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OPINION

'We must learn from the cultural failings at Mid Staffs'

  • 16 Comments

Sister leadership is vital in ensuring an appropriate team culture, says Jean White

I recently attended a thought-provoking lecture on the lessons to be learnt from the care failures at Mid Staffordshire Foundation Trust in 2005-09, which are undergoing further examination by the second Francis Inquiry.

One issue that stood out was the importance of the culture that pervaded the organisation at the time and how it was a major cause of system-wide failures.

Simply put, an organisation’s culture should guide how employees behave and, most importantly, prioritise matters that are valued most.

In health organisations, this should include putting patients’ needs first and prioritising the delivery of safe, cost effective and compassionate care. Leaders from board to ward and at team level should understand and reinforce the organisation’s cultural beliefs and values so everyone has a common purpose - the delivery of excellent patient care.

‘Leaders cannot be seen to cut corners or turn a blind eye to poor practice, as this sets the pattern of behaviour for the whole team’

What does this mean at ward or team level? I offer the following reflections.

Sister/charge nurse leadership is essential in ensuring team culture is appropriate. This includes role modelling behaviour they expect to see, setting standards for team performance and addressing any lapses swiftly. Leaders cannot be seen to cut corners or turn a blind eye to poor practice, as this sets the pattern of behaviour for the whole team. These clinical leaders should aspire to motivate and inspire their teams to deliver consistently great care.

All staff should have an annual appraisal, however hard this is to achieve in busy clinical areas. This is important as appraisals offer opportunities for constructive discussions on performance to identify further development to enable the individual to continue to grow.

It is particularly difficult for team members to speak out when they see colleagues failing to undertake their role appropriately. It becomes easier to speak up if the culture in that team promotes open dialogue - telling colleagues when they’ve done well and challenging poor performance. This is something that should be discussed within the team and ground rules agreed on - I don’t deny that this takes a degree of maturity and confidence in team members that may not necessarily be there.

Problems certainly increase when a culture of fear pervades and stops people speaking up. Recognition of a job well done by your peers can be a strong motivator and should not be dismissed.

Complacency is a serious problem in any team that aspires to give great care and must be guarded against. Another reflection from Mid Staffordshire is that a stable workforce with little turnover is not always a good thing. This resonated strongly with me - teams that have been together a long time often develop set patterns of working and relating to one another that breed complacency and stifle the ability to challenge. Even when an organisation’s turnover is low, there should be internal movement of staff to bring fresh perspectives to care environments.

Students deserve excellent mentors and clinical experience to build confidence and ensure competence on qualifying. The culture of health organisations must be positive so the right values and beliefs are instilled. Mentors therefore need to be supported and recognised for the important work they do.

In Wales, work is under way to explore professionalism in nursing and what influences the behaviour of nurses. Part of this programme is a formal evaluation of the national ward sister/charge nurse leadership development programme. I look forward to the insights this work will give when it reports this autumn.

Jean White is chief nursing officer for Wales

  • 16 Comments

Readers' comments (16)

  • Jean

    Thank you.

    I was drawn to your remarks concerning complacency. Places that have difficulty in recruitment because of geographic unpopularity or reputational difficulty are at particular risk.

    Whilst I would not wish to minimise the harm caused in Staffordshire by senior ward staff but it would appear that more damage was caused by individuals in positions of greater organisational responsibly.

    Huge cuts were made to the Nursing Establishment and mad-cap ward management schemes were introduced in an effort to disguise the lack of Nurses.

    Ward based staff who attempted to draw attention to their plight and their inability to provide even minimal standards of care to patients were routinely ignored, ridiculed or bullied. Untoward incident forms "disappeared". Nursing staff were in effect abandoned by their most Senior Colleague.

    Most of the problems at Stafford could be traced to the then most Senior Nurse in the Trust. She was more concerned with assisting her Chief Executive to achieve "Foundation" status than she was about patients or the nurses struggling against ridiculous odds to provide care.

    We saw another example just recently of a Trust in London being issued warnings about its complacency with regard to patient safety. Rarely does a week go by without the Media reporting on yet another "failure of care" The general public are tired of hearing the mantra about "lessons being learnt".

    Directors of Nursing ( Chief Nursing Officers) have, without doubt, challenging roles. However, they are first and foremost, nurses. A prime qualification for their posts is a requirement to be registered with the NMC. All Senior Nurses should remind themselves that they are as bound by the NMC's code of Conduct as is the most junior,newly qualified staff nurse/midwife.

    You will have noticed the research undertaken on behalf of the European Commission which claims that some NHS Trusts expect one RN to provide care for 15 patients. You will also note that the ratio of RN's to HCA is now approaching 1:1

    Acute care environments expose nurses to having to care for 8 or more patients!

    Who permits these situations to occur?

    I put the responsibility firmly where it belongs and that is with SENOR NHS TRUST NURSES. It is them that agree to the reduction in nursing numbers and the dilution of skill mix in the face of increasing levels of patient dependency.

    May I ask if there is any work under way which explores the behaviour and decision making skills of Senior Trust Nurses? What leads them to abandon their colleagues and ignore the plight of patients who are caught up in the web of the NHS ?

    Jean, I have ranted for long enough although I have much more I could say.

    My hope is that I have given you cause for thought. Change is needed. That change has to affect the Senior Leaders of our profession.

    Thank you for reading (some of ) my thoughts.

    PS

    My pseudonym belong to a lady, long dead now, who was a a very senior nurse at a regional health authority. She never forgot she was a nurse and always had patients and her colleagues at the centre of her thoughts.




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  • well said!

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  • tinkerbell

    Jenny Jones | 7-Aug-2012 1:03 pm

    Keep telling it like it is, keep banging on. It is not moaning, it is stating the facts that most of us have experienced. There's a difference. Well done:)

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  • michael stone

    'Leaders from board to ward and at team level should understand and reinforce the organisation’s cultural beliefs and values so everyone has a common purpose - the delivery of excellent patient care.'

    The problem is fragmentation of 'the common purpose' into individual objectives. Some managers are mainly concerned with achieving cost savings, but in principle front-line clinical staff should be concerned with improving patient care. They conflcit with each other, and things like Mid Staffs seem to happen when the 'balance' moves hugely away from a 'sensible compromise' - normally that implies a very bad management culture (because management has most of the power to alter things, for better or worse), and every one of these reports points at 'bad management/bad culture' as a main cause. But sorting it out, seems very hard indeed - especially when managers also have the power to try and hide problems, and get rid of staff who complain.

    'Another reflection from Mid Staffordshire is that a stable workforce with little turnover is not always a good thing. This resonated strongly with me - teams that have been together a long time often develop set patterns of working and relating to one another that breed complacency and stifle the ability to challenge. Even when an organisation’s turnover is low, there should be internal movement of staff to bring fresh perspectives to care environments.'

    I had not thought about that, but having seen it, I think it has to be true - people do often become set in their ways. That is different from being deliberately 'bad'.





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  • michael stone

    Jenny Jones | 7-Aug-2012 1:03 pm

    'The general public are tired of hearing the mantra about "lessons being learnt".'

    Hearing that, without an actual explanation of 'how ?', is REALLY annoying - personally, I think the phrase 'the lessons have been learnt' should be BANNED !


    People should only be allowed to say 'We have improved things by doing 'this', 'this' and 'this''.

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  • Many thanks for your support !

    Mike -- unless the "culture" at the top is right those at the so called sharp end up feeling unsupported , disillusioned and if that is combined with staff shortages, an impossible workload,and endless criticism from patient/relatives and the media where do you go? The only escape is "sickness" which provides perhaps a little short term relief from the pressures.

    Tinkerbell - I will keep the pressure on Senior Management. I am tired of them exposing my junior colleagues and patient to unacceptable risk.

    Mike ------ Did you know that they go to school especially to learn "media speak" !

    That is why all Senior Pubic Servants make the same grunts when responding to the media!

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  • michael stone

    Jenny Jones | 7-Aug-2012 4:45 pm

    What you say is of course right. I'm not sure if managers go to school to learn 'manager waffle' or just pick it up, but it isn't something only managers do.

    I have problems with quite a lot of phrases regularly trotted out by clinicians - 'shared decision making' is one, and I'm having at present a lot of trouble with 'a clinical decision'.

    The problem with 'clinical decision' is very lengthy to go into, but there are few or no 'shared decisions' - that is why judges sit in odd numbers. There is, because of that fact, a very awkward situation when different individuals can each validly make different and conflicting decisions in the same circumstances (although at present properly describing the situation when there is, essentially, a ranking decision-maker, is sadly lacking in the area of concern to me).

    'The only escape is "sickness"' is really sad - I can see how and why it happens, but people really shouldn't be treating each other this way. And I write that as someone who isn't very empathic.

    Perhaps our brains are still stuck at a level where they can cope properly with life in only small 'tribal' groups, and we are just over-whelmed by the detail and complexity of modern interactions ? Or perhaps many people are nastier than some of us would like to think is the case ? Or with no 'small tribal groups' these days, do people convert the evolutionary pressure to 'defend the tribe' into 'me first and only' ?

    In any event, you definitely need 'good systems' to avoid both stressing people out, and allowing bad personal characteristics to start causing serious problems.

    So far, in my opinion, nobody has managed to adequately deal with the problem of institutions which are rotten at the top - and nobody has managed to properly separate 'the odd unintentional mistake' (where the person who made it is regretful, and won't do it again) from the more serious situations of deliberate negligence (culpable) or 'being asked to do things beyond someone's ability (not so culpable, if the person hasn't realised that is the case).

    Sorry about the whinge.

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  • tinkerbell

    i have observed over many years how bad practice develops and it is usually due to a lack of leadership. Most people appear resigned to follow the path of least resistance and follow a 'herd mentality'.

    It is emotionally exhausting to correct but correct it we must. It is only by leading by example, challenging and nipping bad practice in the bud, that good practice can become the 'norm'.

    It is not so much that most implementing bad, sloppy practice are necessarily bad people but may be ignorant of any other way of doing things.

    It is not practice that makes perfect, but perfect practice. You can become very good at doing something badly all the time.

    Please correct practise and practice as you see fit, never got the handle on that one.



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  • Anonymous

    tinkerbell | 8-Aug-2012 12:21 pm

    Yes.

    And I usually think of advice and advise - I still sometimes look at practise/practice and have doubts.

    People also seem to be saying 'I' instead of 'me' - use we or us, and that one is easy to get right (I've never heard anyone say or write 'between him and we' but they do say 'between him and I'.)

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  • You are really rather bright but...
    9 Aug-2012 1:08 pm

    (sorry, for the incorrect form of address, my NT spell and word corrector seems to be at work again!)

    ... and they ofen put 'me' furst when describin sumfink affektin them and an uther!

    such as 'Me and Blogs finks ....'

    and sometimes even here, in the Nursing Times comments. My Dear, can you simply cannot imagine ...!

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