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Employees get their attitudes from the top.

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There has been much discussion lately of the scandal at Stafford Hospital in the West Midlands of England, where patients were mistreated and death rates were high.

Comments have focused on cost-cutting and managerial box-ticking, but few seem able to answer the most troubling question: What made some nurses at the hospital, people who surely entered the profession to do good, turn so nasty?

The extensive report by barrister Robert Francis failed to substantiate some of the more lurid stories. Although the news media have repeatedly said patients were reduced to drinking from vases, Mr. Francis, who heard from 966 patients and families, found no direct evidence of this. What he did find was worse.

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Take this characteristic incident: A woman whose 96-year-old mother-in-law had been admitted to the hospital arrived to find her in a room with the door wide open, completely naked. Her mother-in-law was covered in feces. "It was in her hair, her eyes, her nails, her hands." The soiling had dried; she had been that way for hours. "So many people must have walked past and seen her. Why didn't somebody go in to her?" the woman said.

Often, there was a lack of human warmth and courtesy. A 72-year-old patient was thrilled to discover she could again wiggle her toes. She told the cleaner, who was delighted. She told the nurse who came to deliver her medication. The nurse left without a word.

Relatives told Mr. Francis of buzzers ignored, of how they had to wash patients themselves, of complaining to nurses who said: "Don't moan … I have had no break today." In some cases, Mr. Francis said, the nurses' behaviour could properly be called "abuse."

Visitors not only had to look after their own relatives. They had to intervene on behalf of strangers. When one visitor saw an elderly man crying for his wife, she went in search of a nurse who dismissed her, saying the patient had "lost it."

The visitor exploded: "That man is somebody's husband, he is somebody's dad."

There have been cases in many other industries of staff losing sight of morality: selling mortgages to people who couldn't afford them, manipulating Libor interest rates, or hacking a murdered teenager's phone. People expect better of nurses. How did it go wrong?

Mr. Francis, who stressed that some nurses provided excellent care, rightly said there was no excuse for what individuals did. But to explain is not to excuse and some of the answers are apparent in his report.

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When staff show disdain for customers – or patients – you can be sure their managers do, too. This is as true of an airline or a call centre as it is of a hospital.

Of course, the Stafford Hospital managers said they cared about the patients, but their real priority was reducing costs, which they did by cutting the nursing staff. Nurses found themselves unable to answer every patient's call. If they were dealing with one, they had to ignore others' buzzers. Overstretched, many went off sick, which made work harder for those who remained.

Mr. Francis was unconvinced that all the reductions in nursing numbers were necessary. Costs could have been cut by more effective management. But that would have meant listening to front-line staff. When managers, after a visit to a U.S. hospital, decided to merge wards, nurses protested that it was a bad idea to put colorectal patients together with vascular ones. Colorectal surgery was dirty; vascular patients, who might have had amputations, needed to be kept clean. Their plea was disregarded.

One nurse who submitted incident reports said she received "no acknowledgment, nothing. … Mine were mainly to do with staffing levels; just not being able to give basic care, not being able to get round to feed patients."

Where were the doctors? Most kept their heads down, but some understood the nurses. "I have never met a nurse who comes to work to do a bad job," one doctor said. "If you are in that environment for long enough, what happens is you … either become immune to the sound of pain or you walk away."

It may not have been callousness that led nurses to avoid patients and relatives. One said how ashamed she was of her inadequate service.

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Managers of failing organizations often talk of changing the culture. How do they measure success? More important than any target or financial outcome is when staff can say: "I am proud to work here."

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