Russell’s Hall Hospital in Dudley is currently under a lot of pressure and challenge in their Emergency Department, and this weighs heavy on the staff - across the whole hospital.

Going back to Russells Hall is always like going home for me; I trained with the Dudley Group to be a Registered Nurse in the early 1980’s, working at The Guest, Corbett, Wordsley and Burton Road Hospitals as this hospitals was still being built and then over the last winter I completed 150 hours clinical for my Return to Practice. The staff at Russells Hall are amazing with Care Support Workers helping me find where things are kept and the routine and registered nurses who encouraged, supported and welcomed me as a member of the team. Nothing was too much trouble and I could see how much they loved their work. It was a fantastic experienced, but I felt, from the day i arrived in October last year, the enormous pressure that the staff were under as their Care Quality Commission visit loomed.

Olly Benson, my colleague at NHS Horizons and I were invited by Rachel Andrew, the Trust's Head of Learning and Organisational Development, to support her work to develop the Trust's Leadership Forum - which also fitted with the theme for the August 30 Day Challenge for transforming perceptions of nursing and midwifery. Rachel, a certified change agent from this year's School for Change Agents is motivated by some of the principles around change and power, which gave her a real 'reset' in terms of ideas that connect with her own thinking - and a way to deliver change with people. Rachel could see how other people in her organisation would benefit from hearing those messages and putting them into practice. Along with another School Change Agent they talked about how they could make it happen and build change agency across the organisation. 

Jenni Ord, Trust Chair had a very clear intention for the session, with the primary focus of considering the impact of everything through the ED lens. Sometimes it is easy to lose sight of where you want to be, and not quite deliver what you would have hoped - without meaning to. I listened to Jenni speak with passion and conviction, wanting the whole organisation to come together through supporting improvements - and support their colleagues; knowing that in times of trouble, it's really important to focus on the people, being clear about needs to be delivered and how we measure up - whilst at the same time creating the conditions for people to be the best they can be. 

Olly and I designed our session around Breaking the Rules. While rules are important: they keep us and our patients safe; they ensure fairness; and they help make sure that everyone knows what to do, keeping the health and care system operating every day, there are downsides to rules. Often they have an unintended impact on us and the people we serve. They can make us feel that we cannot innovate or improve things because we don’t have 'permission'. Rules sometimes contribute to a culture of conformity and get in the way of intelligent judgement and actually doing what is right.

Breaking the rules sessions are not about creating havoc in an organisation! Rather, asking staff to think about the rules, customs, ways of working, habits, policies, and procedures that get in the way of great care and great team working. Rules that restrict more than they enable deserve to be broken.

Breaking the rules is about showing that by working together you can lead the way to better care and better ways of working. Effective rules are not static — they evolve. But that evolution has to be driven by people who are willing to stand up for what is right, challenge the status quo and create a better future.

To help understand some of the behaviours behind this we talked about the different types of people that we work with, of  how a compliant member of staff responds versus a contributor; looking at how rules can leave people feeling disconnected from the shared purpose, controlled and coordinated, held back and usually working to their role specification. Conversely a contributor feels connected, has direction and purpose through shared goals and values, collaborates and embraces change. Team members are not necessarily one or the other, more responding to the conditions in which they find themselves. According to Gallup global research, only 13% of the workforce are engaged (Contributors) yet contributors create six times the value to an organisation compared to the compliant

Although we were in a lecture theatre for our session, which may not be ideal for interacting and having conversations, we used an ice breaker to get them talking and listening to one another. It set the mood for the activities that followed, which were:

1. Identify what gets in the way

A leader's role is to create the conditions for contributors to thrive rather than survive. So in the first exercise we asked the group to identify the rules that are currently getting in the way with a particular focus on how, as a hospital, everyone can contribute either directly or indirectly to the current pressures in ED. We asked the group to consider what stops us being contributors: what 'rules' are barriers to us delivering great care to every patient and family and to making a difference every day. Which rules we should break, challenge or adapt.

They then had to categorise their ideas to one of the following:

  • Habit and myths: Often long held views, passed down from people who have since left the organisation
  • Administrative rules: Internal organisational policies and procedures
  • Regulations beyond the control of the organisation: Rules that require national input, influence or action to change

 2. Check and challenge:

It’s always really interesting to see where people put their ideas and more often than not, the majority put them into the second category as being considered administrative rules, rules determined by the organisation, but more often than not many are habits and myths. This part of the process helps to stimulate the conversation to flush the reality out and free up the energy to make the change happen.

Looking at this from a power perspective is useful and before we asked the groups to review and consider each others’ we looked at Henry and Timms New Power model. This describes old power as a currency, something held by a few, that’s transactional and closed. New power is a current, it's owned by many, it's shared and it’s about a relationship. By using these principles, the groups looked at themes that came from the ideas and considered whether to move them into different categories, using their peer collaboration and collective agency. 

3. Develop the action plan

Working back in their groups, participants were reminded to stay focused on the need to resolve the pressures in ED, and developed their action plans of who was going to do what and by when. 

This is just the start but to see the leadership forum grasp their potential for impact was a powerful thing.  In just 90 minutes we could see the people in the room move from feeling like all they had were rules that they had to follow, to being engaged with a re-energised shared purpose, opening up about barriers whilst collectively finding solutions and starting to generate great ideas with potential for significant change. 

I'm hoping to do a shift in their ED department soon - I like to understand problems from the inside and to be part of the solution too.