Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study

Abstract

BackgroundProblems of quality and safety persist in health systems worldwide. We conducted a large research programme to examine culture and behaviour in the English National Health Service (NHS).MethodsMixed-methods study involving collection and triangulation of data from multiple sources, including interviews, surveys, ethnographic case studies, board minutes and publicly available datasets. We narratively synthesised data across the studies to produce a holistic picture and in this paper present a high-level summary.ResultsWe found an almost universal desire to provide the best quality of care. We identified many ‘bright spots’ of excellent caring and practice and high-quality innovation across the NHS, but also considerable inconsistency. Consistent achievement of high-quality care was challenged by unclear goals, overlapping priorities that distracted attention, and compliance-oriented bureaucratised management. The institutional and regulatory environment was populated by multiple external bodies serving different but overlapping functions. Some organisations found it difficult to obtain valid insights into the quality of the care they provided. Poor organisational and information systems sometimes left staff struggling to deliver care effectively and disempowered them from initiating improvement. Good staff support and management were also highly variable, though they were fundamental to culture and were directly related to patient experience, safety and quality of care.ConclusionsOur results highlight the importance of clear, challenging goals for high-quality care. Organisations need to put the patient at the centre of all they do, get smart intelligence, focus on improving organisational systems, and nurture caring cultures by ensuring that staff feel valued, respected, engaged and supported.

Between surveillance and subjectification: Professionals and the governance of quality and patient safety in English hospitals

“…This paper draws on a wider research programme on quality and safety in the NHS (for an overview, see Dixon-Woods et al, 2013). The study received approval from the Leicestershire, Northamptonshire and Rutland Research Ethics Committee.…”

Whistleblowing Need not Occur if Internal Voices Are Heard: From Deaf Effect to Hearer Courage Comment on "Cultures of Silence and Cultures of Voice: The Role of Whistleblowing in Healthcare Organisations"

“…In order to avoid negative feedback there was a demonstrated tendency to distance themselves from frontline staff, in addition concerns raised or critical comments were perceived as merely as 'whining or disruptive behaviour. ' 37 What is clear is that the 'deaf affect' to internal reporting is certainly prevalent in healthcare and as speculated by Mannion 1 are correct in their call for a strategy to deal with the resistance to bad news by those in a position of power. However, this should be considered as part of an overall strategy to improve patient safety and clinical governance and not framed as whistleblowing strategy.…”

“…What seems to be unknown at this time are the human factors involved in the behaviours of healthcare managers who distance themselves from staff who raise concerns about patient safety. In an examination of management and executive action in the United Kingdom's NHS, Dixon-Woods et al 37 found that while considerable time and resources had been invested into data collection and monitoring systems, the degree to which this was 'translated into actionable knowledge, and then into effective organisational responses' relied on the particular human responses of managers and or executive. DixonWoods et al 38 large mixed method research program involved 7 substudies which included data from 107 interviews with senior level stakeholders involved in quality and safety, 197 interviews with executive, board members and frontline clinicians, 715 surveys, 2 focus groups, and 10 interviews with patients and the public, patient and staff satisfaction survey data from 2005-2011 and 621 clinical teams assessed using Aston Team Performance Inventory.…”

Organisational support for nurses in acute care settings: a rapid evidence review

“…Although the nature of a REA means that it is unlikely to include all the relevant literature related to the search question and some papers may not have been identified, [28] the material retrieved and considered in the review suggests that a reasonable balance between comprehensiveness and timeliness has been achieved. [25] The papers included report empirical data, in the main, and provide some useful insights on the issues involved in supporting staff in caring roles which is an important international issue because a number of countries including England, New Zealand, the USA and the Netherlands have experienced organisational crises in healthcare resulting in failures in care [90] which arise, in part from lack of staff support. For example, Martin and Dixon-Woods [91] argue that if the lessons from a major hospital failure in England are to be learned then the seemingly straightforward solutions that characterise the problem as arising from poor performance in one hospital, or from "bad apple" staff need to be rejected, along with analyses that regard such occurrences as inevitable.…”