Speaking up: it’s what we do around here

Claims of mistreatment and poor outcomes in residential aged care have been back in the news lately. Here, organisational psychologists with experience in the sector share their insights into how providers can create a culture where staff feel supported and safe making a report to management.

‘Leadership is the key’

Leaders must communicate clear expectations about acceptable service standards and behaviours, write Dr Judith Chapman and Emma Read.

Imagine this scene unfolding at the board meeting of an organisation providing residential aged care. The chair indicates they wish to address those present and makes this statement: “From this day forward, each of us, as well as the other senior staff in our facilities, will be deemed to take personal responsibility for the quality of the services we provide, as expressed through our guiding ethos and vision.” How will people respond? Will heads around the table nod in agreement or will the chair’s statement be met with incomprehension and perhaps anxiety?

The chair has made a bold statement but the intent behind it is inescapable. Leadership from the top is the critical ingredient in moulding a culture where the quality of care is all it should be. So what does this leadership look like in practice and how does it ripple throughout the facility so that every resident, staff member, visitor and volunteer feels its influence?

In practice it means that leaders walk the talk. They believe in what their organisation stands for and they take the message to others through their words and actions. They spend time with residents and staff, talking and listening to them. Trust builds and people become more comfortable in opening up and sharing their concerns. In short, these leaders are visible, approachable and authentic. This makes all the difference when staff are faced with the dilemma of reporting incidents of poor care, or keeping them to themselves.

What else can leaders do? In every aged care facility the ethos values the health and wellbeing of residents. Leaders must communicate clear expectations about acceptable service standards and behaviours. Policies alone do not cut it – they are too remote from the reality of busy work days, frequent upsets and resident behaviours that can be challenging for staff. Reminders of standards and appropriate behaviors work best when they are made frequently in face-to-face situations with leaders acting as credible role models.

Opportunities for group learning and skill development in relation to contemporary approaches to client care are also important. During these events leaders should bring issues of service standards, including staff and visitor behaviours that are unacceptable, to the surface. Let people talk openly about what they expect of themselves and others. Encourage everyone to contribute their ideas and clarify their thoughts around these issues. Help to form a shared understanding of what constitutes quality service and what staff will not support in themselves or others. Make service standards a regular item on the agenda of every staff and management meeting. Clarify what staff can do if they notice anything that might be a breach of the service ethos, and what management will do in response. Remove any excuse to hide or cover up problems. In fact, people who come forward with their ideas or concerns should be thanked for playing their part in improving the service.

Supplement these measures with other recognised channels (such as suggestion boxes) for staff’s ideas on how to report problems or make the service better for residents, with their contributions recognised in the staff newsletter or via other social media (anonymously if requested by the person). People are far more likely to take ownership if they are consulted and feel part of processes that benefit the people they care about.

Leaders can do even more to remove the fear of coming forward. Of course guaranteeing the confidentiality and integrity of the reporting process is essential. More broadly, they should create a positive social climate where every staff member feels included and valued. This is how leaders make staff feel safe and supported. People who do not feel included and valued withdraw psychologically, with many ill effects, including a loss of engagement. When it comes to building a strong culture there is no room for leaders to be in doubt about these important issues.

Together these measures will allow trust to build, which is the foundation for everything leaders do to take others along with them.

Dr Judith Chapman is an organisational psychologist and principal of Executive Succession. Emma Read is a psychologist.

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‘New methods, values’ needed

I advocate a new direction in organisational practice, the adoption of distributed leadership in residential aged care, writes Dr Heather Gibb.

Recent reports of poor care challenge the residential aged care industry to recognise that culture needs to change for staff to feel safe and supported when making a report about care standards to senior managers. As well-known organisational change expert Chris Argyris points out, if we keep using single-loop organisational learning strategy – recycling old methods and asking the same questions when trying to solve recurring cultural problems – we fail to recognise the causal roots of the problem. What we really need, according to Argyris, is double-loop learning – to self critically review how we go about our work, be prepared to throw out sacred cows and adopt a new organisational work practice – ranging from fundamentally new methods to new attitudes and values.

A case of single loop learning in aged care is the adherence to a command and control style of leadership throughout the organisation, manifested in directive, task focused and punitive behaviours. Care workers I have interviewed, while working in aged care across three Australian states, feel that the organisation does not trust their judgment, nor is their knowledge and perspective valued. It is not unusual to witness leaders apportioning blame – even yelling at staff who are already distressed when a resident has fallen, for example. This style of leadership fosters a psychologically unsafe environment for care staff to work in. Argyris describes the perpetual adherence to this style of leadership as a defensive manouvre derived from an organisation’s fear, and its habitual distrust of any other approach. The alternative – a leader displaying a sense of concern for how staff are dealing psychologically with the adverse event – promotes trust in care workers. A root cause analysis following a supportive debriefing is more effective in raising awareness of safety and improving practice than punitive behaviour that seeks a target of blame.

Double loop learning would begin when leaders recognise the impact of their behavioural reactions and interactions on the culture of the organisation and seek to change it. For care staff to take responsibility for what happens at work, they require a degree of autonomy and a sense of personal development through the work they do. Both of these ingredients derive from a third component  – the opportunity to take part in decision-making and problem-solving, where it relates to their role.

I advocate a new direction in organisational practice, the adoption of distributed leadership in residential aged care. This is where specific roles in leadership and initiative are appropriately assigned at every level of the team. A sense of interdependence is acknowledged and everyone’s input is drawn upon in care-related decisions, on the understanding that every team member has unique knowledge about residents’ care needs.

There is no place for expression of anger in distributed leadership, rather there is mutual respect and shared accountability to communicate and solve problems as they arise. Teamwork under distributed leadership needs to be consistent and clear, with everyone understanding their role. Teamwork protocols reinforce mutual accountability and mutual support. Examples are communication huddles and the handover acronym ISBAR (introduce resident; situation; background; assessment; recommendation).These  protocols form part of the TeamCare model developed specifically for aged care delivery teams at Helping Hand.

For an organisation to embrace distributed leadership, all leaders are required to develop self awareness of how their behaviour impacts on the psychological safety of the organisation. This level of self awareness, as well as the psychological flexibility to embrace change, is vital to successful culture change and requires coaching. However, success largely relies on a whole hearted commitment to the vision of a new culture by the chief executive and board of the organization. Along with this, an organisation must be willing to introduce new values about how relationships should be conducted and how people should work together to effect this change, which will materially improve the quality of life for aged people in residential care.

Dr Heather Gibb, an organizational psychologist working with the R&D unit at Helping Hand, is an adjunct professor at the University of Adelaide and coach to aged care teams.