Monday, 14 July 2014

Culture Change in the NHS

Leeds Community Healthcare is currently working in partnership with NHS Employers and Southampton University on a project to understand and support culture changes in the NHS. The project will run until November 2014 with specific outputs on tools for development of new cultural paradigms across the health economy.

The project team comprises of Catherine Hall (Service Manager for Specialist Services), Caroline McNamara (Senior Clinical Lead), Julie Mountain (Head of Adult Neighbourhood Services),  Julie Thornton (Development Lead) and myself.
Much emphasis has been placed on 'culture change' over the past couple of years in the NHS and we have seen forensic examination of system failures across the NHS. The outcome of this has immediate impact on patients and their families and the importance of putting these terrible events right is critical. One of the more astonishing and distressing facts to emerge from the Francis Report for example was the number of instances of not only poor care, but inhumane care. Patients were left lying in their own urine, or were left for hours without food or drink. Psychological studies have helped to shed light on the mechanisms underlying inhumane behaviour, such as ignoring distress and harm to an individual, although it is worth bearing in mind that none of them were caring for vulnerable patients.
Particularly pertinent is the ‘bystander effect’, in which individuals stand by and fail to help a victim in distress. Relevant variables (see Fischer et al, 2011) include the number of bystanders present (more means it is less likely that a victim will be helped); the ambiguity of the situation (more ambiguity leads to less help); and the similarity of the victim to the bystander (the greater the similarity, the more likely that help will be offered). Research has also shown that pressing situational factors may readily override explicitly enounced value systems and beliefs, such that a person in great distress is ignored (Darley & Batson, 1973), something that could find parallels in busy clinical settings.
Also relevant is Philip Zimbardo’s Stanford Prison Experiment (Haney & Zimbardo, 1998) where those who were put in charge of prisoners subjected them to inhumane treatment that seemed to transcend all moral boundaries. Relevant issues are discussed by Miller (2011) and by Haslam and Reicher (2012). The latter’s findings indicate that a positive hospital culture of strong leadership in human values and appropriate peer support should help to counteract any negative tendencies.
The vast majority of NHS organisations run perfectly smoothly and cope extremely well under the pressures that are currently being experienced by staff.  When we hear talk 'in the system' of culture change what do they or we precisely mean? It’s useful to nail down a definition here:
"Culture is a set of shared, taken-for-granted implicit assumptions that members of an organisation hold and that determines how they perceive, think about and react to things (Schein 1992)." In other words it’s 'The way we do things around here'. 
In a recent accompanied visit with a District Nurse to one of the poorer districts within Leeds we visited an elderly couple. The patient we had gone to visit had the start of small ulcer around his bottom and the Nurse had visited to offer treatment and reassurance. We had gone only to see the man for treatment but it quickly became apparent that both needed some form of care. Whilst Elaine was attending to the 'real' patient I chatted to his wife. A large portion of what we both did that morning was not only attending to the patient’s clinical needs but also a whole range of social and psychological support. Most of that was through being interested, curious and listening to stories about their journey through life; where they grew up, which school they went to, what their parents did and noticing the pictures on the wall.  Each photograph telling a story about their lives, the histories of their families and how they had grown up in Leeds. 

Often with huge pressure on their time, nurses (and other care professionals) do this day in day out with care, compassion and attention. This is clearly technical clinical competence done with kindness. We could say that kindness is something, which is generated by an intellectual and emotional understanding that self-interest and the interests of others are bound together, and by acting upon that understanding. Human beings have enormous capacity for kindness. It is this essence that is at the core of our change work in LCH.
If we are to support the changes that are necessary and needed within the NHS we also have to be mindful and supportive about the millions of positive interactions that take place every day across the country. The danger is that we become embroiled in negativity regarding the terrible events such as Mid Staffs without paying attention to the amazing work that takes place. There are things that we are doing and can do provided they make sense to staff and patients and also connect to our values and behaviours.
Culture change is happening all the time and as a reminder of this we only have to look back to how things used to be.  The essence of what we stand for in the NHS will never change, this is the greatest of all platforms with which we can truly 'stand on the shoulders of giants'.
‘We are living in a world of change - the tempo of life has quickened considerably. The wheels of “possibility” in our world of nursing would appear to be turning more swiftly. Many hospitals have been enlarged and new departments have sprung up within them. There is a new look in many of the Wards and Nurses' Homes. Revolution is in progress, and like every transitional condition, it has an upsetting and almost bewildering effect on the various members of our profession. Is it not all the more necessary, therefore, that everything possible should be done to ensure stability and continuity? But one of the main foundations is a sense of community, and all efforts should be made to foster and strengthen the feeling that we are all part of a whole, with a common centre and mutual purpose.’ (The British Nursing Journal September 1951)
Steve Keyes, Head of Organisational Development


Darley, J. & Batson, C. (1973). ‘From Jerusalem to Jericho’: A study of situational and dispositional variables in helping behaviour. Journal of Personality and Social Psychology, 27, 100–108.

Fischer, P., Krueger, J., Greitemeyer, T. et al. (2011). The bystander-effect: A meta-analytic review on bystander intervention in dangerous and nondangerous emergencies. Psychological Bulletin, 137, 517–537.

Haney, C. & Zimbardo, P. (1998). The past and the future of U.S. prison policy. Twenty-five years after the Stanford Prison Experiment. American Psychologist, 53, 709–727.

Haslam, S.A. & Reicher, S. (2012). Contesting the ‘nature’ of conformity: what Milgram and Zimbardo’s studies really show. PLoS Biology, 10, e1001426.

Miller, G. (1969). Psychology as a means of promoting human welfare. American Psychologist, 24, 1063–1075.

Schein E (1992). Organizational culture and leadership. San Francisco: Jossey Bass

The British Nursing Journal, September, 1951.

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