Culture and Needs
Many companies finding themselves in a predicament start calling for a change in culture. It is also claimed in the business literature that culture eats strategy for breakfast. Modern human resource management (HRM) is no longer a transactional (i.e. pay and conditions) but more translational (ie investing in your employees). I really do believe the inimitable value of the NHS can be found in our staff. Yet, sadly, national and local leaders do not appear to be investing their employees.
Culture is defined by how things are done around here and ascertained by listening to the conversations in the corridors. But, how do we change culture? What levers do we pull? This is a question that has vexed me for some time until I discovered the guru on organisational culture; Edgar Schein is a Professor at Massachusetts Institute of Technology in Boston. I ascertained this when I attended an Institute of Health Improvement Executive Patient Safety Officer Conference in Boston in 2008. I was talking to two Harvard professors and they referred to Professor Schein in the present tense. So important is his name in the field of organisational behaviour, I wrongly assumed him to be deceased and got his attention by recounting my surprise and delight to find him alive and well.
Professor Schein agreed with me the term culture is bounded about by many with little concept of what it means and with no instruction on how to change it or what levers to pull. He did make a profound observation however, that attitudes and behaviours culminate in culture. I summarise it as
It is that simple. The HRM established paradigm that you hire attitude is upheld. The organisation code of conduct then needs to make explicit and coach desired behaviours. These can all be derived from the espoused values of the said organisation, but, I believe it all stems from the operative word ‘SERVICE’ as in National Health Service. It not surprising that many of the values that are published by health care organisations say the same thing. It is a variation on the trite phrase ‘we aim to please!’ We are all ‘aiming’ but are we achieving it? Do the values actually carry the same meaning to all? Is it just empty rhetoric?
It all very well to talk the talk but can you walk the walk? Modern leadership has moved from the heroic to servant. The role of the modern leader is to attend to the needs of the staff and provide an umbrella to protect the employee from the organisational rain.
This is where I would like to introduce the counter point to culture. It is commendable to call for a change to the culture but if we do not attend to the needs of the staff, I do not believe this will ever happen. Culture of the organisation and the needs of the individual are interdependent.
I would like to draw on the concept of the needs hierarchy as described by Maslow and others.
Culture is the expression of a collective feelings of the staff reflected in the corridor conversations. More often or not the themes express dissatisfaction around pay and conditions of work and how they are implemented by the immediate managers. It is part of the organisational gossip. These are the ‘Deficiency’ needs that are attended to by the transactional activities of HRM. These have to be satisfied before anything else. Six years ago a newly appointed colleague came to me as Lead and sheepishly told me that he had not been paid and since the hospital was running essential services over Christmas, it would be January before this could be addressed. He had bills to pay at the beginning of January. I reached for a cheque book and the phone and was fortunate to find a very helpful person in Finance who sorted it before he left the office. I caught this one but there are plenty of examples. I am disappointed by the ‘banding’ process and the fact that the individual has been reduced to a ‘cell’ on an excel spreadsheet. We are in a people business and not a spreadsheet trade. It is not personal and individual needs are not being met. I believe many of our organisations are failing in their basic ‘hygiene’.
In the West we consider the individual as being one self in contrast to the East where the concept of many selves is recognised. The individual staff, to use a colloquialism, have many hats to wear. Each person has at least a work, social and domestic self.
I have taken the liberty of populating these scales and the ‘deficiency’ needs become apparent – safe, secure, pay and conditions.
The ‘relatedness’ needs are summarised in the word TRUST. I often think it is an oxymoron that we refer to many of our health care organisations in the UK as Trusts. I return to a quote by Edgar Schein.
Integrity, honesty and transparency of local leadership are requisites for cohesion and fostering commitment at work. The most important leaders in a hospital are he Matrons, Ward Sisters and Clinical leads. Before anyone can realise the shared and expressed worth of the staff, which I believe be a mark of a successful organisation, we not only need to attend to deficiency or hygiene needs but also to practice our relatedness skills. The advice to managers holds true. Be seen and communicate, communicate and communicate. Salience is essential in any organisation and will dispel the many conspiracy theories that often echo though our corridors.
How do we get the best out of staff and realise WORTH? Monetary reward is recognised as a motivator in some sectors especially manual labour but for health care staff, once the basic or hygiene need is met and relatedness needs are optimised then further development can only be achieved by creating opportunities for self- improvement and development. Of course, this takes TIME and requires SPACE. These dimensions are, in fact, two of the five basic assumptions described by Edgar Schein as essential ingredients for establishing a culture. It is disappointing that our health care organisations look to remove seminar rooms for clinical space and many rotas are so hectic that time is not given to training the individual yet alone the team. The paucity of learning space is reflected in the fact that we have to book seminar rooms furnished with audio-visual equipment a year in advance.
Lastly, Simon Sinek describes Autonomy, Mastery and Purpose as powerful motivating factors. I believe this applies not only to the individual but also to the team. I would add to this triad the word identity. All the staff that I have worked with over the years have taken pride in their identities as teams that deal with specific patient conditions e.g. Vascular team. Urology team and Respiratory team etc. Almost all these functional teams are organised around a specific patient pathway. They are the Masters of patient care. They should be afforded Autonomy. Deming told us that the professional ‘doing the work’ be allowed to ‘design the work’ and ‘inspect the work’. Is that not what trust means?
It is folly to interfere with these established yet sometimes informal identities that reaffirm Mastery and Purpose. I believe it is unreasonable expect people to cross cover other disciplines. I would go even further to suggest that this may not be safe as staff may not be familiar with ‘the way things are done’ in each area of the hospital.
Empowering is somewhat condescending but emancipation is more pertinent and relevant to motivational theories and individual needs. The question is ‘Do our leaders have the courage to let go and give staff the latitude and discretion to do what they think is best for their patients?’ The opportunity to self-organise and be supported by visible servant leadership is summarised in a simple question, HOW? Wouldn’t it be wonderful to work in an organisation where the leaders ask you ‘How can we help?’
The NHS is the people. It is possible to outsource every other function of a hospital but you cannot find the skills and compassion of the people who care for patients. This is the inimitable and what we should value. An organisation should take responsibility of ensuring staff excel and surpass their skills and those of others. I call this TRANSCENDENTAL HRM. NHS management should assume the responsibility for GROWING people and realising their worth. This applies to any organisation.
Complex systems require that we trust our staff. Our leaders should be visible and be asking HOW can they help. In other words they must be seen and heard serving the needs of the employees.
In summary, I believe a happy productive culture can be achieved through meaningful service values and attending to the needs of the individual and teams. I would call it a HOW campaign. I suggest HOW as it stands for a Happy On-board Workforce. I offer my strap line that we are in the business of
Educating People and Creating Value
David J. O’Regan
MBA (Distinction) MD BM FRCSEd (C-Th) FFSTEd
Thesis –‘Why can’t Dinosaurs Boogie?’