Creating culture at speed in a crisis

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To build a hospital in 13 days is a big challenge. To build a culture in 13 days is an even bigger one. But that is what we had to do at NHS Nightingale Hospital North West.

Our challenge was to create a culture that enabled our people – whether they worked in security, medical services, management, cleaning services or engineering – to be the best they could be in service of the stated purpose of the Nightingale North West – Saving lives. To achieve this, we took a ‘one workforce’ approach to everything we did.

How we organised ourselves
 

Purpose flowchart

In order to create a ‘one workforce’ culture, we looked at four key human factors.

  • Purpose: create a purpose and identity that our people were proud of and attached to.
  • Autonomy: enable our people to be able to make decisions and affect their work environment in service of the purpose.
  • Mastery: enable our people to get better at what they were doing and develop themselves in service of the purpose.
  • Wellbeing: support our people in a real-time, relevant, and transparent way ensuring we had an inclusive environment for all.

Those of you who have read Dan Pink’s book, Drive1, will recognise the roots of his work in this approach but we adapted and added elements to be more relevant to public services.

  • 1. Drive describes the key factors that motivate people. The human need to direct your own life, to learn and create and be driven by a sense of purpose.

Purpose

As human beings we are hard wired to create meaning in what we do and form attachments to others. This is why a congruent purpose and identity are essential parts of a well-functioning organisation. At Nightingale North West, we based our approach to purpose and values on the British Military’s mission command. Mission command provides a clear understanding of ultimate purpose and how this can be achieved (values): centralised intent with decentralised delivery. This approach promotes freedom, speed of action and initiative within defined constraints. A clear purpose (‘Saving lives’) was underpinned by a clear mission (to be the best you can be in the job you are undertaking) and four clear values (support, trust, act and respect) that spoke to the purpose and nature of the organisation.

We didn’t co-create the purpose and values with staff due to the time constraints we had and the mission command approach we took. However, the real value in our approach lay in how we engaged with people on the meaning and implementation of them. I would argue that this was a far more valuable use of time and energy for the workforce as a whole.

A consistent approach to communication and behaviour across the workforce develops cohesive teams. Having an accessible purpose and values allowed everyone to create meaning within the work they were doing and hold each other to account for ‘how we do things around here’.

Autonomy

The advantage of setting up a new organisation is that layers of governance, hierarchy and process have not built up over time. The workforce at Nightingale North West was predominantly from NHS backgrounds and staff feedback told us that people were motivated by the ‘delayering’ of governance and hierarchy. Many of our clinical professionals felt professionally trusted and able to make decisions and changes in a way they had not experienced before. Access to senior clinicians and managers was perceived as easy and effective.

This experience has been replicated across many health and care services during the Covid-19 pandemic, resulting in processes that served the purpose of organisations and enabled the people working in them to work at their best. As the health and care system returns to ‘business as usual’, I would challenge organisations to look to their governance, structure and hierarchy and ask whether these are in service of their organisational purpose and enable people to do their best.

Mastery

A theme throughout our experience was that our people wanted to get better at what they did. We put great value into offering frontline experiences that developed people’s skills and capabilities. Senior clinicians and managers worked hard to pass on knowledge and wisdom through masterclasses and face-to-face support.

At the debriefing sessions delivered before Nightingale North West was put into standby, we heard numerous stories of how staff had developed new skills. Staff said they felt valued and inspired – so much so that some people who had previously worked outside the NHS have now gone on to work for the NHS as a result of their experiences.

Wellbeing

Staff wellbeing took centre stage, both nationally and locally, during the first months of the pandemic and learning from the development and delivery of the wellbeing offer at Nightingale North West has been significant. We considered the physical, practical, and psychological needs of the whole workforce. From socially distanced gym access, through click-and-collect shopping, to onsite processes where staff checked in at the start of their shift with how they were feeling and were given space at the end of the shift to do the same. These offers were accessible and felt relevant to the expressed needs of staff. We aimed to normalise people’s experience and provide them with relevant, simple, and accessible support alongside a compassionate leadership approach. Our offer of psychological support did not pathologise people’s experience of struggling during difficult times into ‘mental health’ issues.

We were clear from the start that equality and inclusion ran throughout our approach and our aim was to build trust and equity. This included building transparent systems and clear ‘freedom-to-speak-up’ processes and access for the whole workforce – including our contractors.

In conclusion

The staff survey results and feedback about the culture we created were excellent. The key learning points are:

  • inspire people with a clear and simple purpose and set of values – and ensure you live them as an organisation and enable your people to make sense of them within their environment
  • ensure your people are supported to have autonomy within their role, to make decisions and changes in a timely way without layers of process hindering their drive or relinquishing accountability
  • wellbeing offers should be rooted in your organisation (remote offers are only relevant where professional help is required) and meet physical, practical, and psychological needs
  • start with an inclusive and transparent mindset. Diverse and inclusive teams operate more effectively and deliver better outcomes for the people they serve
  • governance, structure, and hierarchy are important, but be mindful to ensure they enable people and are in service of the purpose.

Beyond the bricks, mortar, and equipment, we believe that there is much to learn for the health and care system from our experience of building cohesive teams at pace during a crisis. This learning can be applied to our response to the People Plan in whatever health and care system we find ourselves in.

Comments

Robert Varnam

Position
Director of Primary Care Improvement,
Organisation
NHS England and NHS Improvement
Comment date
06 October 2020

Thanks for this fascinating insight into your approach, John. You obviously did a lot of work on the personal and relational aspects of work in designing the culture for the Nightingale hospital. As many leaders have found, autonomy and mastery at an individual level can sometimes make it hard to avoid a lack of cohesive or standardised working, where those would be beneficial for patient safety, clinical effectiveness or productivity. It would be interesting to learn what role you saw for processes of work in that.

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