Moving from a Blame Culture to a Just Culture – Seven Key Elements

August 6, 2020 Phil Taylor

Care for the Caregivers

As highlighted by NHS England with the NHS People Plan[i], healthcare organisations that prioritise workforce wellbeing will be better placed to put lessons learnt from the coronavirus pandemic into practice. Phil Taylor of RLDatix outlines the benefits of introducing a just culture not a blame culture and shares a methodology for positive change.

Towards the end of 2019, nearly 600,000 NHS employees from 300 NHS organisations, including 229 NHS trusts, took part in what is considered to be one of the largest workforce surveys in the world and the results were enlightening.  When it comes to staff wellbeing, 40.3% of respondents reported feeling unwell as a result of work-related stress, a steady increase over the previous 3 years. 56.6% admitted to going into work despite not feeling well enough to perform their duties.[ii]  These statistics are alarming, particularly when you consider they were revealed before the arrival of COVID-19, a hitherto unknown enemy that has shaken and tested the healthcare sector to its very core.

COVID-19 – a powerful catalyst for change
Staff burnout, stress and sickness are nothing new, however, the pressures on the national healthcare system caused by the pandemic have brought them into sharp focus. While members of the public have shown their appreciation for the remarkable dedication and efforts of health and care staff throughout the crisis through the weekly ‘clap for carers’, leading institutions in the medical world are clamouring for action and in our opinion COVID-19 can prove to be a powerful and beneficial catalyst for change.

A statement published by the Academy of Medical Royal Colleges on behalf of the British Medical Association, NHS Confederation, NHS Providers, Royal College of Nursing and UNISON, calls for better working conditions.  These centre on the five key issues of ‘ensuing the wellbeing of the workforce’, ‘flexible working arrangements and at work facilities’, ‘increasing the supply of workforce’, ‘new ways of delivering care’ and ‘leadership’.[iii]  It is interesting to note that ‘ensuring the wellbeing of the workforce’ features top of the list and healthcare organisations should make this their top priority to manage the next stage of the pandemic effectively.

Investigating the root cause of staff stress
Like all problems, the key to tackling them successfully is to first establish what caused them in the first place.  Similar to many fast-changing industries where staff have a critical role to play, lack of involvement in decision-making and having responsibility, without authority or autonomy, are common stress factors.  Apply this general truth to managing COVID-19 and it’s easy to see how stress levels can quickly escalate out of control.  Leaders were in the invidious position of having to take fast decisions around PPE, ventilators and new contagion measures while doctors, nurses and care home staff were struggling to save lives whilst implementing these new procedures with very little warning, autonomy, or ability to feedback.

In a sector where a blame culture has been evidenced, the greatest stressor for staff, especially during a healthcare crisis like coronavirus, is: What will happen to me if something goes wrong? Poor culture and inflexible guidelines around what staff can and cannot do leaves people feeling unable to intervene to improve system safety and likely to avoid involvement for fear of repercussions.

Take inspiration from the grieved and bereaved
The irony is that most people who have suffered grief and bereavement following the death of a loved one in hospital or a in a care home are actually more concerned with ‘what happened and why?’ rather than ‘who is responsible?’. This is based on patient and public feedback to NHS England and NHS Improvement.  However, the unfortunate reality for many doctors, nurses and other clinical staff is that they are victims of an active blame culture where individual practitioners are held accountable for system failings over which they have no control.  This is bad for staff, bad for patients and it reduces the likelihood that the bereaved will be given the answers and closure they deserve.

What makes a just culture?
To redress the balance, NHS England and NHS Improvement have published a guide that advocates a ‘just culture’.  A just culture is fair treatment of staff that supports a culture of fairness, openness and learning in the NHS by making staff feel confident to speak up when things go wrong, rather than fearing blame.[iv]  Supporting staff to be open about mistakes allows valuable lessons to be learnt so the same errors can be prevented.

Another way of considering a just culture is to be guided by the five principles of FREDA (Fairness, Respect, Equality, Dignity and Autonomy)[v].  These form the basis of all international human rights treaties and are today used by the Care Quality Commission (CQC) to regulate health and social care services. Along with the mission of the healthcare sector, which is to preserve the human right to life, we should be making the rights of staff equally sacred. 

Seven key elements for the transformation to a just culture

Leadership teams who are focused on addressing staff welfare need to include the following elements in their thinking and in doing so will make significant progress in building an open and just safety culture:

  • Adopt a ‘human rights’ approach – to overcome the blame culture.  Follow the lead of the CQC.  Today, the CQC aims to regulate all health and social care services using the five guiding principles of FREDA (Fairness, Respect, Equality, Dignity and Autonomy), principles that can equally be applied to the workplace.[vi] 
  • Systems not people – concentrate on the systems or processes that support staff rather than the supposed failings of individuals.  As James Reason proposed, avoidable deaths are often caused by inefficient processes failing to remove or reduce the risk of error.  It’s every healthcare organisation’s fundamental duty of care to staff to lead and review opportunities to improve on this premise.
  • Lead from the front and with compassion - create an open and transparent environment where staff feel valued and flourish, leading to greater collaboration and positive outcomes for patients.  Encourage staff to instigate positive change, learn from success as well as mistakes, make time to communicate change and help staff understand the reasons for change.  Be visible, open and demonstrate a will to learn;  all are essential traits when dealing with the transformational impact of COVID-19.
  • Empower staff – enable and support staff with higher levels of autonomy supported by systems and processes designed to track, evaluate and support positive change. Supporting this culture with acknowledgement of excellence and open accessible processes for supporting change will encourage staff to take opportunities to make positive change when they arise.
  • Focus on what you know can improve – healthcare organisations should encourage positive action by being transparent on which issues they are tackling at an organisational level and why. Organisations should look to avoid wasting energy on speculative or large sweeping changes, especially during a crisis.  It is also important to communicate with staff, being honest about what the organisation is and is not doing to support their wellbeing and evidence ownership of outcomes at all levels of an organisation. 
  • Be Proactive in supporting staff – encourage and build support programs for the mental and physical wellbeing of staff. Use the existing system for identifying harm in healthcare as a way to prioritise supporting impacted staff. Overcoming any reticence or reluctance to ask for help should occur through proactive, not reactive, outreach programs that embody just culture principles
  • Invest in the right places – For organisations to survive and thrive in the new healthcare landscape they need to embrace the concepts of ‘Agile’ that have transformed industries over the last few decades. Organisational agility has to be based on high value and relevant data, transformed into insight through partnership with expert staff and teams. Research and best practice can then be monitored to support and inform fast iterative value focused change. 

COVID-19 has taught the healthcare sector that tackling staff wellbeing is no longer a ‘nice to have’ but an organisational imperative.  Focus on systems rather than people to eliminate blame. Then use data, partnerships and staff engagement to highlight and act on meaningful affordable improvements.

RLDatix is building a global partnership network focused on supporting organisational changes focused on Care for the Caregiver and open and transparent communication with both patients and staff. If you would be interested in working with us on this please contact  Polly Kirk, Marketing Manager, UK & Europe, pkirk@rldatix.com

 For more information, visit www.rldatix.com

 

[i] We are the NHS: People Plan for 2020/2021 – action for us all https://www.england.nhs.uk/ournhspeople/

 

[ii] NHS England Staff Survey 2019 – published in February 2020 - https://www.nhsstaffsurveys.com/Caches/Files/ST19_National%20briefing_FINAL%20V2.pdf
 

[iii] “Supporting the Workforce” – statement published by the Academy of Medical Royal Colleges in July 2020 - https://www.aomrc.org.uk/wp-content/uploads/2020/07/200703_Supporting_the_workforce_joint_statement.pdf
 

[iv] ‘A just culture guide’ published by NHS Improvement: https://improvement.nhs.uk/resources/just-culture-guide/#h2-about-our-guide
 

[v] Care Quality Commission – “Our human rights approach for how we regulate health and social care services: February 2019” - https://www.cqc.org.uk/sites/default/files/20190208%20Human%20Rights%20Approach%20REVISED%20summary%20v2%20FINAL.pdf

 

[vi] Care Quality Commission – “Our human rights approach for how we regulate health and social care services: February 2019” - https://www.cqc.org.uk/sites/default/files/20190208%20Human%20Rights%20Approach%20REVISED%20summary%20v2%20FINAL.pdf

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