Preventing ‘Francis II’ –
using practice development
for culture change
Professor Brendan McCormack
Director, Institute of Nursing & Health Research and Head of the
Person-centred Practice Research Centre, University of Ulster.
Professor II, Buskerud University College, Drammen, Norway;
Adjunct Professor of Nursing, University of Technology, Sydney;
Visiting Professor, School of Medicine & Dentistry, University of Aberdeen.
The ‘Big
Agendas’
• Safety
• Quality – of the
patient/family
experience
• Staff competence
and wellbeing
• Person-centred
outcomes
Lack of a systems-wide commitment to personcentredness
“… I don't think the <service name> nurses I encountered were
uncaring. They were ill prepared for the tasks they faced,
sometimes insensitive, unsupported by the structures and
ethos of the service and very overwhelmed, but I wouldn't say
they didn't care or that they didn't, for the most part, work hard.
They reminded me of the adage 'the road to hell is paved with
good intentions' and even if they had known more … or at least
have been aware of what
they didn't know, they still
couldn't
have
functioned
adequately
within
the
structures and systems”
[‘Prof Faith Gibson, 16th October 2011].
What went Wrong in MidStaffs
 Lack of basic care across a number of wards and departments at the Trust
 Culture at the Trust was not conducive to providing good care for patients or
providing a supportive working environment for staff
 An atmosphere of fear of adverse repercussions
 High priority was placed on the achievement of targets
 Medical staff dissociated themselves from management
 Low morale amongst staff
 Lack of openness and an acceptance of poor standards;
 Thinking dominated by financial pressures and achieving FT status, to the
detriment of quality of care
 Management failure to remedy the deficiencies in staff and governance that had
existed for a long time
 Lack of urgency in the Board’s approach to some problems, such as those in
governance;
 Stats and reports were preferred to patient experience data, with a focus on
systems, not outcomes
 Lack of internal and external transparency regarding the problems that existed at
the Trust.
Warning Signs









Loss of star rating – In 2004
Poor peer reviews
Health Care Commission review of children’s services
Audit reports – poor risk management
Surveys – staff and patients
Whistleblowing
Professional body reports
Trust’s financial recovery plan
Application for Foundation Trust status – focus on
targets and finance only
The Trust’s Culture
“The Trust’s culture was one of self promotion
rather than critical analysis and openness. This
can be seen from the way the Trust approached
its FT application, its approach to high Hospital
Standardised Mortality Ratios (HSMRs) and its
inaccurate self declaration of its own
performance. It took false assurance from good
news, and yet tolerated or sought to explain away
bad news”.
Key Characteristics of the
Trust’s Negative Culture






lack of openness to criticism;
lack of consideration for patients;
defensiveness
looking inwards not outwards;
secrecy;
misplaced assumptions about the judgements and actions
of others;
 acceptance of poor standards;
 A failure to put the patient first in everything that is done.
 “It cannot be suggested that all these characteristics are
present everywhere in the system all of the time, far from
it, but their existence anywhere means that there is an
insufficiently shared positive culture”.
 “To change that, there needs to be a relentless focus on
the patient’s interests and the obligation to keep patients
safe and protected from substandard care. This means
that the patient must be first in everything that is done:
there must be no tolerance of substandard care; frontline
staff must be empowered with responsibility and freedom
to act in this way under strong and stable leadership in
stable organisations”.
290 Recommendations!
 Changing the Culture
 Patient Voice
 Developing compassionate and enabling
Leadership
“To achieve <a change in culture> does not require radical
reorganisation but re-emphasis of what is truly important:
 Emphasis on and commitment to common values throughout the
system by all within it;
 Readily accessible fundamental standards and means of compliance;
 No tolerance of non compliance and the rigorous policing of
fundamental standards;
 Openess, transparency and candour in all the system’s business;
 Strong leadership in nursing and other professional values;
 Strong support for leadership roles;
 A level playing field for accountability;
 Information accessible and useable by all allowing effective
comparison of performance by individuals, services and organisation.”
Need for a Person-centred Culture
Person-centeredness
“Person-centeredness is an
approach
to
practice
established through the
formation and fostering of
healthful
relationships
between all care providers,
service users and others
significant to them in their
lives. It is underpinned by
values of respect for
persons, individual right to
self determination, mutual
respect and understanding.
It is enabled by cultures of empowerment that foster
continuous approaches to practice development”.
Principles of person-centredness
 Treating all persons as
individuals
 Respecting rights as a
person
 Building mutual trust and
understanding
 Developing healthful
relationships
The Four
Elements of
Flourishing
 Challenge
 Connectivity
 Autonomy
 Using your
valued
competencies
(Gaffney, 2011)
Person-centred
Moments
• Care & Compassion
• Sympathetic
presence
• Engaged with her as
a person
• Tried to involve her
in shared decision
making
• But was it personcentred care?
Person-centred Practice Framework
(McCormack & McCance 2010)
Prerequisites
•Professionally competent
•Developed interpersonal skills
•Commitment to the job
•Clarity of beliefs & values
•Knowing ‘self’
Care environment
• Appropriate skill mix
• Shared decision making
systems
• Effective staff relationships
• Supportive organisational
systems
• Power sharing
• Potential for innovation & risk
taking
• The physical environment
Person-centred processes
•Working with patient’s/families
beliefs and values
• Engagement
• Having sympathetic presence
• Sharing decision making
• Providing Holistic Care
Outcomes
• Satisfaction with Care
(experience of good care)
• Involvement with Care
• Feeling of Well-Being
• Creating a Healthful Culture
Workplace Culture
• The way things are
done around here
• Significance of
beliefs, values and
assumptions
• Actors in the field
create and recreate culture
• Patterns reveal the underpinning
culture
• We are each shaped by the culture
• External factors
Characteristic of a Person-centred Culture
•
•
•
•
Shared values – respect for all persons
Situational leadership
Collaborative care processes
Commitment to shared and participative
learning
• Shared
governance/nonhierarchical
• Process and
outcome oriented
• Innovation to enable
human flourishing
Collaboration & integration
Experiences of good care
So how do we
make it real?
Five Principles for a Service to
‘say’ it is Person-centred
• We adopt a caring approach
to how we meet needs.
• We nurture effective
relationships
• We promote social belonging
• We create meaningful spaces
and places
• We promote human
flourishing
Practice development is a continuous process of
developing person-centred cultures. It is enabled
by facilitators who authentically engage with
individuals and teams to blend personal qualities
and creative imagination with practice skills and
practice wisdom. The learning that occurs brings
about transformations of individual and team
practices. This is sustained by embedding both
processes and outcomes in corporate strategy.
(McCormack, Manley & Wilson, 2009)
•
•
•
•
•
Developing
shared
values
Developing
a shared
vision
Role
Clarification
Creative
engagement
•
•
Assessment of
Practice
Context
Leadership
Development
Developing
engagement of
stakeholders
Personcentred
Culture
• Reflection
• Action
Learning
• Workshops
• WBL
•
•
•
•
(adapted from McCormack & Garbett, 2004)
Facilitation
Action Planning
Role modeling
Critical
Companionship
Person-centred Outcomes
•
•
•
•
Experience of good care
Involvement with care.
Feeling of well-being.
Existence a therapeutic
culture.
What can we do to ensure service users are
more satisfied with care?
• Acute Surgical Unit Nurse Manager: Review of complaints
• ‘inconsistent care decisions’
• Local evaluation
– Observations of practice (e.g. case reviews; rounds; handovers;
patient/family consults)
– Review of care plans: the patient’s voice
• Practice development project focusing on ‘consistency of
multidisciplinary decision-making
• Changes made:
– Care planning reflections
– Template for ‘patient voice’ in care plans
– Changes to ‘rounds’
• Follow-up evaluation:
– Stories; observations; care plan review
What can we do to ensure that team members
feel involved in care?
• Community Care Team Manager:
– complaints of care assistants not doing what they are asked to do.
– Lack of RN authority
– Patient/family complaints of ‘attitudes’ of staff
• Meeting with Care Assistants:
– Claims, concerns & Issues
• Key finding:
– lack of involvement in decision-making
• Corroboration:
– Observations of practice; 1: 1 discussions
• Action Plan:
– team building work: involvement of care assistants in handovers;
consistent assignment with service users; participation in care planning
and role clarification activities.
– Leadership development
What can the organisation do to ensure patient
and staff wellbeing?
• Outpatient Dept. doing ‘Releasing time
to Care’
– Used Service Improvement Processes
and Emancipatory PD Processes
• Staff feeling like ‘pawns’ in a
management game (e.g. despite
improvements no replacement of staff)
• Significant changes to waiting times
but patients still spent a lot of time
‘hanging around’
• ‘Communicative spaces’: where staff
spent time together regularly expressing
emotions and feelings about their work and
how this impacted on their sense of wellbeing
• Schwartz Rounds and narratives
What can a leader do to determine the extent to which a
therapeutic culture exists in a care setting?
• Mental Health inpatient unit
• ‘18-month cycles’ evaluating ‘essentials of care’
• Action plans drawing on practice development
and service improvement methods.
• Mapped to the Person-centred Practice
Framework (McCormack & McCance 2010)
• Reported to Trust Board – outcomes against
strategy and resource requirements
• Informing education commissioning
• Model of good practice
“The constant tussle between conflicting priorities
… and the desire to live out person-centred values
in practice was evident from the data … while
acknowledging that everyday practice is
challenging, often stressful, sometimes chaotic
and largely unpredictable, it is important to ask
how we can ensure person-centredness becomes
an everyday cultural norm.”
(McCance et al 2013)