Elizabeth Anderson and Simon Bennett: Are we serious about changing culture?

Healthcare education has enormous capacity to equip future practitioners with the right mindset to promote supportive team-based cultures within the NHS. By this we mean that during training all practitioners should develop skills needed to work in a community that is then manifest when working in clinical and other care situations. They should know how to: form a team; use each other’s skills appropriately; place patients and families at the centre of care; and support colleagues. Proactive, forward-thinking team players stand the best chance of identifying latent errors (incidents and accidents-in-waiting). [1] Foresight and proaction reduce the risk of death and harm. Following the Francis report there have been numerous initiatives within the NHS, some of which, like the rise and recognition of quality-improvement activities, are reactive, while in contrast, education is proactive. [2,3]

There is a strong desire to ensure delivery of the best care for today’s patients, but are our energies focused in the right direction? Changing organisational culture is often tied up with balancing safety and accountability, but Dekker states that creating a “just culture” is incredibly difficult. [4] Changing the culture of the NHS involves helping all employees feel part of meaningful teams where they are valued and supported. The way in which NHS systems are organised has for too long revolved around differences and hierarchies. [5] This approach has alienated patients and families. [6] The World Health Organisation (WHO) argues that health workers must emerge from training as “collaborative practice ready” practitioners. [7] Evidence to date suggests that teamwork training enhances quality and safety and helps people feel valued. [8] These authors reflect that more work in this area is required, and that, at the moment, energy is being directed into considering patient safety issues at the expense of engineered cultural change—something that makes a real difference. With doctors and nurses being taken to court for alleged gross clinical negligence, where does this leave culture, a sense of collective endeavour, and desire to work together?

In professions like aviation and the military, and industries like car manufacture and deep mining, teamworking has bestowed significant safety and performance benefits. [9] However, it has often proved difficult to cultivate a teamwork mentality. Early attempts to introduce teamwork practices on the flight-deck met with resistance, as some pilots suspected a “communist plot” to undermine their authority. [10,11] United Airlines introduced teamwork training for its pilots in 1981. It has taken nearly four decades to replace aviation’s authoritarian workplace culture with one that is communitarian.

Communitarianism is the ideological glue that binds an airline’s flight operations personnel together, from engineers and dispatchers to pilots and cabin crew. Communitarianism supports collaborative labour—accepted as the ideal type of working method for high-risk industries like aviation, off-shore oil and gas production and deep-mining. It encourages collegiality and sustains a just culture (that is, a workplace culture that is non-judgmental and mission-focussed). An increasing number of airlines hold multi-profession teamwork courses, where captains with 20,000 hours flying time can find themselves being trained alongside novice cabin crew or Flight Dispatchers. Training is recurrent.

The actions required are as follows: i) raise the importance of interprofessional team training throughout a person’s career trajectory; ii) persuade leaders of the NHS to develop written commitments to teamworking and a communitarian NHS culture; iii) ensure more middle and senior managers prioritise these efforts so that all employees can feel valued, supported and enabled to build positive cultures.

Everyone must be equipped with the skills necessary to work safely and efficiently with other health workers (surgeons, nurses, paramedics, therapists, laboratory technicians, porters, administrators and so on). The question to be answered is how much emphasis we should place on creating the required teamworking focus. Teamworking emerges from an education and training-supported collaborative practice mindset.

Elizabeth S. Anderson, Professor of Interprofessional Education, National Teaching Fellow, University of Leicester, College of Medicine, Biological Sciences and Psychology, Department of Medical and Social Care Education.

Simon Bennett, Director, Civil Safety and Security Unit, School of  Business, University of Leicester.

Competing interests: None declared. 


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