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• To understand the importance of an effective workplace culture in older people’s care settings
• To learn about the ‘Guiding Lights for effective workplace cultures’ and how they can support staff and patients to feel safe and valued
• To count towards revalidation as part of your 35 hours of CPD, or you may wish to write a reflective account (UK readers)
• To contribute towards your professional development and local registration renewal requirements (non-UK readers)
While much attention has been given to organisational culture, there has been less focus on workplace culture. Yet workplace culture strongly influences the way care is delivered, received and experienced. An effective workplace culture is crucial for the well-being of individual staff members and teams as well as for patients’ experiences and outcomes of care.
This article describes the ‘Guiding Lights for effective workplace cultures’ which were developed by the authors and provide a framework to assist in understanding and promoting effective workplace cultures and creating environments where staff and patients feel safe and valued. There are four Guiding Lights: ‘collective leadership’, ‘living shared values’, ‘safe, critical, creative learning environments’ and ‘change for good that makes a difference’. Each one articulates what good workplace cultures are through descriptors and intermediate outcomes and together produce a set of ultimate outcomes. The Guiding Lights provide nurses working in older people’s care settings with an opportunity to learn from, and celebrate, what is going well in their workplaces and to consider areas that require further development.
Nursing Older People. doi: 10.7748/nop.2022.e1377Peer review
This article has been subject to external double-blind peer review and checked for plagiarism using automated softwareCorrespondence
Webster J, Sanders K, Cardiff S et al (2022) ‘Guiding Lights for effective workplace cultures’: enhancing the care environment for staff and patients in older people’s care settings. Nursing Older People. doi: 10.7748/nop.2022.e1377
Published online: 04 May 2022
The aim of this article is to describe the ‘Guiding Lights for effective workplace cultures’ (Cardiff et al 2020), which were developed by the authors. The Guiding Lights provide a framework that can assist nurses working in older people’s care settings to develop a workplace culture that promotes ‘collective leadership’, ‘living shared values’, ‘safe, critical, creative learning environments’ and ‘change for good that makes a difference’. After reading this article and completing the time out activities you should be able to:
• Describe the effects of workplace culture on how care is delivered, received and experienced.
• Identify the important elements of a positive workplace culture.
• Reflect on the challenges of creating workplace cultures where staff and patients feel safe and valued.
• Identify what elements of the culture in your workplace make it effective and what elements require change.
Think about ‘the way things are done’ in your setting. What terms would you use to describe your workplace culture? What are the behaviours and values that influence how care is delivered to, and received and experienced by, the older people in your care?
• Workplace cultures are complex, multilayered and multifaceted
• An effective workplace culture is crucial for the well-being of individual staff members and teams
• Effective workplace cultures enhance the experience of care and care outcomes for older people and those who support them
• Workplace cultures can be altered through inclusive, person-centred relationships and collaborative practice transformation
• The ‘Guiding Lights for effective workplace cultures’ provide a framework for creating environments where staff and patients feel safe, valued and treated with compassion
A simple definition of culture is ‘how things are done around here’ (Drennan 1992). It can be recognised as the behaviours, patterns and rules that become accepted as the norm. The importance of workplace culture and the underpinning connection to leadership (Stanley 2008, Allen 2020), patient safety (Manley and Jackson 2019), staff well-being (Haddon 2018) and whistle-blowing in older people’s care (Jones and Kelly 2014) have become widely recognised in healthcare literature over the past two decades.
High-profile reports regarding Mid Staffordshire NHS Foundation Trust (Francis 2013), University Hospitals of Morecambe Bay NHS Foundation Trust (Kirkup 2015) and Liverpool Community Health NHS Trust (Kirkup 2018) have repeatedly brought to the fore the importance of culture in its widest sense and the multifactorial elements that contribute to organisational failings in care, with Mannion and Davies (2018) acknowledging that ‘although culture is often identified as the primary culprit in healthcare scandals, with cultural reform required to remedy failings, such simplistic diagnoses and prescriptions lack depth and specificity’.
Mannion and Davies (2018) stated that organisational culture ‘represents the shared ways of thinking, feeling and behaving in healthcare organisations’. In the context of care homes, some authors have recognised the influence of culture on the quality of care delivered and experienced (Killett et al 2016) and on older people’s quality of life (Moss and Dewar 2014). Similarly, the ‘culture of practice’ has long been recognised as contributing to either ‘uphold’ or ‘undermine’ the personhood of people living with dementia (Kitwood 1997).
While there has been much focus on organisational culture, Manley et al (2011) and Cardiff et al (2020) argued that there is a need to focus on workplace culture. The workplace being where care is delivered, received and experienced, with workplace culture strongly influencing the way care is given and therefore staff and patients’ experiences. Skills for Care (2021) suggested that ‘having a positive workplace culture is vital to delivering high quality care and support’. For nurses and other health and social care workers delivering care, and for older people receiving care and those who support them, the importance of workplace culture cannot be overestimated since it influences the experience, outcomes and safety of that care.
This article focuses on workplace culture, since it is the most immediate culture experienced and/or perceived by staff and patients. It describes the ‘Guiding Lights for effective workplace cultures’ (Cardiff et al 2020), which provide a framework for creating environments where staff and patients feel safe, valued and treated with compassion.
The term ‘culture change’ is frequently used in the literature and suggests that workplace culture may be altered, which the authors believe it can through inclusive, person-centred relationships and through collaborative practice transformation and development. However, the term does not necessarily recognise the complexity of workplace culture in health and social care settings, or acknowledge that the wider system often changes rapidly which makes it unpredictable – joyous and challenging in equal measure. In their work on ‘caring cultures’, Sanders and Shaw (2015) suggested that ‘it seems that a lot of attention has been focused on the “what” but not so much on the “how”, particularly at the level of front-line care and services’.
Workplace culture is experienced at different levels across the whole interface of care. For example, it can be experienced in staff’s attitudes and behaviours or ways of working that either enable or constrain innovation and development. Workplace culture is not one-dimensional and cannot be defined easily in the singular. It is complex, multilayered and multifaceted and can be viewed in different ways from different perspectives. Fundamentally, it is the immediate environment in which people work and deliver care. At this microsystems level, culture is a particular focus of practice development (Hardy et al 2021), since workplace culture directly affects the delivery of care (Manley et al 2011).
Traditionally, change related to practice and culture has been driven ‘from the top down’. The primary driver for change instigated from the top is usually organisational needs, which those at the interface between care delivery and care reception may not perceive as ‘change for the good’ (Manley and Jackson 2019). Manley and Jackson (2019) asserted that new approaches that support complex change ‘from the bottom up’ are crucial to understand how to transform services and cultures of care within and across settings.
The importance of workplace culture is noted in all main practice development literature. For example, Buckley et al (2017), in their evaluation of a methodological framework for a narrative-based approach to practice development and person-centred care in residential care settings for older people, recognised the need to identify the existing culture and staff and residents’ assumptions about care delivery, which formed an ongoing ‘exercise’ throughout the study. This highlights the importance of constantly reviewing people’s values and beliefs, which evolve with critical reflection, insight and understanding. It also highlights the importance of systematically ‘sense checking’ people’s values and beliefs and the workplace culture, as a way of informing transformation through practice development by reviewing the culture using the principles of collaboration, inclusion and participation (McCormack et al 2007).
Skilled facilitation forms an integral part of practice development (Hardy et al 2021). The authors of this article suggest that skilled facilitation is central to workplace culture transformation since it supports learning in and from practice that will inform the development of individuals, teams and cultures and promote the well-being of staff and patients. The authors of this article also argue that the practice development principles of collaboration, inclusion and participation (Hardy et al 2021) should provide the foundation for projects related to workplace culture development and transformation because ‘everyone’s voice is important’ (Manley et al 2013).
Workforce well-being is implicit in effective workplace cultures. The coronavirus disease 2019 (COVID-19) pandemic has identified the importance of workforce well-being for staff resilience and a person-centred, safe and effective workplace culture. When considering how services can recover from the effects of the pandemic, the importance of ‘good’ workplace cultures cannot be overestimated. In the wake of the pandemic, which during the first wave disproportionately affected older people and those with co-morbidities (Lewis et al 2020) and brought the challenges experienced by care homes to the fore (Wild and Szczepura 2021), there is potential to change the working landscape radically. Therefore, it is more important than ever to focus on developing effective workplace cultures that enable individuals to grow and thrive and enable practice and care to improve.
In the literature on workplace culture there is overlap and synergy with the Courage of Compassion report (West et al 2020), which focuses on ‘how to develop good work environments for nurses and midwives by changing the workplace factors that affect their wellbeing and effectiveness at work’. The authors of this article believe there is a clear link between this and compassionate leadership, reflected in the fifth recommendation of the Courage of Compassion report – ‘culture and leadership’ – which states that ‘all health and care organisations should regularly review their cultures and ensure that they are continuously developing cultures of high-quality, continually improving and compassionate care for patients, and high-quality, continually improving and compassionate support for staff’ (West et al 2020). While compassion is a central principle of healthcare systems, the challenge is to develop cultures within organisations in which staff are encouraged and enabled to deliver high-quality, compassionate care (West 2021).
The ‘Guiding Lights for effective workplace cultures’ (Cardiff et al 2020, Sanders et al 2021) were developed as part of a collaborative, three-phase study based on the principles of appreciative inquiry and realist evaluation, in partnership with front-line health and social care professionals who navigate contextual complexity in the workplace as part of their daily working lives and lived reality. Manley et al’s (2011) concept analysis on effective workplace culture provided the foundation for this development, critique and learning in and from practice. The Guiding Lights were also built on Cardiff et al’s experiences and understanding of working with practitioners in the complexity of the real world and on being part of health and social care practice, teams, systems and transformation.
There are four Guiding Lights (Cardiff et al 2020):
• Collective leadership.
• Living shared values.
• Safe, critical, creative learning environments.
• Change for good that makes a difference.
Each Guiding Light articulates what good workplace cultures are through descriptors and intermediate outcomes. Together, the four Guiding Lights and their intermediate outcomes produce a set of ultimate outcomes. Table 1 details the Guiding Lights and their descriptors, intermediate outcomes and ultimate outcomes.
|Guiding Light||Descriptors||Intermediate outcomes||Ultimate outcomes|
|1. Collective leadership||
Contexts (with formal opportunities) that support and develop visible, authentic, credible, relational and collective leadership enable leaders to:||
|2. Living shared values||
In contexts where the following is fundamental to the way things are done:|
Patients, relatives and others sense:
|3. Safe, critical, creative learning environments||
In contexts where:|
Service users experience an environment that:
|4. Change for good that makes a difference||
Contexts that focus on:|
Enable staff to:
(Cardiff et al 2020)
Understanding and changing workplace culture in older people’s care settings can be complex, since the work environment is never static. On occasions, the challenges associated with delivering front-line care can seem overwhelming due, for example, to workforce pressures and lack of resources and capacity to meet increasing need. The four Guiding Lights provide a framework to assist in understanding and promoting effective workplace cultures that can inform practice development and transformation. Ultimately, the aim is to support:
• The development of workplace cultures experienced by staff and patients as good and safe.
• Ongoing collaborative and co-designed processes driven from the bottom up and nurtured and encouraged by organisations and systems.
• Responsive and person-centred practice that enables an effective workplace culture and compassionate collective leadership to develop and thrive.
Reflect on collective leadership. Can you think of concrete examples of collective leadership that you have experienced within your team? Would you be happy working in a team in which collective leadership is the norm? What would you feel comfortable taking leadership of? When would you prefer a hierarchical leader to intervene?
West et al (2014) described collective leadership as a new leadership paradigm that can transform NHS culture and prevent scandals and tragedies such as Mid Staffordshire from reoccurring. However, this requires rethinking and redefining leadership and followship. There are no longer hierarchical leaders and subordinate followers. Instead, leadership is a practice that emerges when people meet and make critically informed decisions on how to move forward (Raelin 2018). ‘Who leads what?’ can then be co-determined based on individuals’ expertise, capabilities and motivation rather than rank or position. Everyone in the organisational structure has a responsibility to be a good follower, a good leader and a good team worker.
Collective leadership becomes more person-centred in caring yet critical interpersonal relationships within teams (Cardiff et al 2018), but requires psychological safety, whereby people feel safe to engage in challenging conversations and consider changes to practice (Brown and McCormack 2016). A sense of responsibility and psychological safety enhances sharing of admiration and critique and enables the best person to lead a particular situation at a particular moment in time. This means that the leader may not always be the same person, since individuals, teams and environments evolve.
Experiencing collective leadership can make staff feel respected, heard, empowered to speak out and lead and part of something bigger where there is mutual and shared understanding. Being ‘person-centred’ in the role of leader, meanwhile, fosters relational connectedness, commitment and momentum (Cardiff et al 2018). Although it is associated with hierarchical leadership, transformational and relational leadership practice has positive effects on outcomes for nurses, organisations and patients, for example increasing nurse retention, fostering nurses’ use of research, decreasing patient mortality and reducing medicine errors (Cowden et al 2011, Wong et al 2013, Cummings et al 2018).
Developing collective leadership practice among all staff is logical since all staff are likely to lead on one aspect of practice development at one moment in time. Collective leadership does not eliminate hierarchical leadership. Leaders in hierarchical structures need to be person-centred and transformational, but also need to be responsive and supportive towards their teams. They should only be actively engaged and lead from within the team when collective leadership is lagging or failing, and should retreat, but remain connected, when the team is back on track.
Think about a positive experience of caring for an older person, then write this experience down as a story:
• What personal and/or professional values and beliefs are contained in the story?
• Are these values and beliefs shared by your colleagues?
• Is there one value or belief that you could attempt to promote as a role model for others in your team?
Co-constructing and living shared values is the central concern of this Guiding Light. Clarifying values, beliefs and assumptions is an important method used in practice development to transform the practice of individuals and teams and cultures of care (McCormack et al 2013). The process should start at an individual level, but this Guiding Light acknowledges the importance of a collective approach to the co-construction of shared values involving patients, services users, communities and staff. Ideally, people working at all levels within the team, organisation or system should be involved to encourage buy-in from bottom to top.
In effective teams, shared values are used to inform the creation of collective goals (Martin et al 2014, West 2018) and underpin shared decision-making (McCormack and McCance 2017). Shared values should be reviewed continuously to ensure that they include all voices and therefore identify what matters to people in the team. This Guiding Light reinforces the need to reflect regularly on values, goals and actions to ensure that they are ‘lived authentically’ and that people are ‘doing what they say they will do’ (Manley et al 2011).
Safe, critical, creative learning environments are essential for enabling team members to take informed risks, be creative in their everyday work and live an ethos of continuous improvement, curiosity and innovation. Leaders and facilitators in these environments prioritise learning in and from practice, with and from others – including from formal and informal feedback from patients and students – to guide solution-focused improvements in quality and safety. The workplace itself is therefore used as an important resource for learning integrated with an inquiring approach to practice, and with activities such as practice development and practice improvement, and blending research evidence with local knowledge and what matters to people.
In a safe, critical and creative learning environment this focus on learning would be evident in individual and collective practice and in a strong commitment to allocating time for staff to think and learn as a team and share ideas. Opportunities for mutual, peer and multidisciplinary supervision and support would also be evident, alongside more formal systems of transferring learning into action, for example team evaluation of quality and safety indicators, or the regular use of tools such as emotional touchpoints (Dewar et al 2009) to shape and improve services.
The most important enabler in learning environments is psychological safety (Edmonson 2020), which assists team members to explore different approaches creatively, value difference and diversity and be supported to experiment with new ideas without fear of judgement or negative repercussions. Psychological safety enables self-awareness and courage to question and explore, support and take risks and approach collective evaluation by building on what works.
This Guiding Light focuses on what matters to people. The context in which individuals and teams practise is complex. Sanders et al (2021) identified that ‘grappling with complexity of day-to-day practice, competing priorities and constant pressures, while forging strong and sustainable, collaborative, person-centred relationships, requires skill, understanding and a true belief that change can make a difference, across all points of care (giving, receiving and experiencing)’.
The starting point is the development of a shared purpose that reflects what matters to the people who deliver, receive and experience care. Central to this Guiding Light are ways of working that embody compassion, care and authentic, person-centred relationships. Working collectively and with authenticity with diverse stakeholders enables the use of different types of knowledge generated from and in practice. The outcome is to inform and enable a workplace culture that supports ongoing practice development and transformation in which the context and culture of care are recognised as intrinsically linked to the setting in which care is delivered, received and experienced.
The ‘Guiding Lights for effective workplace cultures’ provide a framework to support individuals, teams and leaders to understand the importance of workplace culture and its effects on how care is received and experienced by older people. While the literature focuses on the significance of organisational culture, workplace culture is central because the workplace is where care is delivered, received and experienced. The benefits of effective workplace cultures for older people and those who support them, which concern their experiences of care and the safety and outcomes of care, cannot be overestimated.
Effective workforce cultures are also important for the well-being of individual members of staff and teams, as well as for creating environments in which people can flourish and experience joy in their work.
Consider how understanding and using the ‘Guiding Lights for effective workplace cultures’ relates to the Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates (Nursing and Midwifery Council 2018) or, for non-UK readers, the requirements of your regulatory body
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