14 Sep

Making Mental Health Wards Great Places to Work

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By Henry Stewart, Chief Executive of Happy, rated 11th best place to work in the UK, in the 2006 Financial Times Best Workplaces list.

 

What can we learn from the UK’s best workplaces?

Imagine that every mental health ward was staffed with highly motivated people who loved their jobs, were full of new ideas and believed their ward was a great place to work. Imagine the patients felt not only nurtured and cared for, but actively engaged throughout the day in activities that they enjoyed. This will be the case in some wards, but how do we get all mental health wards to feel like this?

One place to start is to see what we can learn from the organisations rated the best places to work in the UK, in the Sunday Times and Financial Times lists. My company, Happy (previously Happy Computers) has featured in the Financial Times Best Workplaces list, and we have met with many of the companies who top that list to find out what makes them special.

 

When do people work at their best?

Think about your own experience, and times when you have performed at your best. I have asked this question of thousands of people and there is a very clear common theme to those peak performances. Very few occur when people are closely managed and told what to do. I would bet that your peak performance, like 95% of those I’ve asked, occurred when you were trusted and given freedom to decide how to do something.

One memorable example outside work was Sue, who decided to learn to swim at the age of 28. Now if we were managing somebody to do that we would arrange lessons, set targets and monitor progress. In contrast, Sue decided to learn when she was on holiday on a boat trip in Greece. She simply got all her friends in a circle in the deep water … and jumped in. The fact is that what people are prepared to do if they are self-motivated and trusted to do it their way, is far beyond anything they can be managed to do.

 

Great Management is about Getting Out of the Way

One of my favourite management stories is told by Robert Waterman in Frontiers of Excellence. An engineer called Tom Tribone found himself, at the age of 24, managing a small chemical plant employing 130 people. After some time there, telling people what to do in traditional management style, he realised that the plant produced only 2 million pounds a month of latex goo during the working day but almost doubled to a rate of 4 million at weekends:

To Tribone, this was an amazing statistic – the weekend blip. What was it about weekends? The conclusion was inescapable. The plant did better – two times better – when he wasn’t around. Once he learned this the plant began setting production records. ‘The most effective direction I could give my people was simply to log the orders that came to the plant and convey that data,’ Tribone says. ‘These folks know how to run the plant. If they knew what the customer wanted, and didn’t have too much interference from me, they got it done.’

What could your people achieve if they were left free to do things the best way they could work out?

 

Freedom within Clear Principles

I did have a friend who was told his entire job description was ‘do cool stuff ’ (it was an internet company) but most of us need more guidance than that. And many of you reading this will be wondering what chaos could result if you give your people freedom to do whatever they want in their jobs.

Let me tell you the story of how Happy Computers adopted an approach that gives freedom but within very clear boundaries. In the very early days I was the only trainer. I was very confident in myself and felt the challenge, as Happy grew, was to ensure all the other trainers were as good as me!

When I started to employ other freelance trainers I would sit in on them and make detailed notes through the day of what they were doing right and what they were doing wrong. And then I would sit down with the trainer and feed it back to them in great detail. I was well intentioned but you will probably have guessed that this did not go down well. More like a lead balloon in fact. I was making two mistakes all too common in management. First I was trying to create a clone of myself, doing exactly what I did. And, apart from its effect on motivation, this puts a ceiling on what can be achieved. The best a clone can be is as good as you. Secondly I was trying to create almost a process, where people do the same each time. There is no room then for innovation or improvement.

At the same time I didn’t want the trainers to do whatever they felt like. People came to Happy Computers for a particular style of training, fun and involving. I didn’t want them ever to sit and listen to a lecture, as was common at other training companies.

So I sat down with the other trainers and agreed a set of principles such as ‘Don’t tell when you can ask’, still at the core of what we do. And they agreed a set of targets, based around the end of course evaluations. These were basically that the student had enjoyed the day and left confident in using the software.

The idea is that the principles and targets provide a flexible framework which allows innovation. As a manager I am happy if my person is working within the principles and achieving the targets. I don’t need to approve – or even see – everything they do. It is a concept we call job ownership.

The result, 26 years on, is that the standard of training is far beyond anything I could have achieved. I am now rarely in the top half, on the company’s quality ratings, when I do train. Two Happy trainers have been rated the UK IT Trainer of the Year, and two others have won Silver in these annual award. I couldn’t have won that. And I couldn’t have told people what to do to win that.

Those achievements have been the result of a great set of principles and, more importantly, the freedom to innovate within them. The result is the standard of training at Happy nowadays is far beyond what I could have told people how to do.

What are the principles (and regulations) that your people need to understand and work within? How can you make the framework crystal clear while giving people the freedom to work out their own way to achieve it – so it creates the landscape in which innovation prospers?

 

Removing Levels of Approval

Some years ago I was called into a charity to look at how to improve morale. Talking to staff there I found a lot of resentment around the lack of trust, exemplified by the fact that any external statement (such as a press release) needed three levels of approval. The result was that people felt untrusted and were not motivated to produce great work. One man said he often put stupid things into the press releases, just to see if anybody would spot them. After all, what went out was not his responsibility.

So what would you do to increase job ownership here? Some people respond that they would reduce it to one level of approval but this is missing the point as it still removes ownership. On the other hand the organisation explained that the approval was needed because they were working at the border of charity legislation and could be sued if they were deemed to be acting politically. The question to ask is what the people three levels up know that those on the front line don’t and how can we transfer that knowledge? To its credit the organisation took this on board and trained up front-line staff in the legal knowledge required. They were tested and, if they passed, certified to release press releases without approval.

The result was not just a higher level of morale but a more effective organisation, as it was able to respond much more quickly to the life-and death issues it was dealing with.

Do you find yourself having to give, or get approval on a regular basis? Do things often get delayed because people are waiting for approval? How could front-line staff be trained or involved to enable them to make the decisions without needing approval?

 

Try Pre Approval

Do you ever set up a group of people to tackle a problem or come up with new approaches, and submit their proposal to you? Try saying to them that whatever they come up with, it is ‘pre-approved’. Now you have to make very clear the parameters, what they must be aware of and what budget they are working within.

A counter example was a medical help-line for a health charity I worked with, where the staff wanted to measure how well they were doing. They came up with six questions to ask at the end of every call and passed them up for approval. Several weeks later came back the managers’ ‘improved’ version. There were now 30 questions, clearly a total absurdity. But everybody who had seen it felt the need to be helpful and add their own contribution. Far better if the staff had been simply pre-approved to choose their own questions, and adjust them if they weren’t working.

Where could you pre-approve a group of staff to come up with new ways of working? (But remember, you have to resist the temptation to read their proposal and suggest improvements.)

 

Feedback

Most of us get pitifully little feedback in our jobs, often only at the appraisal. Sometimes managers tell us how we are doing but research indicates they are three times more likely to criticise us for something done wrong than praise us for something done right.

Feedback in a normal job is a bit like playing a game of football where you only find out if you scored six months later, at the appraisal. And even then, you would only get the manager’s interpretation of whether you have scored. Think how well even the Beckhams and Ronaldinhos of this world would do if they never knew whether the ball went in the back of the net.

‘Without information, people cannot take responsibility. With information, they cannot avoid responsibility’- Jan Carlsson, SAS Airlines

 

How can we give staff on a mental health ward more feedback? Actually, it is incredibly easy as the customers are with you and have plenty of time on their hands. My suggestion is that every patient fills out a daily self assessment, at least part of which is shown to the staff on the ward. This would be an assessment of themselves, not of the staff. It could include things that had gone well and any of a wide range of well-tested psychological questions that measure well being. Staff would be encouraged to review them and see what they could do to get measures higher. And yes, I said daily – feedback works best in encouraging changes in behaviour if it is immediate and can be related to what people have done recently.

Think of the effect. Suddenly staff on the wards could get a feel for how their patients were doing. They could see if playing cards with the patients or having a work out had a positive effect. It wouldn’t be a direct measure of their work (as some patients would be much harder to shift than others), and would be best not used for management assessment but – with well motivated staff – could be invaluable feedback.

I believe the effects would be beneficial for the patients as well as the staff. One colleague of mine described the time he had been in deep depression but decided each day to write down what he had achieved. At first it was things like ‘I left my room’ or ‘I tied my shoelaces’. Over time the
achievements grew and recording them gave him a feeling of self-worth and belief he could recover.

How can you initiate feedback on your wards?

 

A Blame Free Culture

At Happy we have a belief in ‘celebrating mistakes’. Literally if somebody comes to me and says ‘I messed up big time’ I say ‘great, tell me all about it’. And it is great, because it probably means they have been trying something new. And the fact they feel able to come straight to me and tell me (because they know they won’t get blamed) means that, if they have just upset our best customer, I can deal with it – rather than finding out from the customer a fortnight later when it may be too late. When told ‘I’ve made a terrible mistake’ I often respond by asking ‘Oh, how many people died?’.

But it is, of course, important to check that nobody has died before asking that question or treating it that lightly. On mental health wards, and throughout the NHS in general, there may be health consequences from mistakes. And celebration may not be appropriate. But the key question is whether mistakes are more likely in an environment where blame is common and people can’t talk about things that go wrong, or in a blame free culture where mistakes can be openly discussed and learnt from.

Next time you get something wrong, try admitting it. It can be liberating to say ‘I got it wrong’ and not having to think up excuses or pass the buck.

 

Key Principle: People Work Best When They Feel Good About Themselves

Think for a moment about whether you agree with this statement. If you do, then what should the main role of management be? At Happy we believe the primary aim of management is to create a framework where people can feel good about themselves. Based on a principle of ‘believe the best’, our first response if somebody is underperforming is to look at whether they are being supported properly or if there is anything we can do to help them.

This is especially important on mental health wards where the entire goal is to help the patients to feel good about themselves. This is always going to be easier in an organisation that models making its staff feel motivated and positive.

Remember that statistic about managers spending three times as much time telling people what they’ve done wrong as what they’ve done right. Think of the effect on staff morale if you reverse it and spend three times as much time telling people what they did well.

What can you do to make your people feel good about themselves?

 

The Best Places to Work

I have met with people from many of the great places to work in the UK. And those workplaces are never places which are described as tightly regulated (even when they do have to work within clear legal parameters) or needing approval to do everything. Some are large companies with fantastic benefits. But others, like Happy, are not. When we were first listed in the Financial Times Best Workplaces at No. 12 we did not even have a company pension scheme.

What these companies do have in common is that people who work there feel valued. They are given freedom and trusted to do the job well using their best thinking. Because those companies know that the resulting innovation and great service will be better for their customers, and therefore for the companies themselves, in the long run.

 

How do we get there?

First, these changes can happen on any ward. They do not need a change in policy at the top of the NHS, or even at the top of your Trust. If you are a manager, you can start encouraging people to act without approval. You can think about what people need to know to take wider responsibility, and set in motion the training to ensure they do.

If you work on a mental health ward, you can also try initiating ideas. You can make them more active places for your patients and you can implement ideas like the patient self-assessment.

What first step could you take to give your people more freedom and remove levels of approval?

 

What would your ward be like if every member of staff was completely trusted?

This is a question I ask of many organisations and answers range from ‘heaven’ & ‘I wouldn’t have to worry any more’ to ‘complete anarchy’. There is a second question, which is how you move towards it, how you train and inform people to the point where they can be trusted.

Is this goal worthwhile? Think about how you want our mental health wards to be. Should they be places full of unmotivated staff, where the focus is risk avoidance. Or should they be great places to work, where staff are full of ideas and trying out new ways to engage their patients? Which would you rather go to if you were to become a psychiatric patient?

 


This article was first published in ‘Star Wards, First Addition’ 2006

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