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RMIT Health Service Leaders: How is the role changing?. Counting the Cost of Caring: Deciphering the culture in a public hospital Division and the implications for change implementation Linda Betts - Project Consultant RMIT Masters Of Business (Management) by Research student.

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RMIT Health Service Leaders: How is the role changing?

Counting the Cost of Caring: Deciphering the culture in a public hospital Division and the implications for change implementation

Linda Betts - Project Consultant

RMIT Masters Of Business (Management) by Research student

Linda Betts & Associates 2004

An Organisational Development Approach
  • Organisations are more than rational systems and processes
  • OD focuses on human and social aspects of organisations
  • OD takes a strategic and planned approach to change that factors in people & behavior
  • The culture of an organisations is seen as key
  • My personal observations of the impact of change in health over last 14 years…...

Linda Betts & Associates 2004

defining culture
Defining culture
  • What is ‘culture’?

“the shared values, beliefs, norms and patterns of behavior in an organisation. It is similar to the personality of an individual…a hidden, yet unifying theme that provides meaning, direction and mobilization” (Gibson et al 1994 p. 62)

Linda Betts & Associates 2004

defining culture1
Defining culture
  • Alvesson (2002) - common assumptions about culture in the literature
      • They are related to history and tradition;
      • They have some depth, are difficult to grasp and account for, and must be interpreted;
      • They are collective and shared by members of the group;
      • They are primarily ideational in character, having to do with meanings, understandings, beliefs, knowledge and other intangibles;
      • They are holistic, intersubjective and emotional rather than strictly rational and analytical. (p.6)

Linda Betts & Associates 2004

why is culture important
Why is culture important?
  • Since 1980’s numerous management theorists and practioners have promoted the importance of culture and its impact on organisational performance.
  • “Culture not official rules or policies ultimately dictate what you can and can’t do” (Deal & Kennedy 1999, p. 40).

Linda Betts & Associates 2004

can you change culture
Can you change culture?

How is culture learned?

  • ‘Socialization’ is a key part of learning a culture
  • not ‘taught’ with the recipient as a passive receiver but is learnt by the new staff members through active learning
  • Includes observation, making mistakes/being punished and being rewarded often in subtle ways by earning approval or inclusion for behavior in-line with the culture. (Schein 1992)

Linda Betts & Associates 2004

can you change culture1
Can you change culture?
  • Much of the Literature shows culture is very difficult to change and happens over a long period.
  • Deal & Kennedy (1999) …2 of the original gurus of change:

“There must be a million consultants promising to help “change the cultures” of companies. What a lot of bollocks. Cultures change only when they need to and are damned well ready to change”

Linda Betts & Associates 2004

what s so special about hospital culture
What’s so special about hospital culture?
  • Allegiance to Professional culture
  • History - class, gender, power influences
  • “strong’ cultures evident - oaths, professional association, registration, training/education
  • Resistance to being ‘managed’

Linda Betts & Associates 2004

a case study of deciphering culture
A Case Study of Deciphering Culture
  • RWH - Division -Identified concerns and problems in a particular Division and asked for assistance
  • Recent history - increased activity, through-put & acuity, nursing staff shortages, high levels of tension & conflict between staff
  • Absence rate - 12.8%
  • Casual staffing - $0.7 million
  • 17 nurse vacancies - staff turnover rates increasing
  • Zero applicants for advertised jobs

Linda Betts & Associates 2004

wider internal external climate


Change of CEO

Changes to senior management

Change to structure

Budget reduction

Quality measurement priorities

Targets priority


Major political & economic reform in 1990s

Casemix funding model

Restructure of hospitals in Melbourne


Competitive Neutrality

Budget reduction

Wider Internal & External Climate

Linda Betts & Associates 2004

deciphering the climate and culture
Deciphering the climate and culture
  • Read the history, listen to the stories
  • Interviews & Focus groups with staff - ‘outsider’ view important
  • Report on findings - acknowledge the positives, identify concerns, make recommendations for change
  • Reference Group - multidisciplinary, cross-sectional, open to learning not ‘fixing’

Linda Betts & Associates 2004

cultural mapping schein s model of organisational culture

Espoused Values

Basic Assumptions


Surface Level - systems, processes, buildings, org structure (hard to decipher)

What the organisation says its about - written documents, speeches, strategic plan

“Unwritten rules” - unconscious, undiscussed values, beliefs & philosophies

Schein, E, 1992 Organizational Culture and Leadership, Jossey-Bass

Cultural Mapping - Schein’s Model of Organisational Culture

Linda Betts & Associates 2004

organisational defensive mechanism
Organisational Defensive Mechanism

Argyris - (Argyris, C. 1997 Initiating change that perseveres, The American Behavioral Scientist, Thousand Oaks, Vol. 40, Iss. 3; pg. 299-310)

  • beliefs become embedded in org culture
  • tacit, unconscious, ‘undiscussable’
  • if challenged - threaten or embarrass beliefs= defensive or attacking response
  • Impact - hard to change, ‘anti-learning’

Linda Betts & Associates 2004

findings artifacts
Findings - Artifacts
  • Environment
  • Hospital structure
  • Quality & measurement
  • Budget reduction
  • New managerial focus
  • Clinical workloads
  • Staff shortages
  • Research

Linda Betts & Associates 2004

respect for staff openness
Respect for staff openness
  • Privilege to work with the staff
  • Cultural mapping requires identifying beliefs and “unwritten rules” - some of these could be judged as ‘wrong’ or ‘outdated’ but need to be understood within the cultural history and context
  • Never denigrate the past
  • Breaking “dirty laundry” rule...

Linda Betts & Associates 2004

findings espoused values
Findings - Espoused Values
  • Quality - Highest standard of patient care
  • Integrity - Honest and open communication
  • Valuing staff - Contribution of all individuals is encouraged & recognised
  • Unity - Team approach
  • Diversity & equity - respect for difference
  • Teaching & training important
  • Customer focus
  • Excellence & Innovation

Linda Betts & Associates 2004

findings basic assumptions
Findings - Basic Assumptions
  • Existence of Sub-cultures evident from process
  • This lead to additional facilitation of cultural mapping sessions with various professional groups from the Division

Linda Betts & Associates 2004

basic assumption nurses
Basic Assumption - Nurses
  • “Don’t rock the boat”
  • Cope…no matter what
  • Credibility equals expertise & length of service
  • Our way is best
  • Know your place
  • Don’t air the dirty laundry

Linda Betts & Associates 2004

basic assumptions new graduate nurses
Basic Assumptions - New Graduate Nurses

Prior to starting:

  • Question everything
  • Nurses will be respected for asking questions
  • Nurses have a voice
  • Nurses can make decisions
  • Nurses are valued as part of the multidisciplinary team
  • New staff are like ‘gold’
  • Nurses should advocate for their patient

Linda Betts & Associates 2004

basic assumptions new graduate nurses1
Basic Assumptions - New Graduate Nurses

Post starting:

  • New staff know nothing
  • New staff are a burden
  • Power equals how long you have been here
  • Don’t question
  • This hospital’s way is the best and it can’t be done better
  • You have to prove yourself by conforming to the group

Linda Betts & Associates 2004

basic assumptions doctors
Basic Assumptions - Doctors
  • Don’t make mistakes
  • Have good clinical skills
  • Please the consultant
  • Adopt a similar practice
  • Learn quickly
  • Always cope and “get through it”
  • Manage all workloads - can’t say ‘no’
  • Don’t stint on cost/care
  • Don’t stick rigidly to rules - individual professional judgement important

Linda Betts & Associates 2004

some implications
…Some implications
  • Professional subcultures
  • Beliefs are strong, traditional beliefs aligned to professional groups
  • Does not appear to have shifted by recent economic & political reforms
  • May be that structure and system change has not necessarily meant cultural change
  • Incongruency may exist btwn management and clinical professional cultures - Lit shows this = staff satisfaction & turnover

Linda Betts & Associates 2004

a final optimistic note
A final optimistic note

Without setting out to ‘change culture’ the project did deliver good outcomes over 18 month timeframe:

  • Absence rate decreased to 4% (from 12%)
  • Staff turnover decreased, 100% of new graduates stayed on for first time in years
  • Zero vacancies
  • Waiting list of new applicants
  • Increased staff satisfaction (Best Practice Survey results)
  • No. of nurses “at risk of leaving nursing or the organisation decreased by 58%” (Best Practice Survey results)

Linda Betts & Associates 2004

  • Thanks to RWH management for supporting & resourcing the project
  • Thanks to RWH Division staff for being so open and honest..and trusting an ‘outsider’
  • Thanks to Rosalie Holian & Ian Woodruff, RMIT supervisors

Linda Betts & Associates 2004

more information
More information…...
  • For further details please contact:
  • Linda Betts

[email protected]

or phone 0409 420 991

Linda Betts & Associates 2004