-qualified’/registered staff. Their study shows the causative explanations of tension, created as organisations juggle between healthcare delivery and the needs of the workforce and how some of these tensions are incompatible.

The call for an urgent rebalance in healthcare working environments to enable healthcare staff to recover and, ultimately, thrive is therefore timely and requires action. A shift to the needs of the workforce as a priority is supported widely in the academic literature and is welcome, but needs to be translated into concrete initiatives in practice. This calls for an open conversation that balances the current risk to patient safety posed by a depleted and unwell workforce versus the likely gains of prioritising the needs of the workforce going forward. Practical measures could be the inclusion of workforce well-being metrics from health and professional regulators. However, caution should be taken that mandating elements of well-being does not become a ‘tick box’ exercise when actualised at a local level.

Ultimately, in support of this rebalance, it is of paramount importance that a fully-staffed, psychologically well workforce is seen as ‘the’ foundational patient safety intervention across practice, policy and research going forward. For example, as researchers, we have a responsibility to make these links obvious when planning, undertaking and publishing our work. Until then, other efforts to improve efficiency, patient experience and safety outcomes can be seen as building a house without laying the foundations… or as one clinical leader told me; the ‘cherry’ on a cake without the flour.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

• The Kings Fund
• Edwards N ,
• NHS England
• The International Public Policy Observatory
• Jagosh J , et al
• Harrison R , et al
• Hochschild AR
• Alderson M ,
• Edgley A , et al
• Stevelink SAM ,
• Gafoor R , et al
• Dawson J , et al
• Sermeus W ,
• Van den Heede K , et al
• Johnson J ,
• Watt I , et al
• Edmondson AC
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X @KateLKirk

Contributors n/a.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Provenance and peer review Commissioned; internally peer reviewed.

Linked Articles

• Systematic review Care Under Pressure 2: a realist synthesis of causes and interventions to mitigate psychological ill health in nurses, midwives and paramedics Cath Taylor Jill Maben Justin Jagosh Daniele Carrieri Simon Briscoe Naomi Klepacz Karen Mattick BMJ Quality & Safety 2024; - Published Online First: 04 Apr 2024. doi: 10.1136/bmjqs-2023-016468

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Opinion What will the Cass Review of treatment for trans kids mean for America?

Regarding Paul Garcia-Ryan’s April 19 op-ed, “ Youth gender care is resting on shaky ground ”:

As a parent of a gender-expansive child, and someone who works with the families of such children regularly, I believe The Post should approach the Cass Review — a report on the gender identity services offered through England’s National Health Service and a set of recommendations about how the NHS should develop its standards of care going forward — with a more critical eye.

The op-ed, as well as the Associated Press article “ A major UK report says trans children are being let down by toxic debate and lack of evidence ,” did not address questions regarding which studies were included in the Cass Review’s survey of evidence, which were excluded and whether Dr. Hilary Cass and the researchers at the University of York who conducted a review of the scientific literature used the appropriate standards to determine whether research was sound. The report claims there is “no good evidence on the long-term outcomes of interventions to manage gender-related distress.” But surely gender-expansive adults who had medical interventions when they were younger exist? Why are their voices not “high-quality” enough to serve as evidence?

The articles lean heavily on the Cass Review’s statements that there is “lack of evidence” and a “toxic political debate” around this topic. I actually agree: Trans kids are being let down by these things, but not in the same way the authors of these pieces do.

Where are the voices of children who have socially transitioned and are thriving? Teens who take hormones and are doing great in school and in life? Don’t try to tell me they don’t exist: There’s one in my kitchen right now! But the way the report covers this makes it seem as though they’re unicorns, some mythological beings only seen in left-wing literature. Their voices deserve a prominent place in The Post’s and the AP’s reporting.

Gender-expansive children exist. Younger generations are approaching gender differently. As such, we are probably going to see more gender exploration than we ever did. Does that mean all of these children are going to grow up to be gender-expansive adults? No. That is what “exploration” means. I think in the “old days” of the 2000s, primarily children with strong gender dysphoria came out. Treatment was probably more clear-cut. Today, it might be less so. More children might be “trying on” gender identities. Treatment should adapt. But this does not mean treatment should be banned, which is what many states and institutions are using the weight of the Cass Review to do.

Tina Neal , Bryn Mawr, Pa.

The writer is the founder of Tertium Quid, a nonprofit support organization.

I am in a support group for parents of trans-identified youths, and many of us have similar stories. Our once-happy kids spent more time online during school closures. After going down rabbit holes on Reddit, Tumblr and Discord, they discovered groups of people talking about gender. Their curiosity became an obsession, and they announced a “trans” identity soon after.

Many of us observed that our children’s obsession was accompanied by uncharacteristic displays of anger, self-harm, anxiety, depression and estrangement from the family. These personality changes and behaviors intensified after our children announced their new gender identities, even if we affirmed them.

Declaring themselves transgender has dramatically worsened our kids’ mental health. The professionals we’ve turned to for help have simply been unwilling to listen to any broader context we shared with them.

Until recently, we have not been able to speak about our pain, because the topic has been off-limits. With publication of the Cass Review, perhaps now we can speak more freely.

K.A. Lynne , Orlando

I am a physician with special interest in the evidence behind medical strategies to affirm a trans identity, and have followed the Cass study for at least two years. The detailed final review is a huge resource for medicine and the broader society as we try to sort out what actually helps gender-dysphoric kids. Unfortunately, opinions on gender identity have become aligned with political identity in the United States. With the Cass Review, Britain is taking the lead in getting politics out of gender care. Our country should follow Britain’s example.

The Post took early leadership in covering questioning voices back in 2021 when it published an op-ed by Erica Anderson and Laura Edwards-Leeper advocating gender exploratory treatment as a first step for gender-questioning kids. That was a good start, but with the release of the Cass Review, journalists now have an enormous opportunity to inject more and better science into the American debate.

Mark Buchanan , Avon, Conn.

A step backward for students’ rights

Regarding the April 20 front-page article “ Title IX widened for trans students ”:

As an attorney who defends students accused in Title IX proceedings. I was distressed to read about the new rules approved by the Biden administration that backslide on the rights to cross-examination guaranteed by the regulations promulgated by then-Education Secretary Betsy DeVos during the Trump years.

It is difficult to imagine how one-sided and unfair these proceedings can be. The schools are under pressure from the Education Department to assure that they are doing everything possible to combat sexual misconduct, and are subject to financial penalties if they are deemed to have fallen short. Before the DeVos rules, the university hired a “neutral” investigator that heard from both parties and made a recommendation — informed by a mere preponderance of the evidence — to a rubber-stamp tribunal. In some schools, the investigator was also charged with acting as the prosecutor, judge and jury.

Under the rules now being discarded, each party had the right to cross-examine participants and witnesses at a live hearing to test the credibility of the testimony. Now, we will return to a system where the alleged victim’s story is not tested by serious questions. In every instance in our legal system, except in student disciplinary proceedings, a participant has a right to confront an adverse witness by cross-examination. In Maryland, you can confront your adversary in a zoning hearing, but not when your ability to graduate or to seek a further degree can be determined by a disgruntled former partner who now reviews the relationship in a different light. In every instance, a crime victim must get on the witness stand and be subjected to the testing of that testimony by cross-examination. Even Justice Ruth Bader Ginsburg, a feminist icon, expressed dismay at the restriction of due process rights in Title IX proceedings. Is our current crop of college students so devoid of agency that they cannot be trusted to stand on their own two feet and tell their story and have that story tested for credibility and truthfulness?

As a liberal, I always believed that due process was for everyone, not just for the group allied with one’s political cause. It appears the Biden administration has forgotten that.

Ronald L. Schwartz , College Park, Md.

A cruel tradition

Regarding the April 21 front-page article “ A legendary cowboy’s last ride ”:

Here’s hoping that Post sports columnist Sally Jenkins will do a follow-up rodeo story, one from the animals’ point of view.

Rodeo is not a true “sport.” That term denotes willing, evenly matched participants. Rodeo doesn’t qualify. Rather, it’s mostly hype, a macho exercise in domination that has little to do with ranching. Real working cowboys never routinely rode bulls, wrestled steers, rode bareback or practiced calf roping as a timed event. Nor did they put flank straps on the animals or work them over in the holding chutes with “hotshots,” tail-twisting, kicks and slaps. Hundreds of animals are crippled and killed in rodeo arenas annually, all in the name of “entertainment.” It needs to end.

Consider what legendary labor leader Cesar Chavez wrote in a 1990 letter to me at Action for Animals: “Cruelty, whether directed against human beings or against animals, is not the exclusive province of any one culture or community of people. Racism, economic deprival, dogfighting and cockfighting, bullfighting and rodeos are cut from the same fabric: violence. Only when we have become nonviolent towards all life will we have learned to live well ourselves.” These are words to live by.

Britain outlawed rodeos back in 1934. Can the United States be this far behind?

Eric Mills , Oakland, Calif.

A hopeful dispatch

Regarding Anna Husarska’s April 20 op-ed “ Missiles rain down, tulips bloom, Ukraine soldiers on ”:

Ms. Husarska’s dispatch contains a powerful message. I had a company in Kharkiv, Ukraine, with an office off Freedom Square and a factory outside the city. I saw a country evolve from an economically destitute state following the Soviet breakup to a thriving, vibrant entity.

Kharkiv has a theater similar to Kennedy Center, a magnificent classical organ theater, shops and, most important, a highly educated, entrepreneurial and technically advanced population. The young people were so amazing — and they still are, having maintained their spirit and willingness to die for their independence. We must stay behind these people. They must know they can depend on us.

Howard Pedolsky , Rockville

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• Opinion | What will the Cass Review of treatment for trans kids mean for America? Just now Opinion | What will the Cass Review of treatment for trans kids mean for America? Just now
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