Creating cultures that put patients first

Recently, at a post-Francis conference, I heard a senior non-clinician tell a story about his experiences on an unscheduled ward walkabout at an acute trust. A ward staff nurse was writing intently at the front station while at least two bells were ringing from nearby patient beds. He noticed the nurse was alone and asked if he could help. She refused politely. He asked what she was doing. ‘Care plans,’ she replied. The trust, she believed, regarded care plans as one of the most important aspects of her job.

The storyteller was incredulous that patients’ needs were denied over the need to complete a care plan and exclaimed to his audience that it is patient care first and foremost that needs attention in today’s NHS. I couldn’t help feeling sorry for the nurse and the frustration she perhaps felt over denying a patient care in order to meet her organisation’s objectives.

Our recent report, Patient-centred leadership, promoted the idea that patients must come first. But it would be wrong to ignore the powerful forces exerted by an organisation’s culture that set the tone and implicit social behaviours of the people who work within it. Most important is the adverse impact that a negative organisational culture has on good patient care. ‘Culture eats strategy for breakfast,’ a colleague reminds our team regularly.

At The King’s Fund we work with high-performing organisations, both here and overseas, and we also support those who are working hard to change their culture to improve the experiences of patients and staff. 

Changing culture doesn’t happen overnight. Robert Francis’s recent report identified the prevailing culture at Mid Staffs as unhealthy and dangerous and this reminded me of the infamous study by Scottish psychoanalyst, Isabel Menzies-Lyth. She looked into how nurses coped with the high levels of tension, anxiety and stress associated with caring for sick people, and found that, on the whole, they didn’t. She witnessed professionals withdrawing emotionally by depersonalising their patients (‘the appendix in bed five’). She also reported how professionals’ feelings were strictly controlled and denied so staff could establish emotional distance from their patients. Sickness absence rates were excessive, as was turnover. The more covert behaviours reported were what Menzies-Lyth described as ‘collusive social redistribution of responsibility’ (blaming others and disciplining them severely) and professionals forcing responsibility up the management chain so that they could disclaim responsibility for their own performance.

This research was conducted in the late 1950s, yet the same behaviours are still seen in all professions, clinical and non-clinical. They are a function of how humans cope with situations that they find extremely difficult and distressing. So if we are to create cultures that put the patient first, we must look after those who care for them. Rather like the flight announcement that reminds you to secure your own oxygen mask before attempting to help others in the event of an emergency.

We need to stop, think and pay attention to our social interactions and their influence on the culture we work in. The culture that patients are treated in is the one that we all work in, and if we are to learn from Francis and truly improve the NHS, it starts with us. Cultural change happens for the better when people help everyone they interact with to feel good about themselves, provide clear instructions, allow autonomy, extend genuine trust and act fairly. For cultural change to be sustainable these behaviours must be evident at all levels; individual, across professions and multidisciplinary teams, and at the very top of each health care organisation with the board being a genuine mirror image of the culture it wishes to lead.

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#40887 Zahurul Sarker
Director (Uzbekistan)
British American Tobacco

Really amazed to see such mission and changing the culture in Health care sector.

#40888 Sandra Pearson
Honorary Consultant P2XZsychiatrist
Devon Partnership NHS Trust

Menzies-Lyth emphasised that primitive anxiety fuelled much of the dysfunctional dynamics involved in caring for seriously ill people and that social systems helped defend those involved against intolerable anxiety. My memory of the paper is that this wasn't just the everyday anxiety of hospital/NHS policy but the existential and deeply disturbing anxiety of life and death and the feelings this invoked. She also wrote about the punitive nursing hierarchy. It is many years since I last read the paper but I do think it's still just as relevant today. I still remember the phrase 'collusive avoidance of responsibility'. In the current health system, there is a risk in too much processing, tick-boxing and policy. The risk is further maladaptive coping by staff too emotionally blunted to care.

#40897 david oliver
consultant physician
royal berks

Dear Zahurul

Lets hope your enthusiasm extends to banning cigarettes or at least making them unaffordable through taxation or putting plain unbranded packaging on them.


#40898 george coxon
Director - care provider and MHNA UK Chair

Im a still registered mental health nurse and also a care home owner subject to balancing the demands of our commissioners and our regulators in regard to culture, quality and viability - a conversation with our CQC inspector visiting one of my homes very early morning this week included the conversation and broad agreement around the principle 'if it is'nt written down it didn't happen' - sadly the original point made by Donna concerning conflicting organisational and patient needs can often place front line staff in very difficult situations. I spent time yesterday with local CCG clinical and senior NHS manager leads where the universal opinion amongst us all related to 'what does good care for the elderly look like?' was a greater need to balance safe with fun - where as much emphasis is placed on residents in care homes having a good time, laughing and having fun as is placed on paperwork and safety

#40906 George

NHS Trusts gain money through achieving government targets such as cquins. Therefore senior management become obsessed with achieving these targets which rely heavily upon masses of nursing documentation being completed. Clearly the nurse in the story above should be answering the call bell. But pressures within organisations to improve documentation that is tied to funding has increasingly taken priority over patient care. Management are not interested in the time I have spent comforting a bereaved relative on my last shift as this is not quantifiable nor will it bring the trust money through cquins. These caring intimate moment's are where true nursing takes place, the value of which cannot be reduced to care plan or recent financial initiative

#40910 yvonne sawbridge
Senior Fellow
University of Birmingham, Health Services Management Centre

This is a great blog and gets us to the heart of the issue- as ours (and many others) research concludes, compassionate care can only be provided by staff who are supported by their organisations in ways which help them perform their emotional labour. The 64 million dollar question is how can we help organisations to do this? That is why HSMC are running a series of action learning sets, aimed at those beginning to think about implementing a system of support.

#40916 Kevin Lewis
Latterly, Director of Personalisation Programme
National Mental Health Development Unit, DH

Donna’s blog and the amplification from Dr Pearson mirror my own experience. As an FT director I observed (I was testing our culture) for 1 ¼ hours, a team of five nurses working industriously on patient related issues – and studiously avoiding eye contact or engagement with the agitated patients milling around the acute mental health ward on the other side of the armoured glass.

I attach no blame to the staff, who were emotionally exhausted and attending to auditable priorities set by the board. Engagement with patients does not show up in metrics, the system blind to the most crucial activity. Mention primitive anxiety at a board meeting and watch the reaction. In the end, the board reaps the culture it sows, but it too is also a victim in a system lacking insight or genuine interest in what really lies behind our collective distress.

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