Effect of Culture on Provision of Care

A number of commissions of inquiry in Australia have shed light on the link between
organisational culture and patient care. The Garling (2008, p. 3) Report closely examined
the provision of acute care services in New South Wales public hospitals. The report
recommended that ‘a new culture needs to take root which sees the patient’s needs
as the paramount central concern of the system and not the convenience of the clinicians
and administrators’.
These issues are not unique to Australian healthcare facilities, and similar culture
and patient care issues have been raised in the United Kingdom. The Francis Inquiry,
which began in 2010, highlighted poor clinical outcomes attributed to inappropriate
culture within the Mid Staffordshire NHS Trust. Examples of poor culture leading to
substandard and dangerous care can be seen in these excerpts from one of the inquiry’s
[The chief executive of the trust] described the Trust’s culture as being inwardly focused and
complacent, resistant to change and accepting of poor standards. (Mid Staffordshire NHS
Foundation Trust Public Inquiry, 2010, p. 22)
WJ:t=• Part 5 Drives Innovation
When [a patient’s daughter] was asked to describe the nursing culture on Ward 11, she said,
‘They were bullies. They bullied … the other staff and they bullied the patients. There was no
word for it. … particularly during the two weeks that Mum was dying, effectively, they were
calling out for the toilet and they would just walk by them.’ (p. 45)
Management imperatives in building positive
workplace cultures
The contemporary literature highlights several critical success factors for creating and
maintaining positive workplace cullures, of which four are memioned regularly: positive
and supportive leadership, workplace learning, collaboration, and a focus on the patient
or client.
Tyler and Parker (2011) claim that role-modelling of positive attitudes by managers
and leaders promotes high levels of teamwork. Working collaboratively,
rather than as a group of individuals, is essential for improwd workplace culture.
Laschinger et al. (2014) found that positive and supportive leadership empowers
staff, lowers patient mortality, improves nurses’ health and Job satisfaction and
reduces absenteeism, staff turnover and incivility. Additionally, managers who
build emotional resilience in their workforce and team members create a healthier
workplace culture, reducing absenteeism, improving teamwork and raising morale
(Sergeant & Laws-Chapman, 2012). To ensure that staff feel engaged, managers
need to be highly visible, provide feedback and coaching to employees and make
sure that doctors are included as part of developing the culture (Hegland, Tarcon
& Krueger, 2010).
The literature also emphasises the development of staff as a key component in developing
positive workplace cultures. Tomlinson (2010), when reviewing an organisation
that had a culture of high employee engagement, identified emphases on leadership,
employee and organisational developmenL, employee recognition and internal communication.
Similarly, Goh, Chan and Kuziernsky (2013) suggest that to develop positive
workplace cultures, managers need to foster collaborative learning among staff, to rid
their organisation of a blame culture and to prioritise patiem safety.
Finally, in an examination of the establishment of sustainable, healthy work environments
through the standards set by the American Association of Critical-Care Nurses,
Hickey (2010) claims that central to establishing and sustaining positiw work environments
are skilled communication from managers, true collaboration with staff, effectiw
decision-making, appropriate staffing levels, meaning[ ul staff recognition and authentic
Chapter25 Building positive workplace cultures
Changing an organisation’s culture
Changing organisational culture is not easy; it t.akes time and effort. There are often longheld,
deeply taken-for-granted behaviours, attitudes and values that form the cultural
reality of the organisation (Schedlitzki & Edwards, 2014). Any attempt to effect a change
in culture requires relationships and leadership that through the use of systems embed
shared values, beliefs and purpose in everyday practice.
Changing to a more desired culture takes concerted and persistent effort by all levels
of management over an extended period. It probably took years for the culture to reach
its current state, so any attempt to change it is likely to take as long. Building trust with
the organisation’s staff, creating new norms, rewarding new behaviours, establishing
new customs and rituals: these all take time, effort and consistent messages from the
When embarking on major cultural change, continued and continual communication
from the executive to the staff should be implemented. The executive team needs to be
adept at ‘selling the vision’, creating a level of excitement and anticipation about where
the organisation is heading and making sure staff buy into this. Both formal and informal
approaches may be used to ensure staff are aware of what is being proposed. Also,
the espoused vision of the organisation must match the lived vision: the leadership and
management should make sure that what they are actually doing is in line with what they
say they are doing. For example, new staff should be selected and recruited in line with
the organisation’s values and beliefs. Failure in this area leads to staff confusion and lack
of trust.
Managers should maintain or create rituals and customs that are unique to the organisation.
This might be as simple as celebrating birthdays or anniversaries, and celebrating
‘wins’ in the organisation. The leadership need to be specific about the kinds of behaviours
that are in line with the new culture and to be proactive about addressing behaviours
that are not in line with the organisation’s vision and values.