Psychological safety, shared vision, staff ownership, and success celebration

Takeaways:

• Signs of a toxic culture include: gossip and negativity, high absenteeism and turnover, bullying and incivility, leadership distrust, lack of transparency, unreported errors, lack of teamwork.
• Staff ownership means that staff members adopt new behaviors because it’s what they expect of themselves.
• Repairing a toxic culture requires driving change through actions and behaviors.

CAROLYN is the new manager of a large neonatal intensive care unit (NICU). She was recruited to the position by the chief nursing officer (CNO), a colleague in a previous setting. The CNO sought out Carolyn’s leadership expertise because she had concerns about high new graduate turnover, reports of staff bullying, and low nurse-engagement scores. Soon after accepting the position, Carolyn met with each staff member on the unit. She learned that the previous manager used a command and control leadership style and that trust among team members was low. Carolyn realized that over time the unit culture had become toxic, and she knew that rebuilding the culture wouldn’t be easy.

Carolyn was wise to sit down with each of her direct reports to discuss their perceptions of the work environment. You can’t improve a culture without an honest assessment of where you are. Even when leaders sense problems within a unit’s culture, they may find that quantifying how serious the issues are is challenging without some due diligence. In their book, Building a Culture of Ownership in Healthcare, Joe Tye and Bob Dent describe culture as the invisible architecture of a unit or organization. It’s a compilation of values, behaviors, actions, and group norms that ultimately becomes the unit’s operating system.

Toxicity in a culture occurs over time and leads to staff behaviors that can become hardwired. New managers who inherit a toxic culture will quickly learn that rebuilding a healthier work environment will not happen overnight. Carolyn will need time to build trust with staff, create psychological safety on the unit, and hardwire new values, behaviors, and norms.

Signs of a toxic culture

Tye and Dent describe how emotional negativity and behaviors such as incivility, disrespect, and bullying, when left unchecked, can lead to a toxic culture. Some telltale signs that Carolyn may have uncovered in her discussions with staff include:

• gossip and negativity
• high absenteeism and turnover
• bullying and incivility
• no warm welcome for new staff
• leadership distrust
• lack of transparency
• failure to manage unmotivated staff
• no accountability for professional practice

Carolyn can use additional data points to assess the culture. If her hospital participates in the National Database of Nursing Quality Indicators^®, she should examine nurse responses to questions on the Practice Environment Scale of the Nursing Work Index and patient outcome measures such as the number of falls and pressure injuries. She also might want to consider data from the Hospital Consumer Assessment of Healthcare Providers and Systems’ patient satisfaction scale and other publicly reported outcome measures, such as 30- day readmission rates and hospital-acquired infections. These metrics are essential to consider because toxic work environments impact employee engagement, satisfaction, nurse retention, and quality outcomes. Carolyn also should ask her human resources department for the unit turnover statistics and exit interview reports to determine who on staff has left and possible reasons why. Once Carolyn understands the key issues, she can begin to construct an action plan.

Steps to repairing a toxic culture

To successfully repair a toxic culture, Carolyn should begin to drive culture change through her actions and behaviors. Leaders set the tone of the culture and the expected workplace behaviors. Carolyn should focus on solutions instead of problems, on relationships instead of politics, and on teamwork instead of infighting.

Leadership experts Kouzes and Posner have identified “modeling the way” as one of the five exemplary practices of the best leaders. This fundamental practice helps leaders earn, sustain, and build credibility. Leaders should serve as beacons for others to follow. Trust is the currency of leadership, and Carolyn will find rebuilding the culture without it challenging. She needs to walk the talk of new behaviors by showing empathy and fostering social connections so staff members can learn more about each other. The following steps can help Carolyn repair her unit’s culture.

STEP 1—Create psychological safety

A crucial part of rebuilding trust will be creating psychological safety for the staff. Mending broken trust can be challenging when blame and incivility exist in a culture. Amy Edmondson, an expert on psychological safety in the workplace, describes it as “the belief that the work environment is safe for interpersonal risk-taking.” Psychological safety consists of beliefs about how others will respond when you ask a question, seek feedback, report a mistake, or introduce a new idea. An action that might be unthinkable in one workgroup can be readily taken in another because of different beliefs about the probable interpersonal consequences.

Carolyn will need to work with staff to help them feel confident that they can share ideas and receive respect from others. She’ll need to model the way by introducing discussions about tough issues, such as the current culture’s toxicity.

STEP 2—Create a new shared vision and values

The best leaders look toward the future with hope and optimism. Carolyn will want to communicate to staff that what they do matters and will continue to matter in the future. She’ll need to inspire staff that a healthier work environment built on different core values is possible to achieve. So much of our behavior comes from perspectives and values that we may not be aware of until we run into someone who acts on values different from those currently held by the team. (See 5 core values.)

STEP 3—Build staff ownership of new behavioral expectations

A unit’s culture is ultimately shaped by the staff’s collective attitudes and behaviors. To be successful in recreating the culture, Carolyn must set expectations and have the staff take ownership, not just be accountable, for the new behavioral standards. Understanding the difference between accountability and ownership is crucial. Accountability means enacting new behaviors because it’s what Carolyn expects of her staff. True change will come only with ownership—staff adopting the new behaviors because it’s what they expect of themselves as professionals.

To accomplish this goal, the new behavioral expectations must be written down and actively promoted. Carolyn will need to coach staff on the expected behaviors and take immediate action if any staff are resistant to the changes. Some staff may try to undermine the cultural improvement efforts and threaten her success. These culture-crushers may find adjusting is too hard and will be happier working elsewhere.

Staff who demonstrate exemplary behaviors should be recognized. To hardwire the changes, Carolyn will need to build employee evaluations around the new values and behaviors. Future recruitment should be based on selecting new staff whose values are aligned with the unit’s new values.

STEP 4—Celebrate success

Carolyn will need to carefully monitor the unit’s new culture to ensure that old behaviors don’t re-emerge. She’ll want to complete ongoing assessments of unit achievements and celebrate successes and milestones with staff. Carolyn also should track the indicators she studied to determine the unit’s cultural issues for signs of progress.

Be the change

Culture change is a big undertaking. In the turbulent healthcare environment, it may not be a high priority for some leaders, but it should be. It’s been observed that culture eats strategy for breakfast. Toxic cultures undermine quality patient care, and the human costs can be very high. Leaders should always look for ways to make things better, to innovate, and to grow their staff. You’ll find it very satisfying to take a toxic culture and turn it into an exemplary unit where everyone wants to work.

Rose O. Sherman is a professor of nursing and director of the Nursing Leadership Institute at the Christine E. Lynn College of Nursing at Florida Atlantic University in Boca Raton. She is the author of The Nurse Leader Coach: Become the Boss No One Wants to Leave. Read her blog at emergingrnleader.com.

Selected references

Edmondson AC. The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth. Hoboken, NJ: John Wiley and Sons, Inc.; 2019.

HCAHPS: Patients’ perspectives of care survey. Centers for Medicare and Medicaid Services. December 21, 2017. cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalHCAHPS.html

Kouzes JM, Posner BZ. The Leadership Challenge: How to Make Extraordinary Things Happen in Organizations. 6th ed. San Francisco: Jossey-Bass; 2017.

National Database of Nursing Quality Indicators^® (NDNQI^®). Press Ganey. pressganey.com/solutions/clinical-excellence/nursing-quality

Tye J, Dent B. Building a Culture of Ownership in Healthcare. Indianapolis: Sigma Theta Tau International; 2017.