Case study: changing workplace culture in the NHS

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Here at Culture Shift our biggest passion lies in helping organisations promote a speak-up culture. Our work started in the education sector, but the problems and issues that people face here don’t go away when they enter the world of work. We’re really proud to have recently started working with the NHS, the UK’s largest employer, this article is a transcript of an interview between our CEO Gemma McCall and the ex Head of Equality, Diversity and Inclusion at NHS LLR Academy, Aloma Onyemah. If you’d prefer to listen to this interview in audio-format,  click below:

: In a University setting, you’ve got a whole melting pot of experience and cultures because you’ve got people travelling from all corners of the UK, and all over the world to come and study. There’s therefore a unique opportunity for institutions to create citizens of the future, as well as help people, get their degrees and educate them. There are different pressures in the NHS and in different public sector organisations, but the common theme is lots of different people, with lots of different experiences. How do you ensure that those experiences and differences are celebrated?

Aloma: Our approach, we feel, is quite unique because we’re very much seeing our work with Culture Shift as being part of our approach to civility and respect generally. So what we are doing is trying to drive a behavioural change in our culture across the trust. So we’re aware that we’re probably one of the first systems that are actually looking at civility and respect at an ICS level (integrated care system level) rather than an organisational level alone. And what we wanted to do is be really clear about the different aspects of our civility and respect work. So there is a piece of work around understanding our current culture and making sure that we do a robust diagnostic of what are the things that we love about our culture and our behaviours and what are the things that we want to change and improve. 

Gemma: How did you get started with this work?

Aloma: We did a series of engagement events last May across the 15 organisations within our integrated care system, and we presented a vision of what we wanted to take forward around our active bystander program. We were so overwhelmed by the response because we knew the program was needed, but we didn’t really understand how much. So we got an insight in terms of the lived experiences of our staff and why they felt that this program would be very important. We feel that the program is a little bit different to other programs because of that. We want to explore not just how we address inappropriate or unacceptable behaviours, but why they occur. 

So looking at what the drivers are behind those behaviours, exploring not just overt behaviours that are very visible and observable, but actually place emphasis on covert behaviours as well, and then provide our staff who are going to go through the program with strategies around how they can intervene across a range of different behaviours. 

So far there’s been a strong focus, quite rightly, on sexual violence and sexual harassment. We wanted to learn from the practice in higher education, but take that further and expand it across areas like micro-incivilities around other forms of prejudice and discrimination, around the protected characteristics, but also place the focus on how we’re all responsible for making that change because at any one time we can be the recipients of those behaviours, those harmful behaviours, we can be the perpetrators of those harmful behaviours, and we can be a witness to them.

We wanted to have a really robust, proactive early intervention approach to dealing with those harmful behaviours because of the impact it has on people’s sense of belonging and their well being. But we also wanted a really robust approach to analysis and evaluation. We see our work with Culture Shift as providing a lot of really great information to inform our approach, as well as being a great tool for staff to use to report instances. So, we’re analysing how many reports we get and the nature of the disclosures, and also working on having a clear intervention approach to address them proactively, and then also working with Culture Shift to look at how we measure the impact of the intervention strategies. We ask ourselves questions like: “Are there trends emerging that are being identified in the Culture Shift dashboard? Are there trends emerging from our active bystanders that correlate to what we’re seeing in those dashboard reports?” We see this as a holistic, integrated approach to civility  and respect.

Gemma: The civility and respect strategy has been driven from data that you’ve gained from your annual staff surveys. And I know that there’s like a question every year about bullying and harassment, and the dial hasn’t really moved in those answers not just in your integrated care trust, but sector-wide. Bullying and harassment remains high and over the last five years levels haven’t moved much. I know it is acknowledged that bullying, harassment and discrimination happens within the NHS, but it seems to me that’s the interventions that have been put in place so far haven’t created enough change. Would you agree with that?

Aloma: Yes. And that was very much visible in the NHS Civilian Respect Toolkit that was developed last year. It identified a persistent problem and very much drew on the research that has been done nationally in this area. So we know that there is a national need to address these types of behaviours. We also know that the data gives us an insight in terms of the frequency of incidents and the types of incidents. But there’s also the impact on the wellbeing, productivity and performance of staff to bear in mind. When you start to look at the figures in terms of the numbers of sickness absences, which will be a consequence of those types of behaviours, the cost of defending discrimination claims through the legal system, the loss of productivity, you start to realise that this is a systemic issue that needs to be urgently addressed.

Gemma: The implementation of Report + Support in the trust supports and builds on the work that has already been done, by introducing things like the Freedom to Speak Up Guardian network. Do you hope this will encourage more people to say when they’ve experienced or witnessed something?

Aloma: The Freedom to Speak Up Guardian network is a really great network of colleagues who work incredibly hard to address certain incidents that do arise in the NHS. And I think ideally we want to create the environment where everybody feels safe to speak up about these incidents, whether it’s something that’s happened to them personally or whether it’s something that’s happened to somebody that they know, a colleague or a patient. That matters as well because obviously, we know that if we don’t address harmful behaviours in the culture, then it does have an impact on our clinical environments and our patient experience as well. Hence the whole movement around civility saved lives. I think this is incredibly important. And the Freedom to Speak Up Guardians play a vital role, definitely.

Gemma: One of Culture Shift’s main reasons for existing is to remove barriers to reporting. And one of the biggest barriers to reporting for some people can be saying what’s happened to you out loud, so one of the first things that we did when we created our software was to give the ability for someone to report at a time and place that felt safe for them. Often that can mean staying anonymous for now because you want someone in the organisation to know that something has happened, but you don’t feel safe enough to speak up yet or you worry about the repercussions on your own career if you were to do so. The people who are prepared to speak up are the tip of the iceberg because everyone else is either removing themselves from the organisation because they don’t want to work in that environment before or suffering in silence and experiencing issues which have a mental and physical toll on them. How do you handle this?

Aloma: We shouldn’t ever underestimate how much courage it takes to speak up and to report incidents. That’s why through our active bystander program work, we’ve placed a lot of emphasis on how do we enable leaders and managers to create psychologically safe conditions for people to speak up, but also how do we hold ourselves accountable to ensuring that we are effectively addressing those concerns? Because again, I think it’s really important that people are able to see how those incidents are taken forward effectively, which then gives us encouragement that if they report an incident, it will be addressed and that it will be delivered in a way that appreciates the courage the person who’s reported the incident has had to display because people are always concerned about repercussions from reporting incidents. And I think when you have psychological safety and leaders are creating those conditions, then it reduces the anxiety around there being some professional or personal implications from reporting incidents.

Gemma: Closing the feedback loop is so important in accelerating change and encouraging more people to speak up if they experience or witness anything because they know something will be done, but in a proportionate way, because actually, another barrier to reporting is because people don’t necessarily want other people to get fired. So with the micro incivilities, which could be addressed in an informal way, I think it’s important for people to be seeing that, understanding that the feedback loop is being closed, and that’ll definitely create a safer environment to give people the opportunity to speak up. Do you agree?

Aloma: I completely agree, Gemma, because what we do know, is there’s some research that’s been done quite recently, by Pearn Kandola. And what they found was the impact on what we call microincivilities, often also referred to as microaggressions, can be more severe than the impact of more explicit forms of bullying, harassment, discrimination, because there are different levels of impact. Due to the stress, actually, of trying to figure out, has something happened that isn’t right, or is it just in my imagination? And so because there’s been a lot of focus on interventions to address overt forms of harmful behaviours, it’s inadvertently led to a lot of those more covert forms of behaviour being unaddressed. And lots of our policies and our practices have been all designed to address more overt forms of harmful behaviours. So through the Active Bystander program, we’re actually doing a lot of work around looking at the impact of micro incivilities as well as defining what they are and providing assurance.

With micro incivilities, it’s perfectly normal to wonder whether you’re being oversensitive or whether you’ve misinterpreted that behaviour, because often the intent to harm is actually quite ambiguous. So there’s a lot of stress that comes from just figuring out whether you have experienced an incident or any form of inappropriate behaviour, and that has an impact on your health and well-being in terms of raising your blood pressure, in terms of stress levels. That then is more likely to lead to other harmful medical conditions. So the well-being dimension of this is really important, but also surfacing covert behaviours and saying, this is what they look like and actually, you’re probably not being oversensitive. That will make a big difference in terms of reporting rates, but also in how we improve culture, because at the cultural level, it’s through not addressing those micro behaviours where we get to a situation where it becomes much more embedded and ingrained in the way that people interact with each other. So the work that we’re doing with Culture Shift, we’re hoping that we’ll be able to capture and measure some of that, and for that to align closely to the work that we’re doing around the Active Bystander program as well.

Gemma: Can you tell us a little bit more about the Active Bystander program you’re running?

Aloma: Yes, the Active Bystander program has got six modules to it. So participants in the program will do two modules per month over a three month period. And across that development, they’ll look at what the drivers of inappropriate behaviours are. They’ll look at the full spectrum of inappropriate behaviours from the very covert, subtle forms around micro incivilities right through to the more explicit forms of discrimination, harassment, hate incidents, and hate crimes. And they’ll also explore this area that society is fascinated by, which is why do good people behave badly and why do good people not intervene when they see other people behaving badly? It all draws on the work of Professor Kathleen Sanderson from Amherst College who worked on the development of the program. Then finally we’ll look at strategies for intervention that active bystanders can use when they witness or observe inappropriate or unacceptable behaviours. So the idea is that we create a network or community practice across our system of people who are fully trained and confident to constructively and safely intervene. What we want to do, as I said, is closely align that to the work that we do with Culture Shift by looking at that baseline data and that diagnostic of current frequencies of incidents, but equally work with you to look at how we measure the impact of the Active Bystander program to bring about a meaningful culture change.

Gemma: That’s really interesting. And one of the things that we’ve always said with our software and how it complements being an active bystander is when you want to do something but it doesn’t feel safe to intervene in the moment. It takes courage to intervene as an active bystander, doesn’t it? So one of the things that you can do is report confidentially through Your Voice and the Report + Support platform so that you are doing your bit to create that safe culture and environment.

Aloma: Absolutely. So we look at direct and indirect forms of intervening. And so you’ve obviously got your direct forms where you intervene in the moment using different strategies for different situations. But then you’ve got your indirect intervention where you can actually use the Your Voice reporting tool that we’re developing with Culture Shift or report it through another method or have a conversation with a senior leader about how to address a particular incident. Our work with Culture Shift really feeds into that indirect intervention piece.

Gemma: There’s been a lot of change over the last couple of years, from the introduction of the NHS People Plan to the COVID-19 pandemic, which has taken a significant toll on NHS workers. How much has that impacted you, and how much have you adapted the work that you’re doing with civility and respect as a result of that?

Aloma: In terms of the People Plan, there’s a really strong focus on a specific pillar which belongs to the NHS, and that’s about inclusion and addressing bullying and harassment in the NHS nationally. But also valuing and getting the best out of the diversity that we do have in the NHS at a national level. So in terms of the work that we’re doing here, we feel it perfectly aligned to that pillar of the strategy, because we’ve now created a more proactive approach to addressing areas like bullying and harassment, but also incorporated that wider spectrum of behaviours. And in that way, we complement and enhance other approaches to addressing harmful behaviours.

So the work that we’re doing in terms of work that we’re doing with Culture Shift and the Active Bystander program absolutely are feeding into a latter amendment to the NHS People Plan, which is around how do we really ensure that we have the right leadership and culture for everybody to thrive in the NHS?

And so the fact that the work that we’re doing with you is very much about a transformational approach, where we can intervene earlier, where we can create a space for learning, because, as you said, Gemma, it’s not just about a punitive approach, it’s about how do we enable people to learn from particular incidences so that they can adapt and change their behaviour going forward? Because that’s going to have a much more positive impact on the culture. And we do know that this work was really inspired by our experience during the Pandemic, where we did witness an increase in certain types of inappropriate behaviours because people are under pressure, they were stressed. But it’s about a longer term vision in terms of the culture that we want to see in the NHS. So that’s why I’m really pleased to be working with the National Civility and Respect Team on looking at how we can add to the national pilot site for that wider rollout across the NHS nationally.

Gemma: If you could give any advice to leaders in other NHS trusts to help them increase people’s sense of belonging and promote inclusion within the NHS, what advice would you give?

Aloma: I think it is about innovation. It’s about moving away from what we’ve always done. We know that that’s had a limited impact and constantly learning and innovating our approach and very much adopting a transformational approach. Often we see incidents being addressed at an individual level, but essentially it’s really important to look at is this one incident, or is this actually a trend in terms of what’s happening in our culture? Is this impacting on a wider group of people? So it’s being really innovative in your approach, having a really robust diagnostic of your culture and really doing different things to achieve different outcomes eventually. Walking the talk. So the behaviours that you want to see in the wider culture yourself and being really mindful of how your behaviour as a leader is constantly being observed. And so people will be looking to you to really set the standard.

Gemma: That’s amazing advice. I think it was really interesting that you said innovate and you have brought the experience of working with Culture Shift from higher education into your role here. We’ve talked before about looking outside of the organisation or the sector at other practices and what is landing well. And looking at what isn’t working so well too is something that could be done more.

Aloma: I absolutely agree that the answers often aren’t only within our own sector. I think it’s always helpful to look at other sectors’ approaches, look at how you can adapt approaches from other areas, make sure that the right strategic organisation will fit for your context, and just be more curious. Actually, I think this starts with curiosity, being curious about how we can learn from other sectors. How can we get the broadest perspective on practice to address the issue that we’re trying to resolve? And so it starts with that curiosity and wanting to find out what others are doing outside of your own sector and then obviously learning from those innovations to create your own model as well and not just taking something off the shelf.

Gemma: There is no cookie cutter approach to solving the issue of workplace culture. And I think understanding you always need to learn and innovate, but then measure, understand and act on your context, because not all organisations are going to have the same focus. In higher education it’s tackling sexual harassment and sexual violence that is a focus, amongst other things. But what is the thing that needs to be tackled in your context? Because that is likely to be different in all organisations. 

Aloma: Yeah. And something else that I’ve been reflecting on recently is really being clear about root cause analysis of some of these issues, because often we’re dealing with the symptoms of something rather than the cause. And so we think we’ve got an issue here around, I don’t know, racial harassment. I think it’s helpful to think about the issues around racial harassment? Are the origins of that the same origins that are leading to sexual harassment in our culture? Often it’s helpful, again, not to look at some of these issues in a siloed way, but look at the root cause of what’s driving them, because it may be having an impact across a number of different areas. I think that’s really important as well.

Gemma: And the measurement and analysis of reports that are being received means that you don’t have to just do that blanket approach across the whole organisation. It means that you can be more targeted depending on what is happening in the different pockets of the organisation.

Aloma: Yeah. I feel that the evidence base is so critical here that it always starts with having that robust information at your fingertips, and then you can then go out and start to engage with staff on that information and start to gain some anecdotal information that gives you greater insight into why these behaviours are occurring in the culture. So I think that’s so important to have that really robust evidence base. It just minimises the risk of bias impacting on your interpretation of what’s happening in the culture. And it just is a key driver, really, for that change.

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