Closed cultures can occur in any industry, profession, or team because closed cultures are the product of a number of conditions having been established.
What is a closed culture? And why does it matter?
The CQC somewhat vaguely define a closed culture as “a poor culture that can lead to harm, including human rights breaches such as abuse.” This is of limited practical use, as it focusses on the consequences of a poor culture more than on its features.
A more helpful example defines the opposite, identifying 37 features of an open culture . These focus on open communication, open-mindedness, and psychological safety, with leadership, employee attitudes, and organisational processes all contributing to a positive culture. Statements indicating an open culture include:
“We are open to views from a wide network, such as those of other departments, professions, and institutions.”
“We trust each other’s intentions”
“Respect for colleagues and patients is one of our most important values.”
Therefore, a closed culture might be indicated by an absence of these features. In healthcare, like aviation, closed cultures can have a direct and catastrophic impact on safety. Closed cultures can occur in any healthcare sector, but we tend to see them more in mental health or care home sectors. Closed cultures in these settings are more likely to be environments of high expressed emotion, with a greater cohort of vulnerable patients, alongside lower paid staff and stretched services.
Wards can go from exemplar environments to closed cultures on a rapid basis and yet this subtle decline can be very difficult to detect; this gives rise to a very real fear amongst board members. Indeed, it might take years for the impact of a closed culture to emerge; it is therefore crucial to try to spot some of the conditions which are required for a closed culture to thrive.
Poor tone at the top
If a Board does not send out a clear and unequivocal message about ‘patients first’ – care, quality and safety -then they risk sending out a very mixed message about what matters. With the conflicting priorities faced by healthcare provider boards, it is surprisingly easy for operational and financial matters to headline and to filter through the organisation as a priority message, particularly when there is often an observable lack of resources (such as staff and new estate) which are made available to support care quality.
Senior leadership behaviour is also a pivotal factor (although not the only one) in the development of a closed culture. Senior leader conduct is a matter frequently mentioned when staff are interviewed after a catastrophic care failure involving a closed culture.
Closed cultures can also develop as a reaction to poor leadership. Consistent leaders exhibiting consistent leadership behaviours, are vital. They should be emotionally intelligent, able to hold the line on poor behaviour, treat everyone equally, and lead by example.
Trauma responses
Environments of high expressed emotion, internalised and externalised trauma are often found in closed cultures. Particularly in healthcare environments where staff might be dealing with aggression from patients (for example CAMHS and secure / forensic mental health services). These staff are also often witness to traumatic incidents of serious (sometimes fatal) self-harm and psychological distress, they witness or participate in acts of restraint and these high incident environments become normalised. What often isn’t recognised, is the consistent psychological trauma caused by this, which can also become normalised.
When this happens, staff can adapt their behaviour to be self-protective or pre-emptive, which reinforces the use of restraint and reduces positive behavioural management approaches. When set within a complex patient cohort (for example in inpatient CAMHS units), where acuity might be rising, a clear downward spiral can occur.
Post traumatic stress responses in staff and patients cannot be discounted as a significant factor in the development of a closed culture. Skilled and supportive responses are required to interrupt this cumulative decline.
Power imbalances
We see the development of a power imbalance in three key ways in closed-cultures; (1) Between staff and patients (2) Between staff and families and (3) Between staff themselves.
1: Between staff and patient: Being a patient in receipt of healthcare services is a power imbalance by itself. However, some services by their very nature increase the power imbalance. Controlled egress units, units where there is restricted patient mobility, or units where there are cognitive or psychological care needs can all set the scene for the development of abusive power-based behaviours if the conditions are not well managed.
Staff who have developed overly familiar and unprofessional approaches with patients can quickly introduce a sense of duress where patients will feel forced to adopt certain behaviours to gain favourable responses from staff, and to be ‘liked’. This is different to staff who ‘loco-in-parentis’ offer a comforting hug or hand on the shoulder to a person who might be feeling isolated; it is important not to vilify or inhibit a truly caring approach.
However, there are occasions where staff use punitive approaches to address behaviour, changes in their own levels of kindness and attention, withholding leave or introducing stigmatising care. Patients become particularly vulnerable when other protective factors are removed, for example, the meaningful involvement of relatives and family members, the use of safeguarding processes, or individualised care adjustments. Additionally, the direct implementation of the power of staff over patients, through physical and chemical restraints and seclusion can in turn increase iatrogenic harms and promote the development of a closed culture.
An open dialogue, with genuine kindness, empathy and non-judgemental curiosity goes a long way in supporting recovery, both for patients and their families.
2: Between staff and families: Families are an utterly vital component within the ‘triangle of care’ and yet so often their views are not meaningfully involved in care planning. Staff forget how exceptionally difficult it is for a family to gain a rounded understanding of the care their loved one is receiving as they are only able to physically connect on such an infrequent basis. This is where devices such as smart phones can become an enormous battle ground between staff, patients and families (particularly in CAMHS).
Families are a vital source of insight and information; yes indeed, they may sometimes be part of the problem, however, they are more often than not a large part of the solution. In a closed culture staff can hold significant power over families through both withholding information and also the exercising of unfounded judgements against them. Both can cause irreparable damage.
The best type of therapy, arguably, supports the notion that the ‘power’ of the therapeutic relationship is held equally by both the patient and the therapist, that knowledge and the therapeutic process is passed on so that individuals can be participant in their own recovery. This is also true of families who are often left floundering when it comes to knowing what to do to support their relative. Collaborative working such as psychoeducation for families, family therapy and attendance at all key meetings is so important in levelling up the power imbalance, thereby promoting recovery.
3: Between staff: A power imbalance amongst staff is not automatically driven by formal role hierarchy. Hierarchy and omnipotence of personality can be more instrumental in a closed culture. A strong personality can quickly become all-powerful within a unit, which can then quickly become partisan and divided. An errant personality which thrives upon ‘playing people off’ against each other can rapidly destroy team cohesion if left unchecked.
The worst of all cases is a unit where the errant personality happens to be in a leadership position, say for example, a ward manager or shift leader and that person thrives upon splitting. New staff will often struggle to integrate into this culture; high turnover of newer staff is a key indicator of a potential closed culture. Very low turnover of staff, however, can also be something to check out, as are all outliers on workforce statistics.
Lower grade staff might be more vulnerable to the impact of partisan behaviours because of an increased likelihood of the combination of low pay and less job security. Going with the flow and not becoming too visible amongst the staff group can lead to compliant behaviours.
Influencing
Basic professionalism amongst staff often wanes in a closed culture. One member of staff having a bad day can easily develop into an acceptance that it is OK to speak and even make notes in permanent records in a detrimental manner about patients. Hostile views expressed about patients can be so destructive, that even one unkind or frustrated comment about someone could embed a sustained detrimental view of that patient, heavily influencing the care and support they have the right to access.
Families can also be seen by staff as an impediment on a unit where there is a closed culture. For every family which asks questions or applies scrutiny there are staff who judge them, apportion blame towards them and deny them their rightful inclusion in the care and treatment of their loved one; they are pathologised for expressing genuine views or asking questions.
Basic standards, basic care and basic kindness all contribute to ensuring professional approaches in staff. Staff might feel that they are unable to deliver these responsibilities because of poor staffing, poor estate, low pay, or lack of training, but the basic professionalism and responsibility of care should be the concern of all staff. A lack of professionalism should be treated on a strict disciplinary basis, at all times.
Operationalising a closed culture
In safety-intensive industries, such as aviation, shift patterns are closely monitored. Air traffic control, for example, can work in shift patterns of between 5 to 8 hours with mandatory total-stop breaks at every 120 minutes. It seems incongruous that on, for example, a high acuity physical or mental health ward staff regularly work 12/13-hour shifts on consecutive days. Planning an off duty is not without difficulty, but the needs of staff and reducing the administrative burden on managers should not override the needs of patients, who benefit from a workforce who are rested, have resilience and the energy to cater to their needs.
We are often told that long shifts promote care continuity, and this may be so in some cases for some patients. However, working long shifts in intense care environments, such as psychiatric intensive care or CAMHS, can, over time, induce compassion fatigue amongst staff, a key ingredient in a closed culture.
Ensuring good governance and adequate supervision of a unit is also key. However, if the chain of command around a unit is equally implicated in the issue, what might the other indicators be?
In services which might have been vulnerable to a closed culture the Covid response may well have helped to operationalise dysfunction. Not only were organisations forced to develop rapid safety responses around lock-down, staff and patients were also scared, working at increased risk, and working differently. The impact of Covid on trauma responses amongst staff is not yet fully known and it seems unlikely that managing this trauma has been part of standard processes in organisations.
Preventing closed cultures
Spotting a closed culture on a service visit or inspection is incredibly difficult. By their nature those units might have become adept at presenting a functional exterior. Equally, statistics alone may not surface the issue. A mixture of hard and soft intelligence is required and the development of a weighted trigger-tool to spot such units is key.
Arguably, the single most important way of preventing the development of a closed culture is through a good ward manager. A good ward (or unit) manager will exhibit role model behaviours and will set the cultural standard. They will ensure that shift patterns are focussed on effective patient care and not convenience for staff (although we accept that this is not always possible).
Role model behaviours within the chain of command, all the way up to the board, are vital in preventing, identifying and repairing closed cultures. Particularly in leadership positions, people should be recruited partly on their values. They should be given specific training to enable them to tackle difficult personalities and to lead with integrity and confidence.
When staff see a positive role model they want to emulate those behaviours. Staff gravitate to the leader who feels ‘psychologically safe’. A closed culture develops when the leader who feels ‘safe’ occupies that influential role without any of the values, skills, experience, and self-discipline necessary to take people on the right journey.
Developed by Kate Jury, James Fitton and with Dr Nim Cave as guest editor.
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