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Impact of organisational culture

Unit No. 6

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1. Learning objectives of this unit

The principal objective of this Unit is to help participants understand what is meant by ‘culture’ and why it is so important in healthcare in delivering high quality and safe care.

To support participants to see how they can have a positive impact on the culture in their team – whether or not they are leading the team at the time.

2. Learning outcomes of this unit

Participants will be able to articulate what organisational culture is, and the

differences between that, and the micro-culture – and climate – of their own area

Participants will be aware of some of the research around cultures that support excellence in care

Participants will have developed ideas – and translated these to action – with regard to how they can influence the culture in a team to create the right environment for them to do their best work

3. Links to overall programme learning outcomes

While the primary focus of this Unit is on the third objective, “Creating a culture for quality”, culture is also a key enabling factor to improving the quality of the patient experience (both as an outcome but also as an input to changing the culture, where patient involvement is key) and to making person-centred coordinated care happen. The theme of culture in integrated care (across professions and across organisations) is explicitly addressed as part of this unit.

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Contents 6.0 What is culture? 6.1 Subcultures and micro-culture 6.2 Why focus on culture? 6.3 Can I shape culture? 6.4 Culture shaping behaviour 6.5 Culture for person-centred care 6.6 A service culture 6.7 Culture in the NHS 6.8 So you want to change the culture? 6.9 And finally…

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6.0 What is culture?

Culture is notoriously difficult to describe. What does it really mean? And are people always talking about the same thing when they’re talking about culture? A common – and helpful – way to describe culture is, “the way we do things around here”. By inference, that might or might not be different to ‘the way people do things around there’ in other organisations. Another way to think about it might be as the ‘personality’ or character of an organisation. You can’t quite put your finger on any one single item – instead it is a wide range of factors that, together, make up what we’re calling the culture of the organisation. It can be fuzzy and difficult to identify. There are many different models and ways of thinking about culture, which is what can make it tricky to define and talk about. Looking at organisations through a cultural lens means seeing the organisation as a system of meanings, values and routines, where our actions comes from habit, tradition and what we take for granted. And because we take it for granted, it makes it difficult to see. After all, a fish takes the water it swims in for granted until it is taken out, and only then is when it realises that it’s whole structure and way of living is specifically adapted for living in the water. Have a look around at work – really notice what’s around you – most of which you’ll take for granted. Who’s in charge? What clothes do people wear in different areas? How do people talk to each other? Which lifts do people use? Who talks with whom? And about what? Who doesn’t talk in meetings? Once you really start looking and noticing – you can get closer to understanding the idea of different ‘bits’ or components coming together and creating a culture. And what about you? Where do you fit in? Why do you do some of the things you do at work? Is it through choice each time – or ‘just that’s what we do around here’? ACTIVITY

Make a few notes in your journal. What are some of the elements, or routines, or behaviours – or even physical things – you could point to in your organisation which are part of the fabric of your organisation’s culture? So now that you’ve begun to notice what makes up the dominant culture, what does this mean for you? How is it helpful to you as a leader? If you’re not sure – let’s take two examples – firstly, what do your observations of the culture tell you about how people might behave if they want to ‘get on’ – or be successful? Secondly – what do your observations of the dominant culture tell you about how you can support people in your team to the maximum? What does ‘seeing’ the organisation’s culture tell you about how you might lead your team even more effectively? How can you help them operate within it to the best of their ability? So that’s the reflection part. What will you do? When?

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6.1 Sub-cultures & micro-cultures You’ll notice that we started the Unit by thinking about the whole organisation’s culture. Trying to change anything at that level might look daunting – and indeed it is very difficult for any one person to change the culture of a whole organisation. So let’s consider another level of culture – a sub-culture. A sub-culture is a culture within the organisation’s (overall or dominant) culture. The dominant culture gives staff boundaries and guidelines that shape their behaviour – but most organisations also have a number of subcultures that include the core values/assumptions of the dominant culture – and additional values/assumptions which are unique to the subculture. Subcultures form when a group have a shared situation or experience that is unique to them. Common subcultures are around professions, or departments, or geographical sites – amongst others. For example, a specialised child development clinic is likely to have its own sub-culture – and ways of doing things – whilst also being part of a larger community partnership Trust, and the dominant culture of the Trust. Or you could say that audiologists may have their own sub-culture, and shared beliefs, whilst still operating within the dominant culture. It’s useful to acknowledge and recognise these, because they help explain the challenges of trying to bring about changes in culture. Let’s break this down one more level – to micro-culture. A micro-culture could be your team. Even if there are just 4 of you – you’ll have your own understanding of how you work together, what’s acceptable and what’s not – and how things get done in your team. And all the time, you are operating within the dominant organisational culture. And it’s at this level, where you can make a difference, most easily. And a final word to just one more term – climate. Climate is different from culture. Climate is specifically how it ‘feels’ to work here – and you, as a leader of a team, have an enormous amount of influence as to how it feels to work in your team. We know that a positive team climate has a positive impact on the productivity of any team. Be aware that sometimes people think they’re changing the culture in a team, when actually they’re changing the climate. Climate is shorter term, and can change more easily with leadership involvement or other interventions. Culture is more stable over time than climate, takes more interventions to shift, and is less to do with emotional engagement at work and more to do with unconscious assumptions and values and practices of workforces. If culture were the ‘character’ of an organisation, department or team, then climate would be its mood. When you consider that the dominant culture, numerous sub-cultures and maybe hundreds of micro-cultures are all running alongside, and threaded through each other, it’s not surprising that people find it difficult to explain what it is, and find it so challenging to change.

In the previous exercise, we asked you about your observations about the dominant culture in your organisation. But what about the sub-culture you’re part of? And your own team’s micro-culture? As you look at culture at the different levels, is it more evident or simpler to see how you might be able to alter the culture through your actions? What could you do? What might be the risks of doing something? What are the incentives?

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And what about climate? How it feels to work for you and your team? This is the area which can be affected most visibly, most quickly. What could you do differently to lift the climate of your team, even if just by a point? Go through the reflection/action sequence again. So consider an area in your team’s ‘world’ – so how they work together, or how things get done – where you think an improvement could be beneficial. In the light of what you have learned here – where might you try something different? And how will you know if anything is happening? Now try and do it! We’ll explore your experiences in the online discussion forum. Remember, you’re practicing – it doesn’t matter if the world doesn’t change overnight – but notice what changes you see – or hear – as a result of your action!

6.2 Why focus on culture?

In this Unit, we’re going to look at how you – as a leader – can think about, and contribute towards, culture in different ways. But why even look at organisational culture? Well, recently culture has been cited often as a driver of poor performance in healthcare. You’ve already come across the Francis Inquiry in your earlier work on the programme. When we looked at it then, it was to understand how it illustrated failures of care. As we look at it again briefly now, we’re specifically looking at Robert Francis’s references to culture. Have a look at this short 6-minute film, “Francis Report: Health Foundation lessons learned”. As you watch the film, listen to how culture is used to explain the behaviours of others. https://www.youtube.com/watch?v=CY-P9n_7atU (1.7)

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ON SCREEN In the first Francis report (2010), there was a clear analysis of the culture of Mid Staffordshire Hospitals. The main features highlighted were

Attitudes of patients and staff

Bullying

Target-driven priorities

Disengagement from management

Low staff morale

Isolation

Lack of openness

Acceptance of poor standards of conduct

Reliance on external assessments

Denial

(Francis report, 2010 pp. 15–16) (ACTIVITY)

So now we’re highlighting many more features which could be include when considering the idea of culture – beyond our initial observations. Reflecting on the video and the report extracts from Robert Francis, add to your earlier notes in your journal – what else makes up culture? In the light of this, what are some of the additional elements you can identify most clearly in your role? Remember to think about the different levels of culture we looked at – the organisation’s culture, any subculture you think you’re probably a part of, and your own micro culture. What additional thoughts are you having about areas of culture you sense you can certainly influence? And what about climate? What could you do tomorrow? What will take longer? What’s stopping you?

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6.3 Can you shape culture?

Leaders are often referred to as key in shaping the culture. But can any one person shape a culture? Now that you’ve explored culture at different levels – the organisational culture, subcultures and micro (or team) cultures, you should have a clearer sense of what this might mean in your role – and in your organisation. It does remain true that a chief executive, and executive team, do have very important roles as perpetuators of culture – as a symbol, through their actions, through what they reward or through the stories they tell. They can also actively shape the culture and change the perceptions of other people about the environment in which they operate. However, we hope you can see that the multiple layers of culture mean that it’s unlikely any one person can shape culture on their own. Senior leaders have the biggest impact on culture because they are more visible across the organisation and they contribute to setting policies that shape behaviour. However, on the front line, leaders are actively interpreting and implementing these policies every day to shape the way that culture is experienced in that team or service. So we’ll be looking at how you can play a part in shaping your micro culture that reflects the values and aspirations of the NHS. However, all this assumes you can change the culture. Yet some researchers question this assumption. Essentially there are two views: 1. Culture is ‘caught’. This approach suggests that culture reflects the very essence of the

organisation. In this view culture emerges over time. It shapes the thinking patterns of staff to

provide what Hofstede calls ‘the collective programming of the mind which distinguishes the

members of one group or category from another.”

2. Culture is ‘taught’. In this approach, culture is actively shaped through ongoing sense-making.

This approach aligns with the Moullin’s approach to developing a service culture, where

assumptions and values are constantly tested and questioned.

What does this mean for you as a leader? The truth probably lies somewhere in between. There are certainly aspects of the culture that are fixed and where you can have minimal influence. For example, the performance management system may not be something you can actively change yet will impact upon the culture of your team. The values enshrined in the NHS Constitution are partly shaped by the long history of the organisation and the ethos of its founders. But there are also many aspects of culture you can have an impact upon. Hopefully this Unit will give you some concrete ideas about where to focus and how you can address these issues. Of course, it is a slow process – most estimates suggests real cultural change is achieved over a period of years rather than months. Yet ‘discomfort’ introduced from events such as the Francis enquiry and a greater focus on integrated care have created a state of ‘unfreezing’ that provides an ideal opportunity for you as a leader to shape things differently for the future. Even for those areas where you can’t actively shape the culture, you can change perceptions of the work environment – which takes us back to our definition of climate. Remember, organisational climate is about perceptions of the work environment which have an impact for people on ‘how it feels to work around here’. So even for those aspects of culture that you cannot impact directly,

Comment [CL1]: Reference??

Comment [CL2]: Reference??

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you can have an influence on the perceptions of your team members. As you may already know, the immediate leader of the team has the biggest influence on the climate that team members experience. So you have the opportunity to make a difference at this level as well as seeking to deliver more fundamental cultural change.

6.4 Culture shaping behaviour

TEXT ON SCREEN/EXERCISE According to Alvesson (2002), culture can play a number of different roles in shaping behaviour in an organisation. Here’s another way of thinking about it – have a read of this list – and make some notes in your journal about what you recognise for your role and team

Control: culture controls behaviour through the psychological contract and rewards. For example, corporate values and constitutions – such as the NHS Constitution – describe what is expected.

Direction: culture gives a sense of direction and provides guidelines for priorities, for example, “a high priority was placed on the achievement of targets” is a key theme in the Francis report

Identity: the common ideas, symbols and values that hold people together as a group. This is strengthened further in professions, where there is a common long-term training path and, in some cases, a common uniform.

Beliefs: at the heart of culture are the basic assumptions and values that people are strongly committed to. So the belief in person-centred care is something that is increasingly emerging as central to the NHS as an organisation.

Emotional regulator: culture shapes feelings and how they are expressed, for example, the Francis report cites a “lack of trust in management leading to a reluctance to raise concerns”

Blinkers: culture – especially strong cultures – can lead to things being taken for granted or blind spots, e.g. “Acceptance of poor standards of conduct”

Fences: culture inherently creates a ‘them’ and ‘us’. Our psychological wiring means we instinctively defend ‘us’ against ‘them’. This can make it difficult to raise concerns or be critical. We can see this in the themes around isolation and denial – “in spite of the criticisms the Trust has received recently, there is an unfortunate tendency for some staff and management to discount these by relying on their view that there is much good practice and that the reports are unfair.”

So culture has some positives – it keeps us together, it reinforces alignment around common goals, and it can provide a sense of identity.

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However, it can also make it harder to be responsive and open to others. So part of the goal of this Unit is to encourage you and maybe those around you (as your team), to recognise, question and actively shape the culture in which you are operating to support high quality and safe care for people who use services.

Go for a walk around your organisation, or another if that’s simpler – and really notice the things which you can see – or hear from people that, in the light of this list and some of the ideas here, help you understand more about culture. We’ve allowed time for this in the Unit – around an hour or so – so take advantage of this if you can – or at least try and take a break during the day to have a close look around

Here are some examples of how this list might come to life in your organisation – but only examples – keep your eyes and ears open!

Control – where are the rules in your organisation? Signs? Locked doors? Are some people sent one way, others another way?

Direction – this is about making clear what’s important, and guiding priorities – so do you see league tables? What’s clearly prized and valued? How can you tell?

Identity – how can you tell who is who? Badges? Uniforms? Hats? What else? Car park spaces? Organisational branding?

Beliefs – how can you tell what your place believes? Can you see anything? Are there publications? Signs? Do you hear stories?

Emotional regulators – this is tricky to see sometimes, but is there anything around that gives you a sense of joy, or happiness, or pride? Or unhappiness? Or distrust? Don’t forget to keep your ears open on this one too…

Blinkers – as the definition suggests, this is likely to be in very strong cultures where things have been taken for granted for so long, standards might have changed. This is something which might be easier to see in a different organisation than your own.

Fences – listen out for the very words, ‘they’, ‘them’ and ‘us’ in conversations. It’s safer to collude with people who we’re comfortable with, and see others as ‘them’…

It takes a while to be inducted or ‘assimilated’ into an organisation’s culture – so maybe ask someone who is very recently joined the organisation what they notice. This can be a good activity for all the points of the list above, especially the ‘blinkers’ since they take time to develop. One thing to be very mindful of here is that it can sometimes be easier to identify things which we think might be slightly negative. Don’t forget the walls of thank you cards you can find in some places, look out for places that are well tended – or make people feel cheerful. Catch people being friendly and laughing – as well as the suspicious looking gossiping in the corner!

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Remember the point of using this list is simply to notice that culture leads to behaviour – and so as leaders, it gives us an intriguing option – what would happen if I tried to influence the culture in some way?

ACTIVITY – as well as your own observations – talk to one or two colleagues as well, and get their observations, against this list – they may notice different things. And begin to have that conversation with them – what would happen if we tried to change an element of this……you’ll be picking up on this in the online discussion forums in the programme.

6.5 A culture for person-centred cared

(WRITTEN INSTRUCTION) Patient-centred care? In the introduction, we saw how culture can be a positive driver of performance but also a negative influence on outcomes. Part of the aim of this programme is to equip you as a leader to be able to understand how you might be able to influence a culture which is conducive to delivering high-quality patient care in an environment where staff feel supported and valued. What does the culture look like in an organisation that is entirely focused on its ‘patients’? Read the extract here How to Measure a Company's Most Elusive Element: Culture by Mark Graham Brown (Business Finance, Oct 3, 2011) about an organisation entirely focused on its service users.

We’ve deliberately gone outside the normal health and care examples here – just because sometimes it’s simpler to see things when we don’t have the inside knowledge about a particular area!

Purina's Pets Before Profits

One of the best run companies I've ever worked with is Purina, part of food giant Nestle. Their culture revolves around the idea that pets are always more important than profits. This value made decision making easy when there have been several pet food scares due to tainted raw materials. A few years ago, when a number of dogs and cats died from bad pet food, Purina pulled all of their products from all retail shelves just to be sure, only later they found out that almost none of their pet food was bad. The move cost the company millions, but Purina president Terry Block wanted to make sure no dog or cat died because the company was worried about losing money. This decision communicated the value loud and clear to all employees and customers.

Another value that characterizes this company is innovation. About a third of its sales every year come from new or enhanced products, which would seem to be a tough challenge in the pet food business. Purina is also known for work/life balance with 97 percent employee satisfaction. The best companies in America get rated at 80 percent satisfaction and average companies get 50 percent. In 2010 Purina was awarded the coveted Malcolm Baldrige Award, while also being awarded best place to work in St. Louis, and the best company in America for work/life balance. And, by the way, they also have the best financial and market share results of any company in their industry.

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(WRITTEN INSTRUCTION) So what did you notice was important in Purina? There was a clear link between the dominant culture – “pets before profits” – and a powerful symbolic act from the president to reinforce this value. There was also the focus on caring for its people, with the emphasis on work-life balance and employee satisfaction. The great thing is that, rather than impacting negatively on their organisational performance, they are highly successful. This suggests that a positive culture can have benefits for employees, “patients” and the organisation as a whole. How does that translate into the NHS? What does a culture that provides high-quality patient care in an environment where staff feel supported and valued look like? One of the best known proponents of work in this area is Professor Michael West. Take a look at this video where he shares his thoughts on the culture and values needed to achieve this goal.

Make a note in your journal of the six key things he thinks leaders need to do and the six core values he sees as important for human communities. You’ll notice that he also references the teams and pseudo teams idea we looked at in Unit 3. We will come back to the dimensions of culture that West discussed – and the values he references, in the online discussion forums.

Michael West video https://www.youtube.com/watch?v=8WChif5qbns

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(ACTIVITY - WRITTEN INSTRUCTION)

Looking over the list you have made based on Michael West’s talk, how does the culture in your area compare to his suggestions? Record the top two strengths of your area against this framework and the two facets of culture where you see the biggest gaps.

6.6 – A Service Culture?

Another researcher, Max Moullin (2002) uses the term ‘service culture’ to describe a culture focused on understanding the needs, wants, anxieties and emotions of patients and service users. In this section, we’re going to use his ideas as a framework for helping you to think about the actions that you can take to shape the right kind of culture in your area. Next to each of Moullin’s steps are some key questions for you to answer. Use your own insights, experience and any existing data you have. If you don’t know, come up with a plan for how you can get the information. A template of the steps is attached to the Unit for you to print off as a guide.

EXERCISE You could do this exercise on your own, but it will be most effective to do it as a team exercise - so why not give it a go with your team? One thing to note is that you might find some question easier to answer than others – or you might think some are from the ‘very obvious’ category! If you lead a team at the moment, this would be a well-structured exercise to introduce either into a regular meeting where you purposefully make time for it in the agenda – or the main focus of a session that is intended for your development as a team. You’ll remember in Unit 3, Michael West talked about teams and pseudo teams – with real teams having goals which they set and achieve together, supported by reviews of how they’re doing. This exercise could be a very useful part of you taking a role in developing your team, and ensuring it doesn’t become a pseudo team. Notice which questions are easier than others – that might tell you something in itself about the things that are seen as important. Where the exercise refers to ‘organisation’ or ‘unit’ – make a decision as to the best level of analysis to use – is it your team alone? Or your department? Feel free to experiment with the exercise – the purpose is to have the discussion – or the thinking – not getting a beautifully crafted answer

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Twelve steps to a service culture

Moullin’s Steps Key questions for you to answer

Step 1: Decide on your key mission and core values.

Identify the main purpose of your department or

unit. This should define who you are providing a

service for and reflect the needs of relevant

stakeholders and your core values.

What is the key mission of your unit or team?

Step 2: Know your service users and other stakeholders.

Talk to your patients, carers, service users and other

stakeholders. Find out their requirements and

expectations. Consider how well you currently meet

their expectations and identify, with service users

where possible, ways of better meeting their needs.

Who are your key stakeholders? What do they need? What do they expect How well are their expectations currently being met? What suggestions do they make about how their needs could be better met?

Step 3: Create your vision. Like your statement of

your core business, the statement of the vision of

your organisation gives a lead to your staff and,

hopefully, the right message to service users.

State your vision here.

Step 4: Define your moments of truth. Moments of

truth are those encounters between users and your

organization that will make the biggest difference to

how they perceive the service they have received.

Make sure the processes are designed to ensure that

these moments of truth provide the best possible

service. In health and social care do not

underestimate the difference you can make in a

single short interaction

What key interactions define the

‘moments of truth’ in your area?

How do people currently

experience these moments?

How could they be improved to

create an even better experience?

Step 5: Give good service to one another. The quality

of service that impacts on patients and service users

begins with the quality of service that staff give each

other. This includes different staff within your

organization and other partners and stakeholders

What are your key relationships

and partnerships, within the team

and beyond?

What can you do to improve the

service you give to one another?

Step 6: Create the service user experience. Service

excellence does not happen by chance. It has to be

carefully planned. In addition to designing the core

service, with the help of users, stakeholders and partners, leaders need to ensure that staff have the

relevant skills and training, both in the technical

nature of the job and in how they interact with

service users. In creating the service user experience,

staff also need to consider whether users and

patients are given the information they need. Are

In terms of service excellence, what

skill strengths do we already have?

How can we build upon these?

Where could we be stronger? How can we improve?

What is the ‘patient service

experience’ – can we map out their

journey to help us understand

where we can get better at

informing, caring and listening?

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they told what is likely to happen, are they greeted

on arrival, do they feel listened to or do they feel

they are being processed? Do staff demonstrate a

positive attitude and give clear messages?

Step 7: Profit from complaints. Complaints are a vital

source of information for any organization. While the

vast majority of dissatisfied users do not complain,

the information obtained from those that do can be

very illuminating. Encouraging users to provide

feedback on their experiences – and acting on that

feedback – will enable you to offer an even better

service.

What insights can we glean from

complaints we have received?

How can we work with patient

representatives to get even more

insight?

Step 8: Stay close to your service users and other

stakeholders. Involve your service users and other

stakeholders when developing your plans for the

service, reassuring them and helping them to

understand what to expect.

How are our mechanisms for

patient and user involvement

working? Could we enhance them

further?

Step 9: Design and implement the service

programme. This means moving from making a series

of improvements in service quality to a well-defined

service improvement programme providing a lead

and encompassing all the different aspects of quality.

Reviewing the patient and user

journey, have we made all of the

improvements we can?

Step 10: Set performance standards and measures.

Setting (and monitoring) performance standards and

measures is an important vehicle for ensuring that

the various aspects of service quality important to

users and carers are actually delivered.

How will we know when we have

been successful?

For measures we already have,

what trends can we identify?

Are we holding ourselves to

account against the goals we set?

Step 11: Recognize and reward service excellence. In

many cases staff who provide excellent service get

direct feedback and recognition from users and

patients. This can be the best feedback of all, but if

you want your staff to continue to give real service to

users, then the organization has to systematically

recognize that this has been done and give some

recognition and reward to the individual concerned.

Make sure that service factors are considered

alongside other factors when considering staff for

promotion, for example.

Who is outstanding in the quality of

service and care they give to

patients? How do we recognise and

celebrate them?

Do we have opportunities to

regularly reward and recognise

those who excel in this area?

Step 12: Review the service programme. You have

made a good start by following the first 11 steps –

now is the time to reflect on what you have done

and develop the next stage of the programme.

Reviewing the whole process, what

can you learn? What can you share

with others? What needs to be

celebrated and recognised beyond

the team? Who do you need to

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tell?

Give yourself a challenge – what will you do? When? How can you and your team specifically help develop this service culture?

Remember – what you’ve done here, has been mostly analytical – so you’ve stepped back and observed/noticed and analysed. This is an important critical skill to have and develop – but don’t stop short of asking ‘so what’? What will you do now? When? And how will we check back in together – to ensure we continue our development as a ‘real team’. The very asking of these questions, and the process of your work together, is changing the shape of culture in your workplace.

6.7 – Culture around the NHS

Moullin’s approach is, in essence, a way to try to ‘capture’ and shape aspects of culture to point towards a particular goal, in this case providing a high quality service to patients. There are some great qualitative examples of using culture change as a driver for improved performance. Have a look at which has some great examples of different NHS organisations that have developed seamless – or more joined up care. Pick just one or two case studies that look like they would be most relevant to your own team and setting – and review it, focusing on the changes in culture necessary to bring about their success. The symbol here – with speech bubbles in it, shows where there is a specific reference to culture change as part of the overall service improvement story, to help guide your reading. Read through these examples and make some notes on the following questions.

- How was culture used as part of this initiative?

- Do you see any themes in how culture is used by leaders to drive

improvements in care?

Remember – this whole Unit needs to be useful to you – so think about, or even better, share with

your team – some of the ideas and themes you’re noticing. What does any of this mean for you,

your team and your patients? What can you see from successful examples elsewhere in the NHS,

which could help you in your work?

(WRITTEN INSTRUCTION – OPTIONAL READING)

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Additional reading: If you want to find out more about how others perceive the culture in the NHS, there is a study by Dixon-Woods, Baker, Charles et al (2014). This study used a multi-method approach to look at the cultural attributes of the NHS more broadly. This is important because it helps to point to priorities for leaders as well as highlighting the overall cultural context in which we are all operating. The article is fairly short – but also quite academic so if you are short of time, read the section on culture and behaviour and the discussion, so from page 113 onwards. Optional activity. In the wake of the Francis inquiry, the BMJ brought together a panel of different stakeholders to discuss their perceptions of the culture in the NHS and what they think needs to change. You can listen to it at https://soundcloud.com/bmjpodcasts/how-do-we-put-the-compassion. While you are listening, pay attention to the source – how different are the view of different professions and roles? We are going to look at that in more detail in the next section.

6.8 …and finally

So we have explored what culture actually is – and some different ways of looking at it, and thinking about it. We’ve also looked at the impact of culture on performance, both positive and negative. And also how easy – or not – it might be for you to influence it in different ways. If you’re particularly interested in the area, there are some fantastic additional resources available. One of these is ‘Do OD’ – which is a network and a collaboration between the NHS Leadership Academy and NHS Employers - (http://www.nhsemployers.org/campaigns/organisational-development). As well as NHS based case studies, it also runs events, networks, national conferences, publishes advice, supplies tools, and supports individuals and organisations in their development. So we’ve asked you to do lots of thinking, and lots of talking to people about some of the ideas in this Unit. How are you getting on with actually making a change – however small? Be brave, and see what makes a difference. No-one needs even know you’re trying something out! When you’re feeling even braver, try something else…. Good luck! (End)