Chapter 10
Creating flourishing workplaces
Jan Dewing & Brendan McCormack
Queen Margaret University, Edinburgh, UK
Introduction
Imagine a workplace or an organisation where person-centred care is the reality for the majority of people for most of the time, by teams who have established person-centred patterns of care and ways of working embedded in a workplace culture that is person-centred; all of which is held within a person-centred corporate culture – an ideal perhaps? We can’t recall having ever experienced, in totality, this type of organisation. However, we have encountered in different organisations various aspects of person-centredness as we’ve just set out here. The ultimate aim of such a person-centred organisation, we will argue, is to create a place and related conditions where people flourish. So this chapter is primarily about the outcome of flourishing within person-centred workplaces. It will also touch on the notion of the person-centred organisation in its totality and the mysterious idea(l) of sustainability. We make parallel connections between person-centredness and human flourishing to help us set out the attributes of a person-centred workplace culture, and introduce a model developed by one of the authors (J.D.), from research and scholarship, to illustrate our discussion. This model can provide a useful heuristic for describing the movement and progress of person-centredness in the workplace as organisations move towards flourishing. Readers are asked to note that person-centredness here, unless otherwise stated, is an inclusive idea that includes employees and those receiving services and care.
Person-centredness and human flourishing
When we consider what person-centredness is for – the intention – we argue that person-centredness is ultimately concerned with human flourishing. In Chapter 2 McCormack and McCance defined person-centredness as:
an approach to practice established through the formation and fostering of healthful relationships between all care providers, service users and others significant to them in their lives. It is underpinned by values of respect for persons, individual right to self-determination, mutual respect and understanding. It is enabled by cultures of empowerment that foster continuous approaches to practice development [emphasis added].
Whilst this definition does not explicitly state an outcome from person-centredness, implicit in the definition is a focus on effective relationships that are healthful, where healthfulness is focused on respecting individual needs, wants and desires that result in a positive experience for all concerned – or, as we would argue, contributing to the condition of human flourishing. Therefore, flourishing is a desirable outcome of person-centredness. Generally speaking, human flourishing is about individuals being in a continued state of well-being and being at their best for prolonged periods of time (Seligman 2012, p. 70), and when they’re not, having the resilience to bounce back stronger. Heron and Reason (1997) view human flourishing as a focus on maximising individuals’ achievement of their potential for growth and development as they change the circumstances and relations of their lives at individual, group, community and societal levels (Titchen & McCormack 2010). Drawing on ecological and transformative perspectives, McCormack and Titchen (2014, p. 19) suggest that:
Human flourishing occurs when we bound and frame naturally co-existing energies, when we embrace the known and yet to be known, when we embody contrasts and when we achieve stillness and harmony. When we flourish we give and receive loving kindness.
This idea that to flourish is both a giving and receiving of energy is important in healthful relationships that are reciprocal and that have the ultimate goal of all persons flourishing.
However, whilst the ideal of person-centred relationships that are healthful is for everyone to flourish, there are some situations for persons, related to health and health care, where flourishing will not occur. Nevertheless, we still need to be mindful of supporting the enabling factors of flourishing because some aspects of flourishing could occur and because it is the morally right thing to do. Although flourishing will be addressed in other ways in this book (see Chapter 11), we want to add to these contributions with a perspective from the field of positive psychology.
In this field researchers do not talk about person-centredness per se; however, central tenets of the discipline are well-being, thriving and flourishing, in which we can see a direct resonance with person-centredness. Seligman (2011) articulated the importance and significance of well-being. He began his articulation of this with three elements he argues are essential for well-being: (i) experiencing positive emotion; (ii) engagement and being absorbed; and (iii) having meaning in life through belonging to and serving something one believes to be bigger than oneself. As a consequence of learning from subsequent research, he has added to these, to form what he now refers to as PERMA: positive emotion, engagement, relationships, meaning, and accomplishment (Seligman 2011, p. 16). These he suggests are the five essential conditions necessary for flourishing. What is of particular interest to us, as practice developers, is that Seligman argues, based on his research findings, that it is possible to build PERMA within individuals, teams and even whole organisations. Gaffney (2012, p. 6) has adapted Seligman’s model and proposes four essential elements necessary for flourishing. These are given in Box 10.1.
Box 10.1 Four essential elements for flourishing (after Gaffney 2012)
- 1. Challenge: Some call or demand for you to do something, to get over an obstacle, to engage with some life task, to make something happen.
- 2. Connectivity: Being attuned to what is happening inside you and outside you. Connectivity orientates you to the challenge and gets you ready to deal with it.
- 3. Autonomy: Feeling free to move and to act in pursuit of the challenge. This gives you the energy to get going and sets the direction of travel.
- 4. Using valued competencies: The experience of using your talents, especially the strengths you most value in yourself, to the full.
Gaffney argues that the best kind of challenge is one that we ‘own’. That does not mean that we have to identify or plan the challenge ourselves as sometimes we can find ourselves being challenged, not of our choice but because of a context we are in. In the context of practice development, we have identified these as ‘critical moments’ when we have a choice to grow, develop and transform or not. However, irrespective of the challenge and where it comes from, Gaffney (2012, p. 8) further argues that flourishing requires ‘connectivity’ or ‘psychological attunement’.
Although others, including Sabi (2013), challenge the view that it is possible to build PERMA, our experience of practice development and working with individuals and teams would suggest that it is possible, but that it is also fragile and context-dependent. Seligman seems to focus primarily on the internal world of persons and seems to suggest that PERMA is the responsibility of individuals. However, we all live and work in communities that are culturally, historically and politically influenced. Critical social theory informs us that these external social and cultural factors bear down on the person and contain and restrain individuals and groups from the freedom to act. It is these forces that need containing or overthrowing for human flourishing to occur. Becoming an emotionally intelligent person will contribute in part to realising PERMA and flourishing in the workplace or to living well with a health-related condition; however, external social structures and perceived power relations are also influencing forces (Schutte & Loi 2014). McCormack et al. (2013) argue that there is ample evidence to suggest that strong connections between team members, between team members and the values and goals of an organisation, and between the organisation and the personal values of employees, create effective workplaces and, indeed, environments that flourish. There is equally strong evidence to illustrate the impact of what are termed ‘psychologically unsafe’ environments, that is, environments that are disrespectful of persons (Brown & McCormack 2011).
What is a flourishing organisation?
A good place to start is to ask ourselves what is a person-centred workplace and a person-centred organisation? How would you know you were in it? What would you see? What would you hear and how would you feel? Person-centred workplaces and organisations, by definition, need to be focused on the people they support and provide services for; but not simply on the work, treatment and ‘care’ or support needs but on what matters to the person given who they are and where they are in their life and in relation to the person’s aspirations and wishes. Trying to do this on a large scale provides huge challenges – but huge opportunities too. Williams and Sanderson (2015), drawing on their experiences within UK health care, propose seven elements they believe are the foundation for person-centred organisations: visionary leadership; shared values and beliefs; outcomes for individuals; community focus; empowered and valued staff; individual and organisational learning, and partnership. We wouldn’t argue with any of these, although they are fairly general. There has to be something else, something more specific. Cameron (2010), for example, suggests five strategies that would be seen in flourishing organisations:
- Capitalising on the inherent human inclination towards positive energy.
- Managing financial and economic challenges virtuously.
- Focusing on abundance gaps.
- Creating positive energy in the face of challenges.
- Implementing positive practices even where they don’t seem to be valued.
These broad-based strategies capture the essence of PERMA as set out by Seligman (2011, pp. 16–20). They are also useful in helping us appreciate that flourishing can take place in organisations where there are challenges due to tough internal and/or external business forces – a current reality for most, whether in public or private health-care services.
We felt that something more specific and more strategic was needed to position and visualise the development needed within the nursing and health-care context, where there was a blending together, in a dynamic way, of some of the principles underpinning person-centred practice and positive psychology. The rest of this chapter will focus on a model that seeks to describe and illustrate the movement towards flourishing in the workplace.
The Compliance, Service Improvement and Innovation Model (CoSII)
The origins for the model began within a three-year practice development programme between The University of Wollongong and Uniting Care Ageing in New South Wales, Australia. The programme’s focus was on developing and evaluating person-centred cultures across one region of a national organisation with a view to transferability and upscaling (Dewing et al. 2010, p. 163; 2014). In one of the workshops we drew out ideas for the coming years’ development activities. The mapping of the development activities then led to a discussion where we tried to uncover what essential attributes were driving our journey towards person-centredness. We hypothesised that these were positive forms of energy and the momentum of movement. These two attributes were left in their raw state for a while. Then a systematic method was used to begin to develop a model that drew on the two attributes of energy and movement. Critical discussion, within the International Person-centred Practice Research Community of Practice (ICoP), offered a forum where an early iteration of the model presented here was critiqued. Since then, four assumptions and three, threefold core concepts representing movement towards a flourishing culture have been proposed; note these are still embedded within the notions of energy and movement:
Assumptions:
- Movement towards an inclination for flourishing.
- Movement away from patient-centredness towards person-centredness as central to achieving flourishing for all individuals, teams and workplaces.
- Movement away from external rewards to internal rewards for individuals and teams in being person-centred.
- Movement away from a technical focus on efficiency and effectiveness and its measurement in organisations towards an integrated system of virtuous practices and evaluation.
Threefold concepts:
- Compliance/Person-centred moments/Performing
- Improvement/Person-centred patterns/Thriving
- Innovation/Person-centred cultures/Flourishing
An unpublished review of the literature relating to these concepts and assumptions led to the ‘three circles’ mode, subsequently called the CoSII model. The model has been further tested within a programme of practice development activity in an NHS Trust in England. The current model, although very much still a work in progress, is depicted in Figure 10.1.
Figure 10.1 The Compliance Service Improvement and Innovation Model (CoSII). Source: Dewing et al. (2015). Reproduced with permission of Foundation of Nursing Studies.
We will now describe the key components of the model, beginning with the horizontal and vertical axes. The model aims to present the forces and key features within workplaces and the organisation that work to enable persons to experience more positive emotion, high levels of engagement, meaningful relationships, acquire meaning, and feel a sense of accomplishment (Seligman 2011, pp. 18, 124).
Absorptive capacity and capability
Absorptive capacity is an organisation’s ability to identify, assimilate, transform and apply external knowledge it considers valuable. There is always a limit to the rate or quantity of scientific or technological information that an organisation (or parts of it) can absorb at any one time (Cohen & Levinthal 1990). Having the capacity for absorption is considered essential for knowledge mobilisation. The term mobilisation is used here as it indicates a shifting focus from traditional management of knowledge (teaching and training) to the provision of space that enables people to act and apply their sense making, toward greater collective understanding and where people make decisions together to achieve genuine outcomes (Hasan & Crawford 2007). The latter is much more of a positive fit with ideas of person-centredness. Of even more relevance to us is that the focus is on the development of systems to support knowledge creation and innovation at the level of a group or community, rather than with individuals or with a few people at senior management level. In the CoSII model we specifically include the translation of all types of knowledge from knowledge ‘about’ to knowledge on ‘how to’. There are a number of factors that influence knowledge mobilisation. For example, Lane and Rogers (2011) claim organisations consider the value of knowledge according to their mission and the interests of their members to absorb different types of knowledge. The type and quality of relationships between different stakeholder groups in an organisation, such as those between general management and clinicians and practitioners, are strong factors in influencing how knowledge mobilisation does or does not take place and what the movement of knowledge looks like (Greenhalgh et al. 2004). Further, Rycroft-Malone et al. (2013) propose that successful implementation of evidence-based knowledge into practice is a planned facilitated process in which individuals, teams and context are major factors. The resources and strengths within an organisation and within a team represent the capabilities available. These will include: human capital (numbers of people, knowledge levels, skills and experience); physical and material resources; strategy and planning; financial and IT resources. Therefore, we have blended in capability as well as capacity. Kislov et al. (2014) set out four principles that fit well with the blended absorption axis in this model because of their focus on capability and capacity as dynamic entities. They are:
- moving from the notion of ‘building’ capacity towards ‘developing’ capacity in a health-care organisation;
- moving from passive involvement in formal education and training towards active continuous participation in knowledge mobilisation practices;
- moving from lower order project-specific capabilities towards higher order generic capabilities allowing flexibility and innovation;
- moving from single-level to multi-level capability development involving transitions between individuals, groups and organisational learning.
Vitality
Vitality has been generally considered as having sufficient physical and mental energy. We like this concept as it can be seen in a number of Western and Eastern traditions. Vitality, or the energy available to a person (chi, ki or bayu), is said to be an indicator of health and motivation (Ryan & Deci 2008). When vitality is present, persons experience a sense of enthusiasm and aliveness. Vitality is associated with feelings of vigour and positive emotions, and can be associated with calmness and being grounded. Subjective vitality, unlike other forms of energy (such as anger, anxiety, or arousal), is a form of energy that a person can harness and coordinate for intentional and purposeful action. Ryan and Deci (2008) point to a number of experimental and field studies suggesting that vitality and energy are enhanced by activities that satisfy core human needs for relatedness, competence and autonomy. We would also add that good physical health is a prerequisite. Therefore, in relation to the prerequisites for vitality as an employee or service user, being in meaningful relationships, the demonstration of competence and having subjective feelings of autonomy are essential – elements that are consistent with the prerequisites of McCormack and McCance’s Person-centred Nursing Framework (see Chapter 3). Vitality is necessary for growth and resilience, which in turn are necessary for flourishing. Depending on the focus of activities in the workplace and the way in which they are carried out, energy levels may become depleted or enhanced. A nurse may feel energised as a result of being with a person they are caring for, or from being in an education session. A service user may feel energised or tired after being provided with care. Activities carried out positively will lead to renewal of energy and over time will add to an increased sense of vitality. By activities we mean anything and everything from the apparently simplest of tasks (e.g. talking to another person, reading or writing an email) through to complex multi-factorial tasks either within the team or with persons receiving care (e.g. adapting to a new manager or team leader, a new role, implementing new guidelines, or taking part in a service improvement project).
Within both the domains of absorptive capacity/capability and vitality, the matrix of time is present. There are some developmental processes that simply require more time than others (Jones & Woodhead 2015). Maximising communication in networks and forward-looking leaders who invest in staff and have positive management practices can positively reduce the time needed for knowledge absorption (Tu et al. 2006). However, no matter how much capacity ‘building’ and energy is put in, individuals and teams will always need time to search out naturally occurring opportunities(Kouzes & Posner 2012) and to absorb new knowledge and to learn how to translate this into everyday practice. As McCormack and Titchen (2014, p. 15) have argued, ‘creating different and complementary spaces for different purposes is an important consideration in enabling human flourishing.’
First impressions of CoSII
The heart of the model shows the three circles. There is also the possibility of moving on from innovation/person-centred culture/flourishing to something else. At this point we do not know what that will look like. Something else will evolve in time. There is a sense of the model being complex; although it is simply a series of repeating arrows. This, we hope, illustrates both the complexity and the repeated patterns inherent within workplace cultures and large organisations. It can engender images of a moving snowball, a glowing firework or a whirlwind. All these may be positive or equally they can be negative, depending on your perspective and imagination.
The three cycles in the model have overlapping arrows and indicate the concepts of energy and impact within the workplace or organisation. The arrows here represent the synergistic relationship between the types and levels of energy and impact in the workplace or organisation. Positive energy will contribute significantly to positive impact, whereas negative energy leads to poor impact and possibly even to negative impact. The notion of engagement is also hidden within these arrows. Engagement is both a process of and an outcome from collaboration, inclusion and participation (Dewing & McCormack 2015).
Necessarily, there is an overlap between each cycle. The small linear arrows in the overlap spaces indicate that the space can expand or contract according to how effectively or not the four core principles (Kislov et al. 2014) are being realised. Therefore, workplaces and organisations are never, in entirety, in one cycle only. There are a number of assumptions, values, artefacts and behaviours (Schein 2010, pp. 23–33) that can generally be found within each cycle, and often these exist despite values, vision and mission statements that might insist otherwise.
The large arrows, external to the circles and moving between each of them, indicate the combined relationship and effects of the positive influencing forces (moving forwards and upwards) or negative influencing forces (moving backwards and downwards).
The effective workplace culture model by Manley et al. (2011) shows the antecedents, attributes and outcomes of the effective workplace culture viewed through a practice development lens, and the Person-centred Nursing Framework (McCormack & McCance 2010, p. 61) indicates the essential attributes of a conducive care environment. The CoSII model adds to these by suggesting that there are complex sets of energies and forces that come into play when working towards achieving an innovative and flourishing workplace and organisational culture where person-centredness is the norm. Getting out of the first cycle for example, or ‘outperforming’ the compliance/performing cycle requires a huge amount of investment in energy creation and absorptive capacity and capability. It also requires a ceiling to be put on the energy that is used up by compliance activities such as monitoring and routine measurement. Many of the methods and tools that are used in compliance-focused organisations focus on reducing error and minimising the impact of error; although necessary, these are not effective when applied to an agenda that is about innovation. The school of Positive Organisational Scholarship (POS) recommends methodologies with a positive lens; assuming an affirming bias; focusing on positive deviant performance and examination of the best people and their performances (Cameron & McNaughton 2014). Changes in rules and practice should be driven by learning what is and is not working in supporting individuals. Using a small set of value-based skills at all levels of the system will drive change throughout the system. Using these skills in conjunction with selected quality management and organisational development tools will improve quality of life and increase organisational effectiveness and efficiency.
Research in international business indicates that outperforming requires three core activities: organisational structures and functions where innovation is core to all business; workplace cultures that enable innovation to thrive; and processes (and we would say people too) that help others to convert ideas into innovation plans and actions. At the point where the compliance and service improvement cultures overlap, the innovation investment is usually regarded as developmental and ‘nice to do’ if there is time and money. We argue that in order to move forwards, and certainly to move beyond the service improvement culture, an innovative way of being needs to become fundamental to everyday business in health care. For this to be nurtured, a number of core driving forces need to be put in place or strengthened (see Box 10.2). We have adapted these from a recent report by the IBM Institute for Business Value (IBM 2015).
Box 10.2 Core driving forces for innovation
- 1. Innovation needs aligning with strategy and aims.
- 2. Structures in workplace and the whole organisations need to adapt to be open and welcoming of innovation.
- 3. Invest in people who can lead innovation from within the workplace.
- 4. Leaders to have a skill set around innovation and work with managers to ensure compliance is achieved but does not dominate.
- 5. Encourage innovative ideas, dialogue and activities in all workplaces.
- 6. Sustain innovation momentum during times of adversity.
- 7. Generate new ideas from a wider range of sources.
- 8. Invest in learning and education that focuses on everyone’s contribution to innovation.
- 9. Fund innovation.
- 10. Measure and evaluate innovation outcomes.
- 2. Structures in workplace and the whole organisations need to adapt to be open and welcoming of innovation.
Adapted from IBM (2015).
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