How can promoting a positive NHS culture promote an increased quality of patient care?
Since the modernised NHS plan was implemented in 2000 (Department of Health (DoH), 2000) there has been a cultural and organisational shift within the National Health Service (NHS) to a collaborative, person-centred care approach that is based upon practitioners supporting individuals’ personal and complex needs (DoH, 2000). This has led to acknowledging that service users’ health conditions can be exacerbated by and attributed to a wide range of personal, physical, social, psychological, economic and environmental factors that thus require not one, but a range of specialist practitioners and service provisions (Sun, 2009). This had led to the NHS promoting a change model of health care that promotes 6 c’s of care, compassion, communication, competency, courage and commitments, which health care staff should promote as their cultural and practice based ethos in working together and with patients (NHS, 2014). However, recent reports (Centre for the Advancement of Interprofessional Education, CAIPE, 2008; Francis 2013) have revealed that whilst a shared ethos can be promoted within NHS organisations, there can be fragmentation in how it is practiced across different organisational systems, such as management, departments and professionals; with staff holding particular assumptions, beliefs and views that can hinder effective collaboration and impede the quality of patient care offered (DoH, 2000; McDonald et al., 2012). This essay aims to examine how the NHS organisational cultures impact upon patient care and what can be done to enhance the quality of patient care through promoting a more unified and collaborative culture within NHS organisations.
Collaboration and barriers to fostering positive and effective NHS cultures
Collaboration is a key aspect of modern health care so that practitioners and patients can work together to develop necessary care plans and gain access to appropriate care, however the literature reveals that often when staff work interprofessionally, conflicts can occur (McDonald et l., 2012). This is due to staff holding stereotypical perceptions of other staff members, which can result in the empowerment or disempowerment of particular team members (McDonald et al., 2012). Such conflicts arise due to dominant discourses - discourses being particular ways of making sense of the world determined by dominant language and stereotyped information - such as doctors being higher status than nurses (Winstanley, 2006). Such understandings of health professionals’ status and roles can lead to unequal power dynamics where one professional’s belief, knowledge and views are valued more than those of another profession (Fairclough, 2013). Brewer (1996) suggests that this occurs because people working in teams need to establish their individuality and uniqueness as individuals can feel restrained and unimportant when in a group situation.
Research (Allen, 1997; Nembhard and Edmonson, 2006) evidences that professionals who are represented as inhabiting positions of a higher status in groups, such as management or specialist staff, tend to have greater social influence in the decision making processes when determining a patient’s care plans, this can therefore lead to a poorer quality of patient care as care may be based on a higher status member’s decision rather than a collaboratively made decision. McDonald et al (2012) evidenced that often within health care, professionals utilise such discourses around the status and power of particular health care roles to enable them to exert greater social influence in decision making processes and to work more independently. However, within NHS cultures this can led to a fragmented workforce that fails to communicate effectively and where decisions are not made collaboratively; thus the priority of care needs can be based on dominant specialist views rather than actual identified needs (Francis, 2013).
The Francis report (2013) evidenced the breakdown in NHS organisations when communication and collaboration breaks down, leading to important patient information not being shared effectively and low standards of quality of care. The Caipe report (2008) also identifies that NHS cultures can be severely affected by dominant management and leadership styles where authoritative and directive strategies are used, as opposed to democratic and transformative styles that are more inclusive of staff and stakeholder’s views, resulting in an ultimate breakdown in care quality and service provision (Storey and Holti, 2013).
Patients may also experience disempowerment within NHS cultures that are fragmented by discourses around power and status, as medical language can be used a tool by health practitioners to reinforce higher status, knowledge, power and to create distinct divides across different specialisms (Fairclough, 2013). Medical jargon can also be used to exclude patients and particular health care staff from taking part in important care decision-making processes due to a lack of understanding (Fairclough, 2013). Grove and Zwi (2006) describe such processes as ‘othering’ which is often seen within cultures and organisations used to separate those who are different and can be used to evidence particular members of a group’s power through disempowering the ‘others’ that are different. Studies have revealed that the use of medical jargon can hinder communication when used within multi-disciplinary team meetings as it automatically excludes individuals who are not privy to such specialised medical knowledge, and this can lead to biased decision making that does not always consider the complex needs of patients (McDonald et al., 2012). This therefore leads to the creation of barriers to collaborative processes and to the facilitation of person-centred care as ‘others’, that lack the knowledge, are positioned as an unnecessary adjunct to the provision of care, which conflicts with the NHS person-centred model of care (DoH, 2000; NHS, 2014). If the NHS culture is unable to resist such demonstrations of authority and power, particularly when working in multi-disciplinary teams, the power discourses within such organisations can be reinforced and constantly perpetuated - leading to poor care quality, inadequate patient involvement and breakdowns in positive NHS cultures as highlighted in the Francis report (Francis, 2013). There are however occasions when medical jargon can serve the best interests of a patient and ensure speedier and more effective collaboration, particularly in crisis situations and emergency care when patients’ conditions lead to greater dependency on specialist knowledge and quick decision making (Carne, Kennedy and Gray, 2012). Medical language can also be a protective strategy in preventing unnecessary risk to patients in emergency and life threatening situations, where if plain language enabled the patient to understand the severity of their condition at that point, it could pose a risk to their psychological well-being (Russell and Ward, 2011). This however is a contentious issue as it similarly fails to include the patient within their care (Nursing and Midwifery Council, 2008)
Challenging negative NHS cultures
However, there are methods that can be utilised to challenge such negative organisational cultures and the wielding of power, in order to enhance collaboration, communication and patient care (NHS, 2014). The NHS change model highlights that strong leadership is needed to implement such changes, but strong as in having the courage to induce change rather than powerful and authoritative (NHS, 2014). Managers should demonstrate compassion for others through making sure to listen to the views of all stakeholders (NHS, 2014; Storey and Holt, 2013). A key aspect of promoting change and transforming the NHS culture and enhancing care is the ability of managers to engage with staff and stakeholders to enhance relationships and build networks, both within the NHS and with external groups, to gain access to services that can offer provisions to better meet service users’ complex care needs (DoH, 2011). NHS managers must not order others, exerting their power, but must instead work in partnership with others so that goals and objectives can be shared, whilst fostering a motivating style that can encourage commitment to the NHS and thus enhance staff morale, which can lead to positive attitudes in supporting patients’ needs (O’ Brien et al., 2008; MacLeod and Clarke, 2009; Cummings and Worley, 2014). Consequently, strong leadership styles and patient and staff involvement are vital in identifying areas for change and employing strategies in promoting collaboration and communication, which is needed to transform the NHS as an organisational culture (NHS, 2014; NHS Employers, 2014; Storey and Holt, 2013).
In conclusion, the literature evidences that quality of care is closely determined by the particular NHS culture that is embedded in that specific NHS organisation. This has lead to disparities in health care provisions and care standards, and has resulted in serious failings in patient care. The literature highlights that there are often conflicts experienced by staff, patients and management due to the power dynamics that are prevalent within particular NHS cultures. Such conflict can impede and inhibit collaboration, communication and the sharing of information, which leads to patients’ complex needs not being appropriately or fully addressed. Fragmented NHS cultures can also ultimately lead to low staff morale, segregation between particular professions, departments, management and staff, with contrasting hierarchical structures exerting greater influence in decisions making process around patient’s care needs. However, policy is now reflecting a greater need to promote change and involve patients and staff more closely in developing more effective ways to collaborate and communicate, so that such conflicts within NHS cultures can be addressed and health outcomes improved. It is therefore recommended that managers need to engage in more transformational and democratic leadership styles that can enable greater collaboration and communication with all stakeholders so that change can be jointly identified and worked towards to promote a NHS culture that challenges barriers to collaboratively developed quality patient care.
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