1. Professor Brendan McCormack
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.

5. The ‘Big Agendas’ Safety Quality – of the patient/family experience
Staff competence and wellbeing
Person-centred outcomes

6. Lack of a systems-wide commitment to person-centredness
“… 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].

8. What went Wrong in Mid-Staffs
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.

9. 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

10. 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”.

11. 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.

12. “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”.

13. 290 Recommendations! Changing the Culture Patient Voice
Developing compassionate and enabling Leadership

14. “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.”

15. Need for a Person-centred Culture

16. 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”.

17. Principles of person-centredness
Treating all persons as individuals
Respecting rights as a person
Building mutual trust and understanding
Developing healthful relationships
In practice, the concept of person is played out through a set of principles that support the delivery of person-centred care.
It is an approach that:
treats people as individuals with their own life history
respects their rights as a person
is built on mutual trust and understanding
and fosters the development of therapeutic relationships.
These ideas are not new to nursing and indeed if we were to look back over several decades in the nursing literature we would see these principles embedded in many models and theories, and indeed I could argue further, are reflected in the knowledge base of other health care professionals.

18. The Four Elements of Flourishing
Challenge
Connectivity
Autonomy
Using your valued competencies
(Gaffney, 2011)

19. Person-centred Moments
Care & Compassion
Sympathetic presence
Engaged with her as a person
Tried to involve her in shared decision making
But was it person-centred care?

20. Person-centred Practice Framework
(McCormack & McCance 2010)
I would like to introduce the Person-centred Nursing Framework, which has been developed by myself and Brendan over a number of years
This Framework is offered as a tool to facilitate nurses to explore person-centredness and has been used by nursing teams to provide a lens that enables them to recognise the principles of person-centred care in practice.

21. Prerequisites Professionally competent Developed interpersonal skills
Commitment to the job
Clarity of beliefs & values
Knowing ‘self’

22. 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

23. Person-centred processes
Working with patient’s/families beliefs and values
Engagement
Having sympathetic presence
Sharing decision making
Providing Holistic Care

24. Outcomes Satisfaction with Care (experience of good care)
Involvement with Care
Feeling of Well-Being
Creating a Healthful Culture

25. Workplace Culture The way things are done around here
Results
Actions
Patterns
Assumptions
Values and Beliefs
The way things are done around here
Significance of beliefs, values and assumptions
Actors in the field create and re-create culture
Patterns reveal the underpinning culture
We are each shaped by the culture
External factors

26. 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/non-hierarchical
Process and outcome oriented
Innovation to enable human flourishing

27. So how do we make it real? Person-centered care Evidence-informed care
Collaboration & integration
Breaking habits
Experiences of good care
Rights and responsibilities
So how do we make it real?

28. 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

29. 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)

30. Shared Values and Vision
Developing shared values
Developing a shared vision
Role Clarification
Creative engagement
Assessment of Practice Context
Leadership Development
Developing engagement of stakeholders
Shared Values and Vision
transforming individuals and contexts of care
Person-
centred
Culture
Facilitated
Active
Learning
Authentic
Engagement
Facilitation
Action Planning
Role modeling
Critical Companionship
Reflection
Action Learning
Workshops
WBL
(adapted from McCormack & Garbett, 2004)

31. Person-centred Outcomes
Experience of good care
Involvement with care.
Feeling of well-being.
Existence a therapeutic culture.

32. 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

33. 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

34. 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 well-being
Schwartz Rounds and narratives

35. Mental Health inpatient unit
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

36. “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)