Staff Sub-Cultures & Perceptions of the Organisation:

An Historical Perspective

North Tees & Hartlepool Foundation Trust

∂

Service Line Management

Resource interconnection

s

Systemisatised care processes

Multidisciplinary based care

Transparent accountability

SERVICE LINE MANAGEMENT

∂

Staff Views on Organisational Practices

Views on:

• Management models appropriate for improving the

overall performance of clinical units

• The management style of Trust

• Trust’s organisational goals

• Staff affiliation with their Trust

∂

Abbreviations

MC Medical Clinician

MM Medical Manager

GM General Manager

NM Nurse Manager

NC Nurse Clinician

AHM Allied Health Manager

AHC Allied Health Clinician

∂

1995 (111 staff) 2002 (102 staff)

1 Financial viability Financial viability

2 Service quality Service quality

3Productivity improvement

Equal access

4Organisational

stabilityProductivity improvement

5 Service innovation Service innovation

6 Equal accessOrganisational stability

7Teaching and

researchStaff welfare

8 Staff welfare Teaching and research

Ranking of Organisational Goals for Whole Trust

∂

Trust Goals 1995(Ranked by Mean Score)

Total MC MM GM NM NC

Financial viability 1

1.881

1.931

1.781

1.761

1.911

2.00

Service quality 2

3.424

3.782

3.003

3.292

3.173

3.86

Productivity improvement 3

3.562

3.043

3.782

3.003

3.7823.679

Organisational stability 4

4.6583

3.777

6.115

4.954

4.394

4.07

Service innovation 5

4.716

5.734

4.564

4.335

4.565

4.39

Equal access 64.87

54.73

44.56

65.38

65.00

64.68

Teaching and research 7

6.167

6.236

5.448

6.807

6.097

6.25

Staff welfare 86.86

86.80

86.78

76.58

87.07

87.07

∂

Trust Goals 2002(Ranked by Mean Score)

Total MC MM GM NM NCAHM

AHC

Financial viability

12.96

12.78

12.20

12.29

54.44

34.17

12.44

12.38

Quality 23.22

33.78

43.40

44.21

22.88

12.72

12.44

23.13

Equal access 33.96

23.43

33.20

54.64

12.81

23.89

54.89

54.88

Productivity 44.18

44.04

22.80

34.00

76.44

54.22

34.00

43.75

Service innovation

54.68

64.96

55.40

23.29

64.81

65.11

35.56 3

3.63

Organisational stability

64.70

44.04

76.40

65.00

33.81

44.06

44.30

65.31

Staff welfare 76.00

86.57

65.6

86.29

44.38

86.17

76.00

87.00

Teaching and research

86.22

76.39

87.00

75.93

76.44

75.67

86.33

75.75

∂

Trust Work Values, 2002

MC MM GM NM NC AHM AHC Sig.

Conformity to rules and risk avoidance

-.207-.22

6-.096

-.044

.654 .202 .464 .000

Inequalities of power are natural and beneficial

.523 .474 .362-.10

4-.33

0-.203

-.070

.000

∂

• Collegial (inclusion, freedom, belief, satisfaction)

• Meritocratic (encouragement, degree of freedom, individual achievement, competition)

• Unit based paternalistic leadership (loyalty, belonging, team solidarity and achievement)

• Hierarchy (direction, compliance, rules, discipline, surveillance)

Styles of Management

∂

Perceptions of Management Structures and Style, 2002

Styles Identified

Style 1 Style 2

Collegial .724 -.421

Meritocratic .689 .067

Unit based paternalistic leadership

.010 .961

Hierarchy -.924 -.014

∂

Staff Perceptions of Received Management, 2002

MC MM GM NM NC AHM AHC Sig.

Collegial/ meritocracy vs Hierarchy

-.459 .174 -.069 .006 -.544 -.359 -.221 .003

Unit based Paternalistic Leadership

-.164 .197 .215 .295 .204 .431 .295 .006

∂

Affiliation Modes of Staff, 2002

MC MM GM NM NC AHM AHCSig.

Value Identification

-.559

-.062 .319 .008 -.530 -.252 -.547.000

Cynical .048 -.121 .496 .189 .454 .210 .158.027

Calculative identification

.179 -.231 -.364 -.140 -.023 -.085 -.077.059

∂

Sub-Culture/KnowledgeMappingViews on :

• Health care issues

• Strategies for addressing hospital resource issues

• Autonomy and accountability

• Clinical governance

• Clinical and resource interconnections

• Causes of clinical practice variation

• Basis for setting clinical standards

∂

Stances of Acute Care Trusts and PCT for the Study as a Whole

Emphasis on financial realism and transparent accountability

Emphasis on clinical purism and opaque accountability

-1.5

-1

-0.5

0

0.5

1

1.5

-1.5 -1 -0.5 0 0.5 1 1.5 2

Acute Care Trusts

Primary Care Trusts

Acute NM

Acute AHM

Acute GMAcute MM

Acute MC

Acute AHC

Acute NC

PCT NM

PCT NC

LC

GP

PCT GM

PN

Individualistic concepts of clinical work

Systematised concepts of clinical work

∂

0.5 1.01.5

1.5

1.0

-1.0

-1.0 -0..5

0.5

-0.5

-1.5

-1.5

1995

NC

MM

MC

GM

NM

MC

MM

GM

NM

NC

AHC

AHM

2002

Individualistic concepts of clinical work

Systematised concepts of clinical work

Emphasis on financial realism and transparent accountability

Emphasis on clinical purism and opaque accountability

Professional Subcultures in NTHFT; 1995 & 2002

∂

Summary of NTHFT Professional Cultures, 2002

Acute MC MM GM NM NC AHM

AHC

Recognise the interconnections +/- + + +/- - + -Balance accountability and accountability +/- +/- + +/- - +/- -Systematisation of clinical work - - +/- + +/- +/- -

Multidisciplinary teams - - + + +/- + +/-

∂

Professional Subcultures of Acute Trusts in an International Sample

-1.5

-1

-0.5

0

0.5

1

1.5

2

-1.5 -1 -0.5 0 0.5 1 1.5

N&Y Region

England

Wales

Australia

New Zealand

MC

MM

NC

NM

GM

Individualistic concepts of clinical work

Emphasis on financial realism and transparent accountability

Emphasis on clinical purism and opaque accountability

Systematised concepts of clinical work

∂

International Sample

MC MM GM NM NC Total

N&Y Region Project

103 24 63 69 81 340

England 162 51 82 105 115 515

Wales 177 42 79 113 284 695

Australia 343 129 134 181 191 978

New Zealand 190 59 111 94 83 537

Total 975 305 469 562 754 3065

∂

Medical Clinicians’ Views on Performance Improvement, 2002Emphasised• Improvement of the internal organisation of clinical work• Increased resources and improved decision-making about their use• More effective organisational management

Tended to believe that• Decision making processes within the Trust were ineffective• Past amalgamations and policy implementation had been poorly

handled

Doubted that• Managers would be able to ensure the Trust functioned decisively and

effectively in the (then) new health economy environment

∂

Emphasised• Improvements in the internal organisation of clinical work within the

Trust• Making better use of resources the Trust already had

Would have appreciated• More time for both clinical work and management activities• Better access to clinical information to guide service design and inform

service delivery• Greater emphasis in team working• Greater skills development in team development and management

Medical Managers’ Views on Performance Improvement, 2002

∂

Emphasised• Reorganisation of clinical work internally

Concerned to• Rein in the power of the consultants

Wanted• More effective team working within the organisation• Partnership and joint organisational working within health economy,

including subsuming aspects of primary care into the Trust

Characterised at times by• Some blame shifting to DoH and clinicians• Apparent lack of ideas to resolve difficulties

General Managers’ Views on Performance Improvement, 2002

∂

Nurse Managers’ Views on Performance Improvement, 2002Emphasised• The belief that clinical performance outcomes were related to virtually

all aspects of organisational life• A concern that clinical work should be better organised and managed

Concerned about• Time pressures• Lack of experience in working in and leading teams• Lack of forums for cross-disciplinary and cross-directorate meetings

Wanted• Leadership development• Reshaping of Trust management structures• Concrete suggestions the new service developments (not just abstract

ideas)

∂

Nurse Clinicians’ Views on Performance Improvement, 2002Emphasis upon• Pay and conditions

Concerned about• Accessing more training opportunities• Sorting out anomalies in working conditions• Poor management-staff relationships

Characterised by• Extremely low response rates• Appeared disengaged with the organisation• Focused upon personal development and personal needs

∂

Allied Health Managers’ Views on Performance Improvement, 2002Emphasis upon• The organisation’s relationships with external bodies• Organisational requirements for improved clinical organisation (on which

they had many and wide ranging opinions)

Believed that• Resources, especially time, were critical for achieving the reorganisation

of clinical work

Concerned about• The role of AHP within the Trust• In effective voice in clinical decision making (though having a wider

understanding of how care were structured)• Pay and conditions, poor access to training, poor accommodation

Characterised by• Disenchantment with work and the way the Trust was managed

∂

Allied Health Clinicians’ Views on Performance Improvement, 2002Emphasis upon• Better access to training• Improvements to the organisation of clinical work and to organisational

management practices• More resources

Concerned about• Difficulties in working in ‘integrated’ teams (though supportive of these)• Poor management both within the profession within the Trust and the

wider Trust management• Better care planning especially in regards to discharge

Characterised by• Unhappiness with their line managers

∂

Percentage Predicted Group Membership, 2002

MC MM GM NM NC AHM AHC Total

MC 45.1 18.3 2.8 5.6 1.4 7.0 19.7 100

MM 20.0 55.0 20.0 5.0 - - - 100

GM 4.1 14.3 49.0 20.4 4.1 6.1 2.0 100

NM 3.5 5.3 12.3 40.4 15.8 12.3 10.5 100

NC 7.5 1.5 3.0 16.4 43.3 7.5 20.9 100

AHM - 12.2 17.1 19.5 9.8 14.6 26.8 100

AHC 9.8 12.4 5.9 7.8 13.7 3.9 51.0 100

∂

Traditional Service Delivery Model

Nursing

GM

Medicine

AHP

∂

“Clinical Product Line” ModelFi

nal Pro

du

cts

Intermediate Products

∂

Previous Improvement EffortsFi

nal Pro

du

cts

Intermediate Products