The hospital operates in a highly politicised environment, which complicates decision making. The Theatre Department is a high-pressure workplace with responsibility for patients’ wellbeing made more challenging by under-resourcing and chronic understaffing. The previous Nurse Unit Manager had an amiable style, avoided conflict, and didn’t build accountability across the department.

Having worked extensively across several departments at this hospital and in connected hospitals, The Real Learning Experience was asked to consult on the project. Internally, the project was supported by the NUM, the hospital’s Nursing Director, and the Nursing Director for Surgical and Perioperative Services.

“There was little structure or governance, and no accountability or responsibility among team members to each other, to the department, or to the patient. We had little groups who were doing whatever they liked. The people who worked hard, worked hard. The people who were lazy were super lazy.”

Theatre Department NUMTheatre Department NUM

After several years of continuous change, unclear and inconsistent messaging, and appeasing and reactive leadership, the team was in a state of crisis. Managers within the department had been appointed based on tenure, technical skill, and pressure for advancement, with no reference to leadership capability. They lacked the knowledge, skills and, in some cases, the motivation to provide leadership, increasing the pressure on the new NUM.

Many (not all) team members, including some managers, were focused on personal needs at the expense of the effective day-to-day running of the department. Standards of interpersonal conduct were arbitrary and generally low. There were numerous unresolved conflicts and damaged relationships, as well as extensive underlying tensions. Gossip was rife, as were cliques that made new people feel excluded, leading to a high bounce rate.

Interactions frequently pushed the boundaries of bullying and harassment. Retention of good people was poor, while there was a significant cohort of long tenure mediocre performers. Attracting new people was difficult due to the external employment climate, the regional location, and the department’s reputation as a workplace.

Good patient outcomes were delivered despite the turmoil within the team, but they were achieved with more effort than necessary and depended on a sub-set of highly committed individuals.

“When COVID happened, people wanted the department manager to step up and protect them. They felt there was a gap between what they were saying to their manager and what was being heard by higher-level management. That led a lot of the staff losing faith in their leader, who eventually stepped down. There was a lot of instability, and everyone felt deserted.

Expectations from different people didn’t align. That created a lot of conflict and unacceptable interpersonal behaviour. Work requirements increased while resources decreased, and accountability and morale hit rock bottom.

People who complained loudest and caused most of the problems were rewarded with the roles they wanted, which made the situation worse. It meant people with no accountability were in positions of power and control for their own self-gratification. The team continued to fracture, and sub-groups continued to form.”

Theatre Department NUM

The workplace culture had become unsustainable and would inevitably lead to a decline in patient outcomes. The broad goals were to improve team morale, reduce loss of high performing team members, and increase consistency of standards.

Sitting below these goals were objectives to:

• Increase the willingness to engage in honest and constructive conversations
• Reduce gossip
• Develop leadership skill and thinking
• Challenge the ingrained mediocrity which had become normalised
• Build accountability
• Clarify and communicate expectations

“The two priorities were morale and accountability. We knew that outcomes for patients and staff engagement would improve as a result. It had to start with getting people to treat each other better. There had been an acceptance of poor standards and inappropriate behaviour for so long, and we had to draw a line in the sand and let people know it would no longer be tolerated.

That’s where accountability came in. Inappropriate behaviour had become so normalised that people felt it was unacceptable to be given feedback about it. That had to change! First, I wanted to get people used to accountability. Then, I wanted all the managers in the department to hold others accountable. Finally, I wanted to make it okay for team members to talk to each other about issues.”

Theatre Department NUM

Over a two-year period, a series of strategies were introduced, each designed to lay the foundation for the following steps:

• Consulting and guidance to develop a collective understanding of the workplace culture, the underlying issues, and to define the ideal culture. At this stage, a series of projects were identified to respond to the causal factors that were preventing cultural growth
• Leadership development through skill building workshops aimed at improving leadership capability and mindset, individual coaching including 360-degree feedback, and facilitated sessions to address issues within the leadership group and build commitment to change
• Development of interpersonal and workplace communication skills throughout the team using information sessions and facilitated discussions to ensure issues were discussed openly (there was considerable denial of problems and responsibility). These were followed by workshops for all team members, including managers, to build specific skills
• Establishing and embedding a values framework and ensuring the team was engaged in creating the standards that defined the workplace culture they wanted to work in – and that they would be accountable to. The NUM spent a lot of time reinforcing the values framework in individual discussions and team meetings to ensure they were reflected in behaviour
• Targeted coaching for individuals who were striving to do well and encountering barriers, and for those who had low awareness of their role in the issues, or low willingness to change
• Mediation for entrenched conflicts in which the parties were unable to reach a workable resolution for themselves
• Genuine consequences for both good and poor behaviour performance and behaviour
• Refined communication systems to address team concerns
• Team Building activities to reinforce the skills and celebrate progress. These activities included structured activities provided for the team and less formal initiatives introduced by the NUM and other managers

“It made it heaps easier for us from a manager’s point of view to have an external person with no history, no prior relationships or prejudice. The Real Learning Experience were able to be unemotive about the process. This was their role, and they were here because this is what they are good at. It brought an extra layer of accountability, which was highly effective for our team.

I couldn’t do this alone, so I needed to engage the other managers and have them step up, accept their responsibilities to be a leader, not just a manager. Most people knew what the problem was, but having The Real Learning Experience there meant that team members could talk in groups and individually to them about the problems they were experiencing, what it was like to come to work each day. They instantly felt heard, and that made them open to playing their role in the changes.

Some people didn’t know about the impact they were having, so how could they improve? Coaching brought so much awareness to people. Ongoing coaching, and the opportunity to sit down, hear some uncomfortable feedback, and develop strategies were critical

There wasn’t a lot of buy-in to our values until we did the launch. The workshop helped them understand how the values would be a useful tool for them in their roles. It helped them understand how to take the values from a poster on the wall and embed them in everyday behaviours and conversations.

The launch was so important because it was entertaining and it was different, and it made people work together who rarely communicated well. It was fun, and it wasn’t just someone standing up and telling them what to do. That really helped.

The team have learned to understand both sides and see where the other person is coming from. It helped with the communication and conversation, and people understood each other and moved towards working better with each other. Having an external person held us more accountable to the process, because of their expertise.”

Theatre Department NUM

Many of the poor behaviours and low standards in this team had been embedded for more than a decade. They had become normalised, a feeling that was reinforced by similar issues in other departments. Change was confronting for many and challenging for all, but it did occur. The NUM and other managers had to come to terms with improvement not being linear – one group would make significant progress, another would regress.

There was a moment in the process where things got easier, and change moved faster. To reach that point, the NUM and other senior leaders had to be willing to persist when resistance peaked. When the people with the most entrenched issues (performance and behaviour) accepted that there would be change, several outcomes were achieved:

• Leadership, both formal and informal, started to become visible through the team
• Collectively, the team developed a low tolerance for gossip and petty behaviour – and were willing to call it out
• There was some turnover, with a handful of individuals who were unwilling to change and uncomfortable with accountability, leaving the team
• Morale improved as people felt more valued in their workplace and more able to use their skills and training
• A patient-first focus emerged
• Employees from other departments applied when there were vacancies in the Theatre Department, and contract staff expressed interest in permanent roles
• The values became an everyday conversation topic and a focal point for accountability

IThis place is 100% better than what it was before. Things are dealt with, people are heard, and they are also held accountable. Having tools and strategies is a big part of it too, instead of trying to band aid one thing while cracks appear elsewhere.

It is a more positive place to be. There is an understanding of how to work with difficult people, how to deal with the people who are not aligning with the culture we wanted to create in the department. People saw accountability was taking place, team members were being held accountable for their behaviour, team members were feeling heard. Now I have people emailing me, wanting to come work in our department!

Because the issues were longstanding and entrenched, there will be a long maintenance phase. I still need to remember that people slip, but I have people helping me drive it so it doesn’t feel like it is all having to come from me, which is the way it should be. More people are pushing the values.

Things have improved out of sight compared to where it was, but we are still working on everyone driving the values and everyone having the conversations that need to happen.”

Theatre Department NUM

This program took a workplace culture of ingrained mediocrity and poor behaviour, and evolved it to one characterised by high standards, strong values, and accountability. This was achieved through the commitment of the department leader and committed support from senior leaders outside the department and from the external provider.