Maria Paviour, an occupational psychologist and former NHS whistleblower, asks if we are creating toxic workplace cultures.

“The Trust’s culture is characterised by homophobia, racism and bullying”. That was how the CQC reported it, and how my conversation with Laura, the associate director of HR for a major NHS Trust, introduced me to the problem their organisation was facing. On the surface, a highly performing, mature Trust, but when you delved deeper, the signs of toxicity were all there.

It is interesting how often culture is quoted as being the problem, with no way of assessing what we mean by that. This has led me to find ways in which we can make sense of this concept of culture, when we are in it, as well as when we review it from the outside.

In The Upside Down People System Report, we saw how culture was being impacted from the top down, but how is it created on the ground? When I was working with the charity Patient Safety Learning, I met a patient advocate who succinctly put it: “cis what happens when no one is looking”. However, what senior leaders measure creates the imperative that drives culture, and according to Goodhart’s law, when a measure becomes a target, it is no longer a good measure. It can also create a toxic culture.

There’s a difference between a culture that is pressurised, imperfect or undergoing change and a culture that is toxic. Toxicity rarely happens overnight, it is a progressive process. In other words, as pressure mounts and performance has to keep up, the people begin to do whatever they need to do to survive in that culture. So, performance can appear outstanding, maybe targets are met, but the manner of meeting those targets may be questionable or even unethical. On the other hand, a high-pressure, high-performance culture can be rewarding.

What type of culture?

As culture is related to subjective, individual experiences, it’s helpful to use a common language that joins the dots between the science, the metrics and employee experience. When measuring cultures, I use these four descriptive culture types: Zombie, Vampire, Angel and Phoenix; because most people can relate to them at some level.

A key factor determining whether a culture is positive or not is psychological safety; a phrase coined by Amy Edmondson in 1999 after she discovered that healthcare cultures where people were able to speak up (psychologically safe) were also much safer for patients. If an employee doesn’t feel safe to say, “I made a mistake”, or “I don’t know” without the prospect of being negatively judged, you have the beginnings of a Vampire Culture.

Vampire Cultures can arise when we require people to deliver on expectations and targets without making it safe to question or call out what concerns us. This lack of psychological safety drives out workplace ethics. People will begin to game the system, such as finding ways to tick the target-achieved box by any means. This is because their internal ‘survival codes’ drive them to act in ‘self-defence’ to protect themselves from criticism – or worse. This can become a groupthink process, whereby we turn a blind eye to certain things that ought to be dealt with rather than become victimised ourselves. Vampire Cultures can have the appearance of high performance in the short term, but in a Vampire Culture, there is less patient care and more reactivity. People rarely last, and this is often demonstrated where leave or sickness absence begins to rise.

Vampire Culture can suppress the cognitive capacity of employees to the extent that their brains actually begin to shut down. When this happens, we see the rise of the Zombie Culture. It can be a precursor to tragedy; if a healthcare worker is no longer able to perceive the world outside their point of focus, they can make basic mistakes that look like a lack of care. This may be the result of a shutdown of their peripheral vision and thinking.

In Zombie Culture, capability, wellbeing and safety deteriorate unseen, beneath the surface.  Unseen, that is, until something goes wrong.

On the other hand, Angel Cultures are not as good as they sound. With no drive, these cultures are not good for the wellbeing of the organisation; and with low energy and engagement, it’s certainly not good for delivering excellent patient care. Angel Cultures are often described as RIP (Retired in Post) with intense focus on the wellbeing of the employee; they can be cliquey and inward-looking, not necessarily good at collaborating and not prepared to go the extra mile.

The importance of workplace culture

Honesty and candour

The Phoenix Culture combines honesty and candour with high performance; everyone learns from mistakes, and as a result, with no blame, the patient’s outcome is the top metric, as opposed to targets like patient waiting time. When things go wrong, as they will, Phoenixes get better; they make learning our priority. And learn earlier and faster. That is how these cultures continually rebirth and get stronger in the process, rising from the flames.

A high-performing Phoenix Culture demonstrates high levels of four key capabilities: decision-making, problem solving, creativity and co-operation. All of which are obviously vital in healthcare, in diagnosing, determining care pathways, finding solutions and working as a team. These are exciting and inviting cultures – you work hard but purposefully. Job satisfaction is the reward.

To aspire to Phoenix Culture, we must identify culture decline early, as part of a business-as-usual, real-time process. This means we need to think beyond disconnected, lag data, and equip managers and HR professionals with data intelligence.

In practice, this means bringing real-time engagement scores, wellbeing and cognitive capacity together to create coherent data that can be presented as a balance sheet.

Engagement is where people add value, this is your People Asset, and wellbeing is your People Liability. Wellbeing is not a target. If people come to work well but don’t go home well, we are creating a business liability as well as a human and societal one.

Data needs to identify those teams where people feel safe to speak out and those who do not.

This thinking can help to produce finance-grade people data that can inform the strategic decision-making of the senior team. When the senior team recognise the measures that matter, it puts us in a stronger position to ensure we drive the right kind of culture and achieve better performance all round.

How do we make the shift?

Starting with equipping the right people with the right data. Most importantly, the line managers. This may actually matter more than management training. If your managers can see, at a glance, their team’s status and can focus on engagement and value creation, there tends to be a natural reduction in team wellbeing liability.

Where endurance is rewarded, employees increasingly normalise extreme levels of stress and strain. We must see past this brave face, and surveys simply cannot. This means that people are under intense allostatic load (stress) but that they are psychologically adapting to this – this normalisation of unacceptable levels of stress will often lead to a bad result – maybe people go off sick or leave. It is a significant indicator of potential patient safety risk. Staff will be unable to apply their skills effectively if their brains are closing down.  We need to see through heroics in the short term and consider their impact in the medium term alongside the attendant personal burnout and absence costs.

Toxic culture is not simply an employee-experience problem. It reduces human capability, weakens organisational performance and creates a direct risk to patient safety. The evidence tells us: when you measure the right things, and you ensure your culture is Phoenix and not Zombie.

My NHS Trust associate director colleague and I took that leap of faith and carried out our extensive assessment of the wellness, engagement and cognitive capacity of every employee. This gave us an opportunity to start afresh, to look at where there was a gap and begin to gently find the missing pieces; making it safer to speak out, manage workload and be human.

Knowledge is the key. Without a way of understanding your culture, you are in the dark, where the Vampires thrive.

This data told us that culture happens at the point of work, and it guided us to focus on that all-important line manager trust relationship. Because when the managers feel empowered and the people feel safe, that’s how, slowly and surely, Phoenixes rise.