Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study
Dixon-Woods and twelve colleagues ask how far the features of the Mid Staffordshire case might be symptoms of more widespread pathologies in the English NHS, and answer from a research programme covering 2010 to 2012 with seven substudies: over 300 interviews from senior stakeholders to the frontline, over 650 hours of ethnographic observation, surveys of patient and carer organisations, data from 621 clinical teams, minutes from 71 trust boards, and national staff and inpatient surveys. It is a high-level narrative synthesis across them, and its answer is hedged: Mid Staffordshire may have been one particularly dark spot, but organisations throughout the NHS are likely to have at least some shadows.
A distinction runs through it, between behaviours in gathering data. Problem-sensing actively sought out weaknesses, using soft intelligence as well as mandated measures: listening to patients and staff, unannounced visits to clinical areas, shadowing. Comfort-seeking is defined as focused on external impression management and on seeking reassurance that all was well, so that what organisations had was data, but not intelligence. It could lead to concerns and critical comments being dismissed as whining or disruptive behaviour, and some staff felt the main purpose of much data collection was to allow individuals to be blamed if something went wrong.
Virtually all interviewees were firmly committed to the ideal of safe, high-quality care, and bright spots and dark spots appeared even within the same organisations. The proliferation of external priorities and agencies created what the paper terms priority thickets, overlapping or disjointed goals that commanded attention and resources without necessarily giving clear direction, and some organisations tended to revert to bureaucratised management, many of its rules and forms seemingly motivated mostly by a need to display compliance. Staff at the sharp end were very often aware of systems problems but felt powerless to bring about change, and in some organisations saw not being consulted and listened to as endemic, while some senior managers, particularly those engaged in comfort-seeking, tended to see frontline behaviour and culture as the cause, so the two ends often disagreed on causes and remedies. In national staff survey data, staff engagement, support from line managers and opportunities to contribute to improvements were associated with lower hospital mortality.
The bridge to psychological safety is ours: the term does not appear, though its strategies for senior leaders end with making sure staff feel safe, supported, respected and valued at work, and we read comfort-seeking as the organisational side of silence. The limits are the paper's own. Given the size of the datasets, the article shows only very limited primary data; the synthesis was interpretive and narrative, without a formal protocol, and others might reach somewhat dissimilar conclusions; and whether the findings generalise to other contexts, including the rest of the UK, is left to future work.
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