Culture and healthcare – what are we on about?

Have you noticed that whenever anything goes wrong in an organization at the moment, it is described as being due to ‘a culture of…(something bad)’? What on earth are people talking about?

The Chairman’s statement of the Francis report, for example, says ‘There was an institutional culture in which the business of the system was put ahead of the priority that should have been given to the protection of patients and the maintenance of public trust in the service. It was a culture which too often did not consider properly the impact on patients of actions being taken, and the implications for patients of concerns that were raised. It was a culture which trumpeted successes and said little about failings.’ (p. 3).

Now I have the greatest respect for the process which Robert Francis went through in his inquiries into Mid-Staffordshire, but this seems to me to be woolly thinking. Have you ever worked in an organization (especially a big one, like a hospital) which had only one ‘culture’. All the ‘culture’s in the quote above are in the singular, and this also goes for the other present examples of the term being used as a cause of poor institutional performance. What do we mean by culture? What do we mean by there being only one of them?

‘Culture’ is a messy word, and there are whole books just trying to work out what it means (even when applied to organizations – my favourite is Alveson’s). The most simple definition tends towards something like ‘the way we do things around here’, so let’s go with that. Now, for there to be just one culture, the ‘we’ would have to be everyone, and the ‘things’ and the ‘around here’ would have to be what they do and where they do them. So when we talk about ‘a culture of…(something bad)’ we are saying ‘everyone around here does (something bad) this way’. And we might add – and there is no other way of doing things, and there are no exceptions, and the people who work here have no choice in that. Really? Have you ever worked anywhere like this?

Culture in the singular suggests that everyone does the same thing. That would actually be quite an achievement in itself (have you tried getting everyone to do exactly the same thing?). Now think of this in the context of healthcare, where we have multiprofessional teams who we know tend to regard the world in different ways (we know that different professionals view health reform in different ways, and different professionals prioritise different care treatments as two obvious example). So we have different professionals groupings who ‘culture’ somehow has got everyone to all behave in the same way.

I’m not suggesting that nothing cultural goes on in the case of poor performance. The problem is that describing culture as singular over-simplifies complicated situations and stops us from trying to find what was really going on. If we are to understand how carers can reach a situation, as at Mid-Staffordshire, where they were falling so short of the standards they knew to be acceptable, then we need careful research and not to impose over-simplified ideas on them. Equally, suggesting that we can make things better by creating ‘a culture of (something good)’ is equally sloppy. Well-run organizations are not the result of some magic bullet, but the hard work of those who keep working at making them well-run. This stuff doesn’t happen by itself.

Organizations have many cultures. I’d go further and suggest that particular meetings can have cultures, and that those cultures can vary depending on who is chairing them and who turns up for them. Wards can have cultures, but they too will vary depending on who is on duty (think of night shifts especially, which can be wholly different depending on the particular mix of staff working at a particular time). Understanding how cultures change and when they seem to support good work is the key – not suggesting that there is somehow just one culture and that the people within that organization apparently have no choices in deciding to go with or against it.

So please, next time someone says ‘a culture of (something)’ to you, say ‘really, just one? And the people in that culture had no alternative?’. Only by getting to grips with the detail of how organizations fail (or succeed) can we hope to try and make things better.

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