Senior stakeholder views on policies to foster a culture of openness in the English National Health Service: a qualitative interview study.

Abstract

Objectives: To examine the experiences of clinical and managerial leaders in the English healthcare system charged with implementing policy goals of openness, particularly in relation to improving employee voice. Design: Semi-structured qualitative interviews. Setting: NHS, regulatory and third-sector organizations in England. Participants: 51 interviewees, including senior leaders in healthcare organizations (38) and policymakers and representatives of other relevant regulatory, legal and third-sector organizations (13). Main outcome measures: Not applicable. Results: Participants recognized the limitations of treating the new policies as an exercise in procedural implementation alone and highlighted the need for additional ‘cultural engineering’ to engender change. However, formidable impediments included legacies of historical examples of detriment arising from speaking-up, the anxiety arising from increased monitoring and the introduction of a legislative imperative, and challenges in identifying areas characterized by a lack of openness, and engaging with them to improve employee voice. Beyond healthcare organizations themselves, recent legal cases and examples of ‘blacklisting’ of whistle-blowers served to reinforce the view that giving voice to concerns was a risky endeavour. Conclusions: Implementation of procedural interventions to support openness is challenging but feasible; engineering cultural change is much more daunting, given deep-rooted and pervasive assumptions about what should be said and the consequences of misspeaking, together with ongoing ambivalences in the organizational environment about the propriety of giving voice to concerns.