Creating cultures that put patients first

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. The King's Fund