that it is structurally very hierarchical which is linked to pay structures. The ‘command and control’ mechanisms, by which nursing generally works, does not allow or enable the highly skilled and motivated workforce to make suggestions as to how to improve care if it is given by someone deemed to be at the lower end of the experience or command structure. Thus, the frequently spoken phrase of ‘nurses eating their young’. The reduced opportunities for making contributions to innovative ways of working are frequently why staff at an early stage in their careers, opt to move away from direct patient care.

There is a huge inherent challenge to enabling nurses and midwives to have some influence and authority over the way that they work and the strategies and processes of their organisations. Results from the 2019 staff survey in Wales and England suggest that only somewhere between 50% and 60% of registered nurses and midwives feel they have any influence or even involvement in changes to their working environment. Those staff who do report being able to influence their team/ department had higher levels of work engagement, more satisfaction with their organisation and also their immediate work environment. It is part of the challenge that local leaders should seek to ensure that there are effective means to enable nursing and midwifery staff at all levels to shape decisions, policy, practice, work processes and culture in their organisations. Leaders should ensure that there are means to evaluate the response to concerns raised by staff and ensure a focus on listening, learning and compassion, and not on blame. All organisations must work to ensure that the level of voice and influence experienced by staff from minority ethnic groups is equivalent to that of other staff in their organisations.3

Justice and fairness in the workplace relates to the removal from all work environments any and all discrimination

and injustice. In addition, workplaces must sustain cultures of psychological safety and learning rather than cultures of fear and blame. Minority ethnic groups have particular burdens to bear in relation to their experiences working in healthcare as particularly highlighted by the COVID-19 outcomes, but also evidenced in all staff surveys to date. Bullying and harassment can affect us all, but pertain in greater frequency to BAME staff in healthcare. In order to redress the balance, Trusts must urgently address the structural inequalities and barriers to career progression experienced by minority ethnic staff, including through changes to appointment and promotion processes, disciplinary procedures and complaints handling, as well as through coaching, mentoring and development opportunities. It is essential that organisations take a strategic approach to creating cultures of inclusion, built around a vision of high-quality, compassionate care and characterised by compassionate, collective leadership.4 Working conditions and schedules come in for some fundamental criticisms such as poor or inadequate facilities for taking breaks, access to toilets when needed and availability of food, drink and even water. Many staff work twelve hour shifts and the absence of appropriate facilities can cause energy sapping conditions. Additional concerns raised were the lack of lockers for valuables. Space for taking breaks also appears to be a major issue. Wobble rooms and multi-disciplinary rest space were created for many teams during the pandemic and together with access to food, time to decompress and “team time” to relax, have been much valued by staff recently. It demonstrates that when effort is made to make change to benefit staff terms and conditions, hospitals can make those changes and in double quick time. Staff have also been allowed to work more flexibly and e-rostering has significantly increased during recent times. The improvement to organisational culture for the workforce has had benefits but some positive changes made during the peak of the pandemic have been withdrawn by some Trusts, while others have sustained the changes.

There is considerable evidence in the

report of the detrimental effect of twelve-hour shifts on the health and wellbeing of nurses and midwives and, with the current level of vacancies in healthcare, chronic workload stress is on the increase. Pay is also a huge issue for many staff. The report recommends that minimum standards for facilities and working conditions are implemented.


Belonging is defined as the need to be connected to, cared for by, and caring of,


colleagues; to feel valued, respected and supported. The need for belonging reflects our desire to feel and be connected to others – to feel included, valued, respected and supported in teams and organisations, and to care and be cared for in those contexts. There is abundant evidence to show that support from colleagues enables people to thrive in their work, helps them to cope with difficult work experiences, and buffers them from the wider organisational factors that cause irritation and stress.5


discrimination, bullying, incivility and chronic conflict have the opposite effect. The support of nursing and midwifery colleagues for each other has been overwhelmingly evident during the pandemic, as well as within the whole team, improving inter- professional relationships. Belonging or being part of a well structured and organised team of colleagues gives work a sense of purpose and collegiality, which is hard to sustain and is often taken for granted. Working in teams is vital for health and care quality but there is also good evidence that those working in supportive teams, with good team leadership, have significantly lower levels of stress than dysfunctional teams in health and care. The more members of staff working in such teams, the lower the levels of stress, errors, injuries, harassment, bullying and violence against staff, staff absenteeism and patient mortality, and the higher the levels of patient satisfaction.6 It is clear that, across all health and care organisations, that training for effective teamworking and team leadership is required at all levels. The recommendation in the report is that all nurses and midwives would benefit from working in inclusive, stable, effectively functioning and, ideally, multidisciplinary teams freed from unnecessary hierarchical or inter-professional constraints. Dixon Woods and colleagues suggest that organisational culture is shaped by the nature of its leadership. It is the behaviour of leaders – top to bottom and end to end, individually and collectively – that powerfully determines whether care quality


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