Influencing organisational culture: a

leadership challenge
ABSTRACT
In the wake of the Francis report, the need for NHS trusts and hospitals to adopt a culture of learning, safety
and transparency has been highlighted. This article considers different aspects of culture in health care, and
hones in on the link between culture and safety for patients in putting the patient first, embedding the 6Cs and
considering the options to measure and influence organisational culture. The article reflects more deeply on
how leadership across all levels can influence and inspire change in organisational culture, ensuring that the
patient remains the focus of any changes in care delivery.

Robert Francis QC, a barrister with extensive experience in clinical negligence claims, led a public inquiry into
why poor care at the Mid Staffordshire NHS Foundation Trust in the UK between January 2005 and March
2009 resulted in the unnecessary deaths of up to 1200 people. In February 2013, his final report on the
commissioning, supervisory and regulatory bodies, and their role in monitoring Mid Staffordshire hospital
between January 2005 and March 2009, was published (Francis, 2013). The document and its 290
recommendations are built on Francis's earlier report on the findings of the independent inquiry on the failings
in the Mid Staffordshire NHS Foundation Trust (Francis, 2010). The first report focused on failings within the
trust itself and concluded that patients were routinely neglected by an inward-looking trust preoccupied with
savings, targets and processes at the expense of its fundamental responsibility to provide safe and effective
care to patients. The second report highlighted the need for a culture across the NHS whereby patients are the
first and foremost consideration of the system and all those who work in it.

In the wake of Francis, the need for NHS trusts and hospitals to adopt a culture of learning, safety and
transparency were themes running through three important subsequent publications. The Berwick report
(2013) made recommendations ‘from board to bedside’ on how to address patient safety in the NHS.
The Keogh review (2013) into the 14 NHS trusts and NHS Foundation trusts identified as having higher than
average mortality rates highlighted areas of action to address issues of safety and quality of care. The
Department of Health (DH) publication Hard Truths: The Journey to Putting Patients First (DH, 2013)
underlines the importance of seeing everything from the patient's perspective, the need for transparency,
having a learning culture and accountability as key messages for all staff working in the NHS.

The major regulatory organisations have published statements in response to the Francis Report and all trusts
in England have formulated action plans to prevent such events happening again. While the Francis Report is
important for all professional groups represented in health care, nursing care lies at the heart of our healthcare
system's ability to thrive—but also, as has been seen, to fail. This article will reflect on the importance of
leadership in health care and how organisational culture plays a significant role in ensuring patient safety and
in implementing the recommendations of the Francis Report.

The Francis Report

‘It is a truism that organisational culture is informed by the nature of its leadership. The Department of Health
has an important leadership role to play in promoting the change of culture required throughout the healthcare
system.’

(Francis, 2013: 64)

There is consensus that patients and their families were badly let down by the failures of care at the Mid
Staffordshire NHS Foundation Trust. To prevent it happening again, a proactive as well as a reactive response
to cultural change is called for. This is no time to be complacent. The introduction of the Statutory Duty of
Candour (DH, 2014) is seen as a mechanism to support cultural change, particularly for providers who have
not fully embedded a bottom-up approach to openness and transparency as part of a continuous improvement
processes (Care Quality Commission (CQC), 2014).

To evolve in response to society's healthcare needs, all provider organisations need to engage in a variety of
ways to ensure that care and services are high quality, safety focused, culture sensitive and responsive to the
needs of patients. Jane Cummings', Chief Nursing Officer (CNO) for England at the NHS Commissioning
Board, work in shaping the 6Cs in health care—care, compassion, competence, communication, courage and
commitment (Table 1)—reflects aspects that are equally important in the vision and strategy for leadership in
nursing, midwifery and care staff (Cummings, 2012). Health professionals must set aside time to pause and
look at what they do and how they do it, and, if necessary, to change the way they do it for the sake of better
outcomes. Embedding the 6Cs in health care is fundamental to this process. This article considers some of the
initiatives available to do this.

Table 1.The 6Cs explained

Our core
business and
that of our
organisations,
and the care we
deliver, helps
the individual
person and
improves the
Care health of the
whole
community.
Caring defines
us and our
work. People
receiving care
expect it to be
right for them,
consistently,
 throughout
every stage of
their life.
How care is
given through
relationships
based on
empathy,
respect and
dignity—it can
Compassion
also be
described as
‘intelligent
kindness’ and is
central to how
people perceive
their care.
All those in
caring roles
must have the
ability to
understand an
individual's
health and
social needs,
and the
Competence expertise,
clinical and
technical
knowledge to
deliver
effective care
and treatments
based on
research and
evidence.
Central to
successful
caring
relationships
and to effective
Communication
team working,
listening is as
important as
what we say
and do and
 essential for
‘No decision
about me
without me’.
Communication
is the key to a
good workplace
with benefits
for those in our
care and staff
alike.
Enables us to
do the right
thing for the
people we care
for, to speak up
when we have
concerns, to
Courage have the
personal
strength and
vision to
innovate, and to
embrace new
ways of
working.
A commitment
to our patients
and populations
is a cornerstone
of what we do.
We need to
build on our
commitment to
improve the
care and
Commitment
experience of
our patients, to
take action to
make this
vision and
strategy a
reality for all,
and to meet the
health, care and
support
 challenges
ahead.
(Department of Health, 2012)
View larger version
Culture in health care
The word ‘culture’ is mentioned 486 times in the full Francis Report. Although the report does not give a
broad definition of culture, it does describe a positive culture and outlines what an undesirable culture looks
like (Figure 1).

Figure 1. Aspects of an undesirable organisational culture

The Francis Report highlights the need for organisations to create and maintain the right culture to deliver
high-quality care that is responsive to patients' needs and preferences. Francis describes a positive culture as ‘a
shared positive safety culture’ (Francis, 2013: 1357) (Figure 2). Several initiatives throughout the NHS, such
as the ‘Sign up to safety’ and ‘Freedom to speak up’ campaigns and the inspections led by the CQC, have
resulted in the promotion of a culture of openness, learning, and professional and institutional humility as the
bedrock of safe care (DH, 2015).

Figure 2. Aspects of a shared, positive safety culture

Linking culture and safety: putting the patient first

There is an overall agreement in the literature that the concept of organisational culture is complex, diverse and
not well-defined (Scott et al, 2003a; Davies and Mannion, 2013). However, a plethora of studies discuss
various aspects of organisational culture relating to safety and safety culture (Cox and Cox,
1991; Guldenmund, 2000; Scott et al, 2003b); Hudson et al, 2009; Singer et al, 2009; Carillo, 2012; Davies
and Mannion, 2013). This concept comes from industry and has been adopted in health care. Safety culture is
the way by which safety is managed in the workplace and often reflects ‘the attitudes, beliefs, perceptions and
values that employees share in relation to safety’ (Cox and Cox, 1991: 93). Safety culture within health care
comprises multiple distinct dimensions or domains (Hudson et al, 2009). The notion that organisational culture
is just one part of the many pieces that make up the puzzle of public-sector organisations is an important one
(Jung et al, 2009).

Appeals for a shift in culture in health care are based on the belief that culture is correlated with organisational
performance. There is some evidence to suggest that organisational culture may be a relevant factor in
healthcare performance, yet articulating the nature of that relationship is difficult. Simple statements such as
‘strong culture leads to good performance’ are not supported. Instead, the evidence suggests a more contingent
relationship, in that those aspects of performance valued within different cultures may be enhanced within
organisations that exhibit those cultural traits (Scott et al, 2003b; Singer et al, 2009).
The Francis Report calls for a common and shared culture. It specifies that patient safety should be a priority at
all times. However, culture in a large organisation is seldom uniform and subcultures do exist (Morgan and
Ogbonna, 2008; Davies and Mannion, 2013). Morgan and Ogbonna (2008) found that there are only two
united views held by NHS staff across different settings and disciplines: the need for care to be based on
individual need rather than funding; and a dislike of constant interference by successive UK governments into
healthcare provision. In general, the notion of shared values is over-emphasised and over-simplified (Morgan
and Ogbonna, 2008).

It is recognised that several values compete at different levels and in different professional groups.
Organisational culture differentiates across two dimensions: an emphasis on stability, order and control, versus
an emphasis on flexibility, discretion and dynamism. Four basic organisational cultural types can be
distinguished. Over time (2001–2008), the NHS has moved from a predominantly ‘clan’ culture towards a
more ‘blended’ culture, adding more attributes of developmental, hierarchical and rational cultures into the
mix (Jacobs et al, 2013). This begs the question of whether the concept of a shared organisational culture needs
to include core aspects correlating to the code of conduct for health professionals in general, yet
simultaneously reflect subcultural attributes and dynamics.

As the definitions of both ‘organisational culture’ and ‘culture barometer’ are open to consideration, there is an
opportunity to reflect the notion that organisational culture manifests itself in different ways and has several
components at its core, but, at the same time, is part of something bigger.

Carillo (2012) opens her article with a candid reflection:

‘Maintaining safety as a priority in people's minds is a leadership challenge.’ (Carillo, 2012: 35)

Several organisational influences, such as leadership style, supervisor involvement and communication
systems, determine the importance allocated to safety (Carillo, 2012).

As change is continuous, static approaches such as rules and procedures do not influence priorities, and how
people interact within and across departmental lines is an indicator of the organisation's ability to prevent
failure (Carillo, 2012). This is reflected in four common characteristics that can unlock an organisation's
potential: confidence, curiosity, connectedness and compassion (Hadridge and Pow, 2008).

Learning as an organisation, collectively, requires creativity, flexibility and adaptability to an ever-changing

reality, whether this be financial, structural, educational or service-development related (Malby, 2007). A
dynamic approach to developing character strengths that include creativity calls for investment and
commitment on an intellectual, social and emotional level. A response as an innovative connector, rather than
an isolated competitor, enhances diversity, increases social resource and results in attracting the right people
for the job (Kramer, 2013). Perseverance and grit (defined as ‘perseverance and passion for long-term goals’
(Duckworth et al, 2007: 1087) are shown to correlate with achievement and retention, and are, alongside
creativity, very important qualities in leadership (Hokanson and Karlson, 2013).
A brain-based model for collaborating with and influencing others explains that understanding the drivers of
human social behaviour brings insights that can be applied in practice. The ‘SCARF’ model (Rock, 2008)
involves five domains of human social experience: status (relative importance to others); certainty (being able
to predict the future); autonomy (a sense of control over events); relatedness (a sense of safety with others);
and fairness (a perception of fair exchanges between people).

Two themes emerge when thinking of human social behaviour in this way. First, much motivation that drives
our social behaviour is governed by an overarching principle of minimising threat and maximising reward
(Gordon et al, 2008). Second, several domains of social experience draw on the same brain networks to
maximise reward and minimise threat as the brain networks used for primary survival needs (Lieberman and
Eisenberger, 2008). A mind set of constant awareness and inquiry is the strongest preventative measure against
missing the signs of when things go wrong (Weick et al, 1999). The Francis Report showed that warning signs
were present, but ignored. In embedding the 6Cs, the improvements in openness and transparency, as endorsed
by the Duty of Candour (DH, 2014), can become interlinked.

How can we measure organisational culture?

Several consultancy agencies suggest a variety of tools to assess the culture within an organisation and their
scope is varied (Scott et al, 2003a; Smith, 2013). Reviews have highlighted that there are no published, widely
accepted criteria for comparing and contrasting existing survey tools. The tools vary greatly, with some
looking specifically at the culture itself, and others aiming to identify and assess existing culture as well as
modifying culture with the aim of aligning ‘high-performance’ or successful organisations. The tools may aim
to assess a variety of predefined categories or domains of organisational culture (Singla et al, 2006; Jung et al,
2009).

Different methodologies to collect information on the organisational culture are used. Self-reported
questionnaires range from a structured approach to the gathering of more unstructured data, including
emergent ethnographic approaches obtained from qualitative research paradigms. The latter methodology has
been identified as generating data on the underlying values, beliefs and assumptions that influence the cultural
dynamics within an organisation. A more structured approach has, perhaps in more recent years, provided
more information from a large sample of participants, but has been criticised for its more rigid approach and
the use of predetermined categories within the tools used, thereby limiting the information gleaned.

When considering whether to use a tool to assess organisational culture in practice, it is important to ask what
the purpose of the assessment is and how to translate and use this information in clinical practice (Jung et al,
2009).

The choice of the most suitable tool must be based on the underlying intention of assessing culture in an
organisation, the personal perspectives of those assessing culture, in addition to the resources available.

A tool such as the cultural barometer has been suggested as a way forward to raise awareness of factors
influencing organisational culture throughout the NHS. A cultural barometer is proposed as a tool to give the
employed health professional the chance to assess the resources and support available for the job; how
worthwhile it is; and what opportunities there are for improving teamwork. This is combined with a request
that he or she records actions the employee could take in respect of these matters, thus reinforcing personal
professional responsibility for the standards applied and the value placed on personal contribution (Francis,
2013). Two specific recommendations (2 and 198) in the report mention the use of the cultural barometer as a
tool to achieve this, and its use is recommended on a trial basis.

The 6Cs
Culture is shaped by the language that we use. Jane Cummings and Viv Bennett (Director of Nursing at the
Department of Health) shaped the 6Cs (DH, 2012). The 6Cs reflect aspects that are each equally important in
the vision and strategy for leadership in nursing, midwifery and care staff. In 2014, the initiative was rolled out
to allied health professionals, doctors and non-clinical staff, as it embraces the values of a high-quality care
environment (Stephenson, 2014).

The values and behaviours covered by the 6Cs are not new; but putting them together to define a vision for
building and strengthening leadership in health care reinforces the values and beliefs that underpin care,
wherever it takes places.

Role of leadership in health care

The role of leadership in health care is pivotal and has been addressed by a number of health professions.
The Point of Care Foundation (2014) highlights the need to accelerate change and the role of leadership. The
NHS Leadership Academy has developed a Healthcare Leadership Model with nine dimensions supported by
appropriate tools and resources, encouraging professionals to develop their leadership skills and consider the
implications for the safety and quality of the service they provide (NHS Leadership Academy, 2013).
The Berwick report (2013) also clearly outlines leadership at every level throughout the NHS, and asserts that:

‘Cultural change and continual improvement come from what leaders do.’

(Berwick, 2013: 16)

Allied health professions have been encouraged to be involved in the ‘Big Conversation’ about
professionalism and professional behaviour (Hughes, 2012; Middleton, 2012). The aim of this is to encourage
discussion and debate within departments (communication); create an environment where unprofessional
behaviour is challenged (courage and competency); and where professional behaviour is supported despite the
presence of external challenges (commitment). Discussion across professional groups provides additional
debate, enhances collective learning and ultimately feeds into the culture of an organisation.

Leadership is not limited to nursing and evidently includes all professions in health care. However, from a
nursing and allied health care perspective, the role of senior staff members is essential to ensuring that a
‘culture of leadership’ filters through all levels in the healthcare system. Leadership development should focus
on developing individual performance in order to improve the performance of the team, organisation or
system, and should include all staff (The King's Fund, 2013).

By connecting the 6Cs of nursing and the issues about professionalism in allied health care to the knowledge
and skills framework, it is apparent that all six core domains of this framework—communication; personal and
people development; health, safety and security; service development; quality; equality, diversity and rights—
offer leaders in health care the opportunity to influence culture through a wide variety of ways (NHS Staff
Council, 2010). Leaders in health care are both the architects and the products of organisational culture
(Malby, 2007). One could add that the leaders in health care today are the designers of our health care for the
future.

In health care, the quality of relationships among staff members correlates with the quality of care delivered
(Carillo, 2012). This includes basic communication but also courage and compassion, in addition to awareness
of the unexpected and remaining mindful that personal expectations limit one's ability to see reality. Personal
expectations also influence the process of gaining knowledge through experience and through interactions with
experienced individuals; the ability to interpret data accurately; and the ability to act on the data to adjust
conditions. Such themes were explored in the seminal work about emotions in the workplace—The Managed
Heart by Arlie Russell Hochschild (1983). This book established the concept of emotional labour and
describes the emotionally draining process of managing one's emotions in the service of a job or organisation.
Often, people are required to express an emotion that they simply do not feel, or not to express one that they do
feel (Ashkanasy et al, 2009).

Conversations in which divergent perspectives are heard and result in the correct action require commitment,
time investment, listening skills, and openness to different viewpoints. Maintaining trust and open
communication requires constant reinforcement (Carrillo, 2012). Creating an inclusive environment is a
prerequisite for enabling open communication and links in with mindfulness (Ross, 2011).

Behavioural observation, as encouraged by allied health professionals, is based on reinforcement theory and is
designed to encourage the development of safe behaviour and professionalism. However, without ongoing
interaction, assessment and vigilance, the behaviour may revert to poor practice (Carillo, 2012). Relationship
psychology proposes that people decide what they believe according to conversations with people they trust,
which helps with making sense of a complex situation (Weick, 2013).

Not recognising the trade-off when shortcuts are taken, or making exceptions without thorough
communication, may ultimately influence priorities and compromise safety (Carrillo, 2012). Collaborative
learning is key (Singer and Edmondson, 2006).

Inspiring change
Organisational culture has been referred to as an anthropological metaphor used to inform research and to
explain organisational environments (Parmelli et al, 2011). There has been an increased focus on reviewing the
cultural environments that healthcare staff work within, with the aim to change cultures and, where necessary,
to improve healthcare performance. It is recognised that healthcare cultures, where values mirror an
environment that encourages staff to feel part of a group, promotes teamwork and coordination, sustained
levels of quality improvements, and delivers high-quality compassionate care (Scott et al, 2003a; DH, 2009).
Culture cannot easily be dictated; it develops over time as an adaptation to conditions and brings desired
results (Carroll and Quijada, 2004). Ensuring that staff are part of the vision of an organisation and understand
the meaningful consequences of any organisational change includes all the concepts of the 6Cs. This is crucial
in ensuring that change is necessary, otherwise staff will believe that current practices are acceptable and
change is not needed.
One way of achieving collective learning that feeds into the culture of an organisation is by generating
discussion across professional groups through ‘Schwartz rounds’—meetings that provide an opportunity for
staff from all disciplines across the organisation to reflect on the emotional aspects of their work. Several
organisations in the UK have set up these rounds on a monthly basis, with the focus on fostering healing
relationships, providing support to professionals, enhancing communication between caregivers, and
improving the connection between patients and caregivers (Penson et al, 2010; Goodrich and Cornwell,
2012; Pepper et al, 2012).

Various models have been developed to guide and understand change (Brown, 1998). If it is agreed that to
improve healthcare performance it is necessary to look at changing the culture within an organisation,
consideration must be given to the best way to do this. A systematic review of the effectiveness of strategies to
change organisational culture recognised over 4000 articles within the authors' search terms (Parmelli et al,
2011). Out of those 4000 articles, selection criteria only identified two articles suitable for inclusion in the
review. The two articles, while reporting positive outcomes, were, according to Parmelli et al (2011), at risk of
bias. The authors suggested that before implementing any strategies to support organisational change in
culture, an evaluation using a robust design should be considered. Leadership, which is addressed within this
article, is key when engineering change of organisational culture.

Conclusion
This article has focused on how organisations have been affected by the Francis Report and how it has enabled
the leaders within them to reflect on their own organisational culture and its bearing on patient safety. A
commitment to share a culture of safety among all health professionals assures that the patient remains the
focal point of any changes in care delivery. Many research papers highlight the complexity of organisational
culture and of how to measure it.

The organisation, in its learning, needs to ensure leaders hold the shared values of a culture of zero tolerance
for substandard care, and work towards empowering staff to report poor practice and recognise their
contributions towards good care by creating an environment conducive to collective leadership and embedding
the 6Cs.

How organisational culture is measured, and how that information is used to guide leaders in health care to
start a continuous process of improvement, needs to be carefully considered. A shared set of values and a
shared purpose is more important than small differences in subcultures that exist in any organisation.

Fostering leadership at every level throughout the organisation, and creating capacity to develop future leaders
by investing in programmes to support this, highlights the education and ongoing development aspect of health
care. If, as leaders we can embed the 6Cs into our practice, this will allow us to build and strengthen leadership
throughout healthcare organisations for the benefit of patients and staff.

Key Points
 ▪ The Francis Report suggests using a cultural barometer to measure organisational culture and its
impact on patient care
  ▪ The concept of organisational culture is complex, diverse and not well-defined, and comprises a
wide variety of domains

 ▪ Leadership is not limited to nursing and includes all professions across all levels in health care

 ▪ Schwartz rounds focus on fostering healing relationships and provide support to health professionals
in order to enhance communication between caregivers and improve the connection between
caregivers and patients

Conflict of interest: none

References