Everyone matters; everyone contributes; everyone grows: a pilot project cultivating psychological safety to promote growth-oriented service culture after the Oakden Report

Keywords: health services, mental health, workforce.

This case study presents the Northgate House Growth Culture Pilot, a quality improvement project, led by the South Australian Department of Health and Wellbeing (SA DHW), experientially exploring an innovative approach to health service culture change. Project insights may inform culture change enterprises in other healthcare settings.

In April 2017, the South Australian Chief Psychiatrist released the Oakden Report, identifying failures in service culture, governance, clinical practice and care of older people with complex needs at the state-run Oakden Older Persons’ Mental Health Service.¹ The Oakden Report Response Plan presented a codesigned culture framework as a blueprint for service reform.² The culture framework described a central philosophy of compassionate relationship-centred care, supported by four priorities: developing a values-based workforce; cultivating psychological safety; facilitating excellence in care; and providing transparent accountability.³ Further, an objective of the South Australian Health Strategic Plan 2017–20 was to cultivate a learning culture, translating learning and innovation into practice.⁴

In response to these strategic objectives, the SA DHW partnered with Uncharted Leadership Institute (Uncharted) to design a pilot program delivered at Northgate House, which was established following the Oakden Report, providing 16 places-of-care for people with extreme behaviours and psychological symptoms of dementia.^1,5 The immediate post-Oakden period was highly disruptive, with reactive and punitive organisational responses, a dramatic media narrative and public outrage. Nevertheless, by early 2018, Northgate House had developed robust governance, implemented values-based recruitment and introduced person-centred ways of working. Despite this, trust in organisational management remained low and restorative culture reform was greatly needed.

The project was predicated on psychological safety as an enabler of a flourishing workplace. Edmonson defines psychological safety as an organisational climate in which ‘people are comfortable expressing and being themselves’.⁶ Staff can share concerns and mistakes without fear of embarrassment or retribution, fostering an environment conducive to growth. The project was also informed by principles of the deliberately developmental organisation (DDO), described by Kegan and Lahey, in which personal and professional growth of staff is intrinsic to organisational success.⁷

A project board was established to address probity and strategy. Northgate House was selected as the project site, reflecting the Oakden reform agenda. Participating staff included registered and enrolled nurses, allied health practitioners, allied health assistants, hotel services staff, an administration officer, medical practitioner, consultant psychiatrist and consultant geriatrician. Workforce increased from 30 to 50 during the project, reflecting progress through values-based recruitment towards the service staffing establishment, reducing the use of casual and agency staff and supporting embedding of the project principles and practices.

A three-phase project plan was developed, including a foundation phase, promoting cohesion and psychological safety; an accelerated growth phase, focused on individual and team development; and a final phase transitioning to self-sustainability (Fig. 1).

Fig. 1.  Three-phase project plan.

The project was launched in April 2018, with an opening staff forum convened by the Chief Executive Officer (CEO) of the network, supported by the SA DHW and Uncharted. The CEO transparently acknowledged previous punitive organisational responses, modelling vulnerability to cultivate psychological safety.

Activities in each phase were determined by Uncharted, in partnership with the SA DHW project team, who worked closely during all phases. Decisions were informed by the literature regarding organisational culture change and psychological safety and made in consultation with the Northgate House core staff and ‘change champions’.

Phase One focused on enhancing communication, cohesion and psychological safety. Several practices supported this.

Uncharted facilitated weekly forums, involving activities for building relationships and psychological safety, supported by role-modelling from clinical and non-clinical disciplines. For instance, the regular sitting together of the medical Head of Unit, a position of traditional power and privilege, together with hotel services staff, traditionally excluded from meetings of this type, reflected the counter-cultural ethos of the project.

Check-ins/check-outs were introduced in weekly forums and became a vital communication touchpoint, including at clinical handovers and governance meetings. At the start of a meeting, team members were invited to ‘check-in’ with one another, sharing openly, giving permission to bring concerns to the group and show up authentically at work.⁸ As confidence developed, check-ins became increasingly transparent and supported respectful relationships. Check-outs encouraged reflection and enabled set-shifting towards the next task.

A ‘hub-space,’ consisting of a large whiteboard colloquially referred to as the ‘non-digital Facebook page’, provided a place for posting summaries of forum discussion points and relationship-building activities, such as staff ‘get-to-know-you’ information.

Uncharted facilitated an exercise, contrasting media headlines about Oakden, with aspirational future headlines. This supported healing conversations and provided material for a shared statement of values and vision, developed by the whole Northgate House team, informing recruitment and onboarding activities, as follows:

At Northgate House we deliver exceptional, innovative and compassionate person and family centred care through teamwork where everyone matters; everyone contributes; everyone grows.

Personal and carers leave reduced by 59%, representing a reduction of 269 hours. Incident reporting increased, suggesting an improvement in safety climate. An independent reviewer was engaged to undertake qualitative interviews with consenting team members. Data were analysed using thematic analysis (Table 1).⁹

Table 1.  Phase one outcomes interview themes

Deliberately developmental organisation ‘growth culture principles’ were distilled to inform future work, as follows:

1. Better you + better me = better us (everyone can grow)

2. Rank doesn’t have its usual privileges (everyone is accountable)

3. Everyone builds the culture.⁷

A voting process confirmed support for phase two.

Phase two promoted the growth of team members through personal goals and accountable relationships.

Forum meetings continued and were known as ‘Culture Club’. Smaller culture club huddles were established on weekend and night shifts, increasing accessibility. This strategy supported inclusion of staff who were not present during the weekly forums held during office hours. In addition, rostering configurations were established to ensure that all staff had opportunity to work day-shifts to increase access to the core culture change work. One of the huddles evolved into a ‘consumer of the month’ discussion, where clinical and non-clinical staff brainstormed how to support holistic quality of life. Another session evolved as a staff wellbeing huddle, led by the service clinical psychologist, providing information and skills development around topics such as self-care and mindfulness.

Uncharted developed materials assisting team members to identify a personal growth goal and develop a progress plan. Plans were integrated into professional review and development discussions, adding increased meaning to a mandated organisational activity.

Uncharted facilitators provided debriefing and coaching for the site leaders. The nurse unit manager (NUM) coordinated program delivery, including team members leading discussions and disseminating materials.

Self-selecting buddy relationships supported team members’ progressing growth goals, coordinated by the NUM and Hotel Services Supervisor to optimise engagement. Group debriefing occurred in Culture Club meetings.

An anonymous online survey was conducted pre and post phase two. The survey was based on psychological safety and growth culture literature.^6,7 Questions assessed perceptions of the organisational climate and personal engagement in growth culture, using a Likert scale from zero to five, with five being the most positive response. The response rate after phase one was 77%. There were positive responses to all questions, indicating that phase one had already contributed significantly to culture change.

Response rate after phase two was 70%. In 24 out of 28 questions, there was further improvement regarding understanding the shared vision of Northgate House, orientation to growth culture and psychological safety, including being able to disagree with a senior team member, although this item was the lowest scoring item overall in both surveys.

Four out of 28 questions did not show improvement, relating to being transparent about error and inadequacy, and receiving difficult personal feedback, suggesting there remained ongoing work to be done in this area. The survey was conducted during the first 2 years of a culture change process following a highly public healthcare scandal, which resulted in staff trauma. This finding may reflect a greater challenge sustaining improvement in this area. Experiencing feedback, potentially perceived as negative, places the receiver in a vulnerable situation, which may cause learning anxiety driven by the fear of losing effectiveness and self-esteem.^10,11 Figure 2 shows responses to selected questions regarding personal engagement in growth culture, comparing responses pre and post phase two.

Fig. 2.  Questions and responses pre and post phase two.

Data were compared for differences between nurses and other staff. Although still positive, there was a lesser degree of positivity from nurses compared with other staff, which included medical, allied health and non-clinical disciplines. Nurses expressed a lower degree of confidence in their ability to talk honestly with others about their own areas of improvement, sharing uncertainties and inadequacies, disagreeing with others and openly acknowledging mistakes. Speculatively, this difference may reflect the greater trauma experienced by nurses, who were the focus of punitive responses following the Oakden Report. It may also be that there are discipline-specific features that result in different responsiveness to work of this type. This difference and what might enhance the meaningfulness of a project of this type for nurses are issues worthy of further investigation.

A commercially available weekly pulse-survey, completed by email or mobile phone, assessed team morale and engagement, providing further data. All measures showed improvement from baseline, above validated industry benchmarks, embedded within the tool.

Phase three focused on sustainability. Facilitator coaching increased staff capability until the team felt ‘ready’ to continue without external support. Coaching was provided with a weekly meeting before the Culture Club forum, during which strategies for delivering content and engaging participants were discussed. Following the Culture Club, debriefing provided opportunity for reflection on what worked and what could be improved. Over time, this resulted in up-skilling of embedded staff in facilitation skills. In addition to this, an extensive folio of ideas, session prompts and activities was collated and stored on a shared computer drive, so that the embedded leadership team could access resources to continue developing sessions on an ongoing basis and could access a record of what had been undertaken previously.

Service leadership provided clear direction for the ‘the Northgate House way’, including core practices of check-ins/check-outs, Culture Club, consumer of the month, personal improvement goals and partnerships. These were selected as having had the greatest effect on driving culture change, based on the qualitative interviews conducted at the end of phase one and the evaluation conducted in phase two. On-boarding introduced staff to the culture framework, person and family-centred care and growth culture principles. Combined with values-based recruitment, this supported growth-oriented service culture.

The project encountered several constraints. These included changes in project board membership and delayed decisions. The project was constrained by delivering a continuous clinical service. Although adding complexity, this ensured the project was grounded in a realistic service environment. The exploratory project design may have been enhanced by clearer baseline knowledge of service culture from commencement.

The project demonstrates a design to deliver compassionate person- and family-centred care through multifactorial microsystems cultural transformation, with lessons learned that may be useful across other health contexts. It illustrates service culture change at the frontline, where the interface between staff and patients directly affects delivery of safe and effective, person-centred care, requiring consideration of the need to enculturate staff, encourage innovation, address staff priorities and incorporate consumer perspectives.^12,13

The project demonstrates several features consistent with the theory of health service culture change described by Manley and Jackson.¹² These include the development of transformational leadership and the role of skilled facilitation as individual enablers of change. Organisational enablers include senior leadership support, a focus on bottom-up change, recruitment to shared values and an integrated approach to learning and development, adapting strategy to what works locally.¹²

Leadership is a vital component of culture change.¹⁴ In this case, several leadership layers enabled transformation. The project board and CEO provided high-level organisational support. The medical Head of Unit and Nurse Unit Manager provided key local leadership, critical to program uptake and success. Local leadership ‘buy-in’ contributed to the successful transition to sustainability, supporting emergence of frontline leaders from clinical and non-clinical disciplines as ‘change champions’.

The experiential nature of the program, embedding learning within the workplace, and encouraging personal growth for all staff, promoted reflection and self-awareness.¹⁵ Skilled facilitation was initially provided by external consultants who were able to engage staff in a co-creation process. The coaching model increasingly transitioned facilitation to embedded staff, supporting sustainability.

The project demonstrated the benefit of a ‘bottom-up’ approach. Developing distributed leadership models, promoting engagement and encouraging continual learning are factors sustaining culture change.^16,17 Consistent with conceptual roots in the DDO approach, the program did not remove existing line-management responsibilities, but intentionally reconsidered relationships, seeking to remove impediments to communication and provide everyone a voice.⁷

Continual evolution and adaptability are critical to success in culture change efforts.¹⁶ Flexibility to deviate from the planned agenda to identify and apply what worked supported success. This was demonstrated in the commitment of the project team to continue phase one beyond anticipated timeframes and adapt phase two to suit staff needs.

A cornerstone objective was cultivating psychological safety, consistent with the culture framework.³ A meta-analysis of psychological safety research confirms benefits in performance, increased learning, engagement, information sharing, workforce interdependence, teamwork, improved satisfaction and commitment.¹⁸

Manley and Jackson identify five features of effective workplace culture, resulting from microsystems change.¹² These include values translated into practice; effective teamwork; consistent achievement of high standards; innovation; empowered and committed staff; and flourishing for all involved. Although the transformation journey of Northgate House is a work-in-progress, the outcomes of the project are consistent with these features. This was captured by one staff member, who reflected on her experience in the project during a team check-out: ‘I like what we’re becoming’. These words reflected the dynamic and experiential nature of the project, the essence of which is continuing transformation to deliver enhanced wellbeing for patients and staff.

Authors AS, SO and DR represent Uncharted Leadership Institute, which was contracted to provide project facilitation. Authors DM, AG and AD have no competing interests to declare.