• GMC research identifies five problematic subcultures among doctors
  • Development of leadership skills found to be a matter of trial and error
  • Link found between quality of care and expression of emotions at work
  • Quarter of senior leaders interviewed reported negative behaviours from the top of their organisation or NHSE/I

Medical leaders need to prevent and tackle “problematic subcultures”, which can include groups of “divas” who are viewed as “untouchable”, new General Medical Council research has concluded.

The research, published today, found medical leadership identified five “notable clinical subcultures” that could be harmful if allowed to develop and would take time and resources to “turn around”.

The five medical subcultures identified were: “diva”, “factional”, “patronage”, “embattled” and “insular” subcultures.

There was a “widespread view” among respondents that a diva subculture – one where powerful and successful professionals were not held to account for inappropriate behaviour – was “extremely difficult to change” if the “chief actor remains in situ”.

The GMC commissioned the research to understand how doctors in senior leadership roles sustain and build positive team cultures, in which patients experience safe care. It said there is a growing body of research that suggests there is a relationship between working cultures that are collaborative and supportive and better patient outcomes.

Twenty-seven medical leaders were interviewed in depth in 2018 with questions centred around four themes and included medical directors, assistant medical directors and consultants with additional leadership responsibilities.

The research found the most demanding, but also unsupported, step into leadership was the first one beyond the level of a consultant and that developing leadership skills was often “a matter of trial and error”.

The research also found:

  • A quarter of interviewees reported “negative behaviour” directed at them from the top of their organisation or from NHS England and NHS Improvement. The worst of these behaviours corresponded with descriptions of workplace bullying;
  • A direct connection between the expression of emotions at work and the quality of care patients were likely to experience;
  • The importance of how clinicians informally care for each other during the “day-to-day hurly burly” of clinical work; and
  • Working relationships between doctors and managers were a “good cultural indicator” and in a collaborative culture they had overcome their lexicon differences when talking about the same thing.

The research added that the idea of positive culture seems “superficially simple” but further discussion of healthcare workforce cultures will need to recognise “diverse conceptions” of culture if they are to provide credibility.

Suzanne Shale, medical ethics consultant and report author, said senior leaders are “vital” in developing cultures and many fulfil the role to a high standard despite facing pressures.

“Until now there has been limited research into how senior medical leaders view the culture they work in and meet the day to day challenge of building positive working environments,” Dr Shale said. “This study set out to capture their perspectives, and to convey their lived experience of attempting to nurture positive cultures in a wide range of healthcare structures and organisations.”

The five clinical subcultures

Diva subcultures – powerful and successful professionals are not held to account for inappropriate behaviour. Left unchecked, divas become viewed as untouchable, and colleagues accommodate them and work around them.

Factional subcultures – arise when disagreement becomes endemic, and the team starts to organise itself around continuing conflict. Those in dispute look for support and loyalty from colleagues, and staff may seek to avoid working with those on the ‘other side’.

Patronage subcultures – arise around influential leaders who have social capital in the form of specialist knowledge, professional connections, high status, respect and access to resources.

Embattled subcultures – where resource has been inadequate, and unequal to demand, practitioners eventually become overwhelmed. They feel besieged by the unmet need they see in patients, and may show signs of chronic stress such as short temper, anxiety and burnout.

Insular subcultures – some units become isolated from the cultural mainstream of a larger organisation, resulting in professional practice or standards of care that deviate from what is expected. The isolation can be geographical or psychological.