Workplace Culture

Culture is happening right now, whether you like it or not. 
Neil Baker, MD IHI Faculty

The College of Midwives of Ontario’s (CMO) Guideline on Managing Personal & Practice Health (PDF, 1536 KB) states: “the manner in which a practice is run can affect a midwife’s professional experience and well-being.” Related CMO standards require that practice owners must “manage [their] practice in a way that supports the physical and mental well-being of all individuals involved in client care.” This is for good reason; workplace culture is fundamentally tied into both client safety and the sustainability of midwives’ careers.

What is workplace culture?

Many will say that culture is how organizations ‘do things’, and that it binds together an organizations’ different parts, giving it an identity and a certain image. Others recognize how workplace culture mimics broader societal culture, replicating the systems of oppression that already exist, such as white supremacy and colonialism. Workplace culture is also, for better or worse, dynamic. There can be pivot points, where a collective recognizes a need for a change, but there can also be incremental shifts over time. The culture that develops can help an organization, or hinder midwives and employees from achieving their goals as a collective or as individuals.

For midwives, workplace culture happens in clinic spaces, hospitals, client homes, birth centres as well as on electronic communications and social media. Midwives don’t have very much control over some of these environments; for example, in a community health centre midwives must follow institutional policies and might be subject to institutional hierarchies. However, in every environment, midwives can control how they treat each other and make a conscious choice to support a healthy midwifery culture.  

Culture & Safety

Midwives in Ontario share a vision for providing safe, client centered perinatal and reproductive care. It is integral midwives work within and contribute to a culture that supports this vision. Over the last decade, midwives have identified barriers in their professional and workplace cultures to enacting the vision. This led to the AOM’s campaign to Denounce Bullying and the development of a multi-pronged campaign to action racial justice and human rights within the profession. Other terms you might hear of, in relation to workplace culture and client safety include: patient safety culture, just culture and psychological safety. They are all interconnected.

Patient safety culture is the extent to which an organization’s culture supports and promotes patient safety (AHRQ, 2024). At your workplace, which behaviours are rewarded, which are accepted or expected? Just culture is complementary, in that it seeks provider accountability while also exploring the circumstances and environments which led to specific decisions or safety incidents. It is one in which individuals are not held responsible for system failings (HIROC, 2017). It is closely linked to learning or improvement culture. Patient safety culture and just culture tie together, and set the tone for psychological safety.

Psychological safety is how comfortable workers feel expressing ideas, opinions and concerns (Murray et el. 2024). When psychological safety is high, event reporting rates and teamwork improves (Lee et al, 2023). In safe environments, those who raise safety concerns are perceived as helpful rather than as a hindrance. The presence of psychological safety has been directly linked to improved health outcomes, including fewer medication errors, infections and falls.

At the 2023 Ontario West Midwifery Conference, Niki Landau, a professional mediator who works with midwives and midwifery practices, addressed how to build a psychologically safe workplace within the unique context of midwifery. It is important to note that racism, microaggressions and other forms of discrimination will undermine psychological safety. More resources, including a template Client and Practice Group Commitment to Anti-Racism and Anti-Oppression can be found in the Racial Equity Toolkit.

A workplace culture which fosters midwives’ wellbeing, through equity, just culture and psychological safety can positively impact client care.

Culture & Sustainability

A workplace in which midwives feel a sense of safety and security also ties into midwives longevity in the profession. The leadership style of those with power in a workplace can play a key role in establishing and sustaining workplace culture. Additionally, it can’t be understated how much influence policies, protocols and procedures have on the workplace culture. Do they facilitate autonomy, belonging and contribution? And, how are these structures enacted: Are they equitable? Are they transparent?

All workplace cultures have a direct impact on human resources, whether positive or negative. High turnover might indicate a need to examine common practices and policies  internally, or with external support. For more on human resources, including legal obligations, how to give and receive feedback and recruitment, explore this section of the website.

The Midwifery Sustainability Project is also taking a deep dive into the experiences of midwives and the culture they work within to determine what midwives need to feel supported in their work.

Improving or changing workplace culture

Workplace culture doesn’t change overnight. It requires concerted, targeted efforts. More importantly, it requires consistency and transparency. Practices may choose to invest in outside facilitators or consultants to develop and/or help reset their workplace culture. The AOM OnCall team can be contacted for more information and recommendations; the professional development fund may cover the cost of some educational sessions.

More resources & Further Learning:

A Better Culture is a national project funded by the Commonwealth to improve the culture of healthcare workplaces in Australia.

Civility Saves Lives explores how incivility (belittling, talking over, swearing, aggression etc.) impacts providers ability to do their jobs.

Compassion in Action Webinar Series. The Schwartz Center for Compassionate Healthcare features various speakers on fostering healthcare worker and organizational well-being.

TeamSTEPPS Canada™  is an evidence-based, short educational program to enhance collaboration and communication for healthcare team members in relation to patient safety.

Books

Care Work: Dreaming Disability Justice, Leah Lakshmi Piepzna-Samarasinha (2018)

Emergent Strategy: Shaping Change, Changing Worlds, adrienne maree brown (2017)

How We Show Up: Reclaiming Family, Friendship, and Community, Mia Birdsong (2020)

The Art of Gathering: How We Meet and Why It Matters, Priya Parker (2020)

The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth, Amy Edmondson (2018)

Tools & toolkits

Basic Needs at Work Toolkit Sonia Nosheen, NHS. (PDF) More graphics and information on her website.

Culture Change Toolbox, BC Patient Safety & Quality Council (PDF 871 KB) “This guide outlines the steps that we can take to shift culture in health care: engaging people, setting foundations, assessing the current state, identifying and analyzing opportunities, choosing tools, and testing changes.”

Healthy Professional Worker Toolkits. Examines mental health, leaves of absence and returning to work from a comparative and intersectional gender lens. The AOM is a partner in this initiative.

Learning from Excellence. Supports and resources for healthcare professionals. Includes template entrance and exit interviews that highlight culture.

Racial Equity Toolkit, AOM. Includes a practice group assessment tool, a guide for recruitment and hiring processes and a template Client and Practice Group Commitment to Anti-Racism and Anti-Oppression.

Podcasts

Being Better, Together is a collaboration between Learning from Excellence and Civility Saves Lives. “The podcast is a series of conversations with people who inspire us, about making healthcare a better place to work. We cover a wealth of topics, from workplace cultures, through inspiration, laughter and joy, to appreciative inquiry and how do work safely.”

Caring Corner is a podcast about the use of appreciative inquiry in healthcare.

Healthcare Changemakers is a podcast from the Healthcare Insurance Reciprocal of Canada. This podcast highlights leaders in Canadian healthcare; a number of episodes address the intersections of culture, leadership & safety.

Lead with Levity is a podcast about leadership and strategies to improve workplace culture.

Leading through Trauma explores leadership in the context of trauma.

The Nocturnists: Shame in Medicine. Explores how shame manifests in medical culture, and its impacts on healthcare providers.

References

Agency for Healthcare Research and Quality. What Is Patient Safety Culture? Content last reviewed June 2024. https://www.ahrq.gov/sops/about/patient-safety-culture.html

HIROC. Just Culture. (2017) https://www.hiroc.com/resources/risk-notes/just-culture

Lee SE, Dahinten VS, Lee JH. Testing the association between the enabling and enacting factors of patient safety culture and patient safety: structural equation modelling. BMC Nurs. 2023;22(1):32.

Murray J, Sorra J, Gale B, et al. Ensuring Patient and Workforce Safety Culture in Healthcare. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.