Aims and intended learning outcomes

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:

Introduction

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.

Practice development and transformation

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).

Well-being and compassion

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).

Guiding Lights for effective workplace cultures

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):

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.

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:

Conclusion

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.