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Culture starts from the top, but takes root and grows from the bottom

The healthcare industry is doing its very best to take care of all of us and protect our lives, so I believe they deserve our respect and appreciation for the work they do.

But no industry is perfect, and healthcare is no exception. In my 36 years of nursing, I’ve seen that there are certain areas in hospitals that often need improvement to be better equipped to care for those in need. 

The unfortunate reality of healthcare is that the smallest details, if done wrong, can lead to patient harm. 

On top of that, harm doesn’t only happen to patients. Healthcare workers are currently experiencing harm while working on the frontline. Sometimes, it’s part of the job’s risks (like getting sick), but other times, this harm is preventable.

Violence against nurses from patients, for one, is well-documented, and there is reportedly horizontal and vertical violence and bullying behaviour among healthcare professionals themselves. This is something I experienced myself when I was asked by a theatre nurse if “I brought my brain today” back when I was a junior nurse.

One can dismiss these as isolated cases, but the numbers don’t lie: one in every nine patients experience harm while receiving treatment in a healthcare organisation, and one in three doctors in Australia experienced or witnessed bullying, harassment, or discrimination in the past 12 months.

What these statistics tell us is that the issues are both widespread and deeply rooted in the sector. And even when you look at the problem at an organisational level, it’s not one person’s fault; it’s a systemic problem that has evolved over the years. It’s about culture.

This doesn’t mean it can’t be changed. Anything can be changed for the better with the right mindset and determination.

With the issue stemming from a flawed workplace culture, rebuilding this culture from the ground up will do wonders for the quality of service delivery in the healthcare sector.

What is “culture” in healthcare?

Culture, in the context of workplaces, is the mix of an organisation’s values, leadership, interactions, beliefs, behaviours and attitudes that build the environment of the workplace.

It’s no secret that workplace culture significantly affects the productivity of a business. A recent study by Glassdoor revealed that companies with positive work cultures significantly outperformed those with low employee satisfaction.

I’ve worked long enough in the healthcare sector to have experienced a variety of workplace  cultures. I’ve also seen how the perspectives of management and staff, albeit coexisting, have a disconnect. Things that management know are often opaque to frontliners, and issues that frontliners experience rarely ever reach management. The result is that management and staff often don’t see eye-to-eye on matters regarding quality.

This again is no one person’s fault – there is simply a conflict in priority that has been reinforced over time.

However, this disconnect isn’t invisible to all management and frontline staff. In trying to repair the statistics mentioned earlier, many healthcare organisations have started focusing on improving their culture.

This is not a random decision; rather, it is an acknowledgement of several studies that have shown how better culture improves patient outcomes and staff satisfaction.

The best healthcare cultures are those that promote and reward transparency, communication, flexibility, accountability, learning, and continuous improvement.

Some organisations do these things very well. Others, including some I’ve worked at, are genuinely well-intentioned but nevertheless fail to achieve many of their ideals. In some cases, it is as if senior management was following the how-to-create-a good-culture formula and wrote a terrific statement of values, but then gave up on the exercise when it came to implementing and supporting those values.

Of course, building culture is not the job of management alone. Sure, the values, beliefs, and leadership should come from them, but while culture starts from the top, it takes root and grows from the bottom.

In healthcare, it’s when management and frontliners see eye-to-eye in their values and attitudes that they can build a healthy culture where safety and quality come first.

How culture impacts healthcare

Propagating poor culture affects how staff and hospitals operate. Poor culture causes harm not only to the very patients these hospitals are treating, but also to the staff that work there.

Poor culture isn’t always easy to spot, particularly to the casual observer, but there are tell-tale signs of it that I’ve observed across many healthcare organisations. Some of them include:

  • High turnover of staff. Whether it’s due to stress, ill-treatment, dissatisfaction, etc, having many of the staff leave says a lot about how the organisation is being run. 
  • No regular face-to-face meetings between staff and management. While I acknowledge this is difficult during COVID-19, having these meetings ensures that both sides are updated about the goings-on in the organisation and all parties are on the same page regarding their goals and priorities. It is also an opportunity for staff to give feedback to management.
  • Lack of recognition for staff. It can be demoralising for frontliners to work hard without any recognition for their efforts, and no one wants to keep working in a thankless job.
  • Lack of support to improve staff education. Staff education is important in ensuring that all procedures and protocols are done correctly. Additionally, educating staff will help them find better ways and ultimately improve the quality of processes within their organisations.
  • No responses on staff feedback. Not responding or listening to staff feedback invalidates their concerns. 
  • Developments done without consulting staff. When staff are not asked about the design of the facilities they work in or the rollout of new initiatives, this can give the impression that management doesn’t care about what’s good for the staff.
  • No exit interviews. Exit interviews are important in identifying problems and pain points in the organisation and therefore how to address them. 

How to build a positive culture in healthcare 

This image was created by Neil Spenceley, the Clinical Lead for the Paediatric Intensive Care Unit in Yorkhill Children’s Hospital in Glasgow Scotland.

Neil Spenceley has beautifully captured the issues and solutions in healthcare.

The image shows both cultural problems and solutions in healthcare workplaces. “Change the system, not the people,” because as I mentioned earlier, this is no single person’s fault. 

A better system will develop a better culture, and a better culture will better address quality issues in the organisation through effective communication and collaboration among and between staff and management.

Culture starts from the top and grows from the bottom, so here are four simple principles for senior managers to follow to ensure that their cultural ideals are translated into cultural norms across the organisation.

1. Practice what you preach

Be a role model to your staff. Walk the talk – embody and demonstrate the attitudes and behaviours you expect your staff to display. Ingrain these attitudes in all your actions and let them guide how you respond to people and events.

Do this always, and not just when it’s convenient or expedient to do so.

2. Enable the culture you claim to want

Valuing the knowledge and experience of your staff means supporting their growth and improvement.

Nurture their knowledge and be supportive of their willingness to learn and help. Provide mechanisms to regularly capture their perspectives and act on the information you receive. Respond to their feedback, and show them that their ideas and concerns are valid.

3. Acknowledge and reward actions that embody your desired organisational culture

Rewards are reinforcers, and reinforcement increases the probability of a desired behaviour.

When you reward good actions, you motivate the rewarded to keep it up, and motivate others to follow suit.

4. Acknowledge (but definitely do not reward) actions that are antithetical to your desired organisational culture

It’s not necessary to name and shame everyone who does the wrong thing, but it’s important that the problems are acknowledged so that they can be addressed.

There is a better way forward for healthcare 

Much preventable harm still happens in many healthcare organisations today. I’ve seen firsthand how this harm is brought about by the disconnect between frontline staff and management.

Hence, it’s important to bring the two together and give them the time and the means to build a new culture that engages staff and values their ideas and feedback.

Of course, doing this is easier said than done. It takes a lot of commitment, work, and dedication to get to a point where a collaborative, quality-focused culture is achieved. It’s difficult, but once achieved, a healthcare institution will be a much safer place for both professionals and patients.

Importantly, creating and maintaining a good culture is a habit and it needs to be nurtured at the frontline, where it takes root and grows.

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