Understanding the Dynamics of Organisational Culture Change: Creating Safe Places for Patients and Staff
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SDO Project (08/1501/92) Understanding the dynamics of organisational culture change: creating safe places for patients and staff ! Professor Lorna McKee Health Services Research Unit, University of Aberdeen Professor Michael West Aston Business School, Aston University Professor Rhona Flin School of Psychology, University of Aberdeen Professor Adrian Grant Health Services Research, University of Aberdeen Professor Derek Johnston School of Psychology, University of Aberdeen Dr Martyn Jones School of Nursing and Midwifery, Dundee University Christine Miles East Lancashire Hospital NHS Trust Kathryn Charles Health Services Research Unit, University of Aberdeen Queen’s Printer and Controller of HMSO 2010 1 SDO Project (08/1501/92) Jeremy Dawson Aston Business School, Aston University Dr Sharon McCann Health Services Research Unit, University of Aberdeen Dr Steven Yule School of Psychology, University of Aberdeen Address for correspondence Health Services Research Unit University of Aberdeen 3rd Floor Health Sciences Building Foresterhill Aberdeen AB25 2ZD Lead researcher Professor Lorna McKee Health Services Research Unit University of Aberdeen 3rd Floor Health Sciences Building Foresterhill Aberdeen AB25 2ZD Lead researcher email [email protected] Queen’s Printer and Controller of HMSO 2010 2 SDO Project (08/1501/92) Contents Acknowledgements ....................................................................7 List of Appendices ......................................................9 List of Tables............................................................11 List of Figures .......................................................... 14 Glossary ................................................................... 16 Section 1 Introduction.............................................18 1.1 Introduction .....................................................................18 1.2 Aims and objectives of the study .........................................18 1.3 Why patient safety and staff well-being? ..............................19 1.4 The multidisciplinary team and key strands of work ...............20 1.5 Study research design .......................................................22 1.5.1 Trust selection .........................................................23 1.5.2 Description of Selected Trusts ....................................25 1.5.3 Gaining access .........................................................26 1.6 Project timeline.................................................................26 1.7 Engagement with key stakeholders ......................................27 1.7.1 Project team ............................................................28 1.7.2 Advisory team..........................................................28 1.7.3 Participant Trust representatives.................................28 1.7.4 Action workshop ‘intervention’ ....................................28 1.8 Organisation of the report ..................................................29 Section 2 Organisational Strand ..............................30 2.1 Introduction .....................................................................30 2.2 Research context ..............................................................30 2.2.1 What is organisational culture? ...................................30 2.2.2 Organisational culture: can it be moulded to drive performance? ...........................................................32 2.2.3 Developing safe cultures............................................34 2.3 Methodology.....................................................................43 2.3.1 The research strategy ...............................................43 2.4 Findings...........................................................................51 2.4.1 Commonly perceived barriers to patient safety .............52 2.4.2 Links between patient safety and staff well-being..........61 2.4.3 Environmental ‘shocks’: comparing Trusts’ capacity to change ....................................................................65 2.4.4 Comparative cross-case analysis.................................68 2.4.5 Characteristics of Trust typology .................................71 2.4.6 Discussion ...............................................................92 Queen’s Printer and Controller of HMSO 2010 3 SDO Project (08/1501/92) 2.5 Conclusion .......................................................................95 Section 3 Leadership strand .................................. 100 3.1 Introduction ................................................................... 100 3.2 Introduction and literature review...................................... 100 3.2.1 Senior managers and safety in industry .....................100 3.2.2 Transformational/transactional leadership and safety...103 3.2.3 Health care senior managers and patient safety ..........106 3.3 Aim ............................................................................... 108 3.4 Method .......................................................................... 108 3.4.1 Organisational setting and participants ......................108 3.4.2 Measures...............................................................109 3.5 Results .......................................................................... 112 3.5.1 Leadership survey...................................................112 3.5.2 Leadership interviews - results .................................119 3.6 Discussion...................................................................... 122 3.7 Limitations ..................................................................... 124 3.8 Policy and practical implications ........................................ 125 3.9 Future research .............................................................. 125 Section 4 Staff well-being strand .......................... 128 4.1 Introduction ................................................................... 128 4.2 Literature Review ............................................................ 128 4.2.1 Nature and impact of work stress in the general workforce ..............................................................128 4.2.2 Nature and impact of work stress within health care ....129 4.2.3 Effects on mood and behaviour.................................130 4.2.4 Impact of the work environment, staff well-being on patient safety .........................................................130 4.2.5 Theoretical approaches linking work environment, well- being and performance ............................................132 4.2.6 Influence of shift climate and incidents on well-being and performance ..........................................................135 4.2.7 Capturing variation in perceptions of linking work environment, well-being and performance ..................136 4.2.8 Benefits of the EMA approach ...................................137 4.3 Aim ............................................................................... 138 4.3.1 Objective: Work environment and well-being..............138 4.3.2 Objective: incident characteristics, well-being and performance ..........................................................138 4.4 Methods......................................................................... 138 4.4.1 Design ..................................................................138 4.4.2 Selection of Trusts ..................................................139 4.4.3 Participants............................................................139 4.4.4 Procedure..............................................................139 4.4.5 Questionnaires .......................................................140 Queen’s Printer and Controller of HMSO 2010 4 SDO Project (08/1501/92) 4.4.6 Materials ...............................................................140 4.4.7 Statistical analysis ..................................................142 4.5 Results .......................................................................... 143 4.5.1 Return rates ..........................................................143 4.5.2 Are the high scoring and low scoring Trusts comparable?145 4.5.3 Testing the demand control and effort reward imbalance models using questionnaire assessment .....................148 4.5.4 Ecological Momentary Assessment using the PDA-based diaries...................................................................151 4.5.5 Testing the demand control and effort reward imbalance models in real life ....................................156 4.5.6 Differences between the low scoring and high scoring Trusts on EMA measures..........................................160 4.5.7 Effect of incident characteristics on nurse well-being (negative and positive affect) ...................................162 4.5.8 What is the nature of end of shift incidents? ...............171 4.5.9 Do averaged values of the work environment (shift climate) predict nurse performance following the worst incident?................................................................177 4.5.10 Who is involved, colleagues or patients, and what is the effect on performance? ............................................180 4.6 Conclusion ..................................................................... 183 Section 5 Integrated strand analysis..................... 185 5.1 Introduction ................................................................... 185 5.2 Integrating primary data strands ....................................... 186 5.2.1 Cross-cutting themes