Deploying trust building, thinking, and learning tools to create an inclusive culture of innovation and collaboration

The workshop brought together a committed group of healthcare professionals from across the country and represents a first milestone on the journey to transforming the workplace culture in the healthcare sector in New Zealand.

After a short round of introductions participants outlined the following problem statements:

1. Workplace bullying
   • Team dynamics
   • It seems to be everywhere in New Zealand
   • The level is best described as toxic
2. How to incentivise change in behaviour and thinking
   • Without using carrot and stick
   • How to gather intelligence from people
3. Constant change
   • Changes in contractual obligations
   • New and updated technologies
   • The effects of change on skilled and unskilled staff
4. The tension between defined roles and the need to collaborate and innovate
   • How to make good use of all skill sets that people have to offer
   • How can we change the culture?

The group agreed to combine statement 1 and 2, and then used the first hour of the workshop to illustrate the problem statements with concrete examples, and to explore contributing factors and root causes. It became obvious that institutionalised hierarchies play a significant role in workplace bullying in the healthcare sector.

Neurodivergent people very often become the targets of bullying. This topic is no laughing matter. Multiple studies confirm that the suicide rates for autistic people are several times higher than in the general population. There is a strong consensus within the autistic community that bullying is one of the most important issues that needs to be addressed.

Jorn Bettin presented a few slides to introduce participants to core design principles for creating inclusive and non-hierarchical organisations, based on first-hand experiences gathered locally at S23M and based on research conducted by Frederic Laloux, including the example of Buurzorg, a non-hierarchical aged care service provider with 15,000 staff in the Netherlands.

Often autistic people are needed as a catalyst for cultural change. Frederic Laloux has the same message on the toxicity of power dynamics, but stays clear of the hot potato of neurodiversity. Here is a good example of an autistic teenager.

The remainder of the workshop was used to identify concrete problems, opportunities for improvement, as well as sources of creative potential for driving transformative change. The discussions are summarised below:

In the diagram above and in the following diagrams, opportunities for improvement and transformation are coloured in green, downstream problems resulting from a dysfunctional culture are coloured in red, and pockets of creative potential are coloured in blue.

Opportunities for improvement:

1. Investigating and understanding the broader system and root causes to incrementally dismantle institutionalised hierarchies
2. Creating and maintaining a psychologically safe environment to incrementally build up levels of mutual trust
3. Agreeing on a working definition of bullying that focuses on power dynamics and abuse of power (see below)
4. Create a cohort of empowered people to experiment with new organisational operating principles, new collaboration patterns, and new supporting processes and tools
5. Nurturing trusted relationships by sharing individual competency networks

A key insight of the workshop was the discovery that there are multiple significantly different definitions of bullying that are being applied in the healthcare sector.

Bullying (Ministry of Business, Innovation, and Employment) : Workplace bullying is repeated and unreasonable behaviour directed towards a worker or a group of workers that can be physical, verbal or relational/social (excluding someone or spreading rumours).

Repeated behaviour is persistent and can involve a range of actions over time. Unreasonable behaviour are actions that a reasonable person in the same circumstances would see as unreasonable.

It includes victimising, humiliating, intimidating or threatening a person. A single incident of unreasonable behaviour isn’t considered workplace bullying, but it could escalate and shouldn’t be ignored. Bullying is a psychosocial health risk which may increase the potential for workplace safety risks.

It isn’t limited to managers targeting staff, or vice versa. It can happen between co-workers or involve customers, clients or visitors.

If there is bullying, or may be bullying in your workplace the person conducting a business or undertaking (in workplaces, this is usually your employer) has an obligation to manage it.

This definition relies on the term “unreasonable”, the interpretation of which is defined by the cultural context at hand. In a toxic environment behaviour that would be deemed unreasonable in a different culture may be deemed “reasonable”, making it extremely difficult for victims of bullying to be taken seriously. In short, this definition is problematic and may explain why high levels of bullying persist in New Zealand workplaces.

Bullying (New Zealand Nurses Organisation) : Bullying is a persistent misuse of power, whether formal or informal.

It is ongoing offensive, abusive, intimidating, malicious or insulting behaviour.

It may make the recipient or target feel upset, threatened, humiliated or vulnerable and undermine self-confidence. It may have a detrimental effect upon a person’s dignity, safety and well-being and may cause them to suffer stress.

Bullying can be overt or covert. Bullying can be perpetrated by anyone in any position in an organisation.

This definition is much more aligned with the experience of bullying that workshop participants have observed in their organisations, and it represents a working definition that is worthwhile adopting as a de-facto standard across the sector. The NZNO definition highlights power differentials and the abuse of power as fundamental ingredients of bullying, and it implicitly points towards potential solutions.

Healthcare delivery organisations are complex organisations, which means that the details of organisational design (collaboration patterns, people, available clinical knowledge and systems / tools) are always a work in progress. Complexity is no excuse for uncritical or naive adoption of new tools. Instead the inherent transdisciplinary complexity in healthcare delivery should spur organisations to continuously look out for and reduce spurious complexity – which is only possible in a culture where it is safe for staff to point out over-complicated practices or instances of naive wishful thinking.

Opportunities for improvement:

1. Applying a critical approach to the adoption of new tools, to ensure alignment with the purpose of the organisation
2. Not shying away from identifying sunk costs invested in systems and tools
3. Crafting roles around the skills and expertise that staff bring to work, rather than around the “needs” of specific tools, some of which may not be a good fit for the context at hand
4. Reviewing and clarifying the purpose of the organisation in the light of new technological capabilities that are at the disposal of staff, patients, and other organisations in the healthcare ecosystem
5. Letting go of the flawed assumption that hierarchies are the only viable or the optimal structural foundation for operating large teams and organisations
6. Acknowledging that organisational learning is an ongoing and never-ending process, and that therefore the organisational operating model is always a work-in-progress

Opportunities for improvement:

1. Taking the courage to review contractual obligations where these may no longer be adequate and may stand in the way of improved staff morale and improved service delivery
2. Recognising the value of the broad and deep tacit knowledge that comes from many years of experience in various roles, to minimise the risk of ageism influencing hiring decisions
3. Recognising the evolution of team norms as a an adaptive dynamic process within a bigger environment – teams only collaborate if performance incentives are team focused (or organisation focused) rather than focused on individual behaviour
4. Investing in up-skilling staff to allow the organisation to benefit from the combination of collective tacit knowledge and new technologies
5. Tapping into external skills primarily for knowledge transfer and for support during times of peak demand, and not as an approach for minimising the need to up-skill staff
6. Evaluating new technologies in terms of their ability to reduce (rather than increase) cognitive overload, and their ability to automate the coordination of work at human scale

Towards the end of the workshop participants summarised their key learnings from the workshop:

1. Don’t be restricted by hierarchy
2. We looked at workplace trends and I hope to learn more about prosocial organisational design
3. I have learned about tools to create non-hierarchical spaces
4. The workshop has confirmed I am on the right path to creating an inclusive collaborative environment
5. There is no end in sight for constant change
6. Don’t speculate; remember to always ask whether we have shared understanding
7. There are lots of us (who are working towards inclusive culture of innovation and collaboration)
8. Always try to add everyone’s voice to the conversation
9. Separate the people from the problem
10. We have identified several levers for transformation, and it is now up to us to grow a sector wide anti-bullying initiative that complements and supports the neurodiversity movement in New Zealand

Next steps

In the coming months participants will continue to collaborate and share experiences via web based tools and online meetings, and coordinate concrete steps towards creating psychologically safe places and an inclusive culture within their respective organisations.

If you work in the healthcare sector and would like to get involved, please email Jorn Bettin.

Additionally the quarterly CIIC unconference at AUT in Auckland can be used for further discussion in Open Space across organisational boundaries, and similarly individual organisations can make us of regular Open Space workshops to progress cultural changes, to overcome cultural inertia, and to tackle the identified opportunities for improvement.