Cardiovascular

Does your workplace culture need CPR?

You’d never start cardiopulmonary resuscitation (CPR) before assessing the patient’s airway—right? Similarly, if you suspect your workplace culture needs to be resuscitated, you must evaluate the culture before implementing interventions.

All too often, we treat the symptoms of an “ill” workplace culture before we assess the cause of the problem. But as with CPR, taking action before collecting assessment data is a bad idea. It could lead you to implement policies and procedures that don’t adequately address the issues at hand, leaving the “illness” untreated and possibly even making the situation worse. So before even thinking about starting a workplace cultural intervention, be sure to “look, listen, and feel”—in other words, assess.

Decoding the culture
Workplace culture refers to the totality of norms, attitudes, values, and behaviors—both written and unwritten—by which employees function. To assess the culture of your workplace, start by asking the following questions:

• How do things get done here?
• What do employees value as important?
• How do they interact with each other and with patients?

The answers will give you insight into the strengths and weaknesses of your workplace and tell you whether it needs CPR.

Behavior—the key to cultural change
The common thread connecting norms, attitudes, and values is behavior. Observing how people behave is the first step toward changing behavior and, in turn, changing the culture. But be forewarned: Altering norms, attitudes, and values takes honesty, time, patience, teamwork, energy, continuous monitoring, and relentless consistency.


Assessment approaches and tools
Various approaches and tools can be used to assess workplace culture. Choose a method that focuses on observable behaviors, because this allows true norms, attitudes, and values to surface. Objective behavioral assessments also can uncover unknown strengths of both staff and leadership. Such assessment data become the key drivers behind the cultural change initiative.

Assessing observable behavior may sound like a simple proposition. But all too often, inadequate and ineffective data collection methods contribute to failed workplace culture change initiatives. Unfortunately, the drive to “treat” and the pressure to make quick changes commonly overshadow the need for thorough assessment. However, using an established assessment tool to observe workplace behavior helps you avoid this trap by promoting thorough data collection.

Dimensional® Model of Behavior™
Developed in the 1960s by Robert E. Lefton, PhD, and Victor Buzzotta, PhD, the Dimensional Model of Behavior is a tool for identifying observable behavior patterns in the workplace. It has two dimensions; one focuses on accomplishing tasks and the other focuses on relationships.
The vertical dimension, task orientation, describes how workers accomplish tasks, ranging from a dominant style to a submissive style. Dominance refers to proactive, take-charge, make-things-happen behaviors. Submission describes a more passive, reactive approach in which the behavioral norm is to let things happen.

The horizontal dimension, relationship consideration, describes how workers demonstrate regard for others. The responsive end identifies behaviors that express warmth, sensitivity, trust, and responsiveness. The opposite end, unresponsiveness, identifies behaviors that convey insensitivity, mistrust, and anger.

Combining the two dimensions yields four quadrants, each of which describes the four variants of behaviors that occur in the workplace on a daily basis.

Quadrant 1 (Q1) behaviors. Behaviors that fall within the Q1 quadrant (dominant-unresponsive) reflect an active approach toward reaching goals but little regard for others. Workers get things done but generally don’t treat each other well. They may dictate to one another, “eat their young,” engage in frequent infighting, blame one another, and eschew teamwork. In the Q1 workplace, task accomplishment occurs at the expense of others; in a healthcare setting, these “others” may include patients.

Quadrant 2 (Q2) behaviors. Behaviors that fall within the Q2 quadrant (submissive-unresponsive) reflect a passive approach toward attaining goals. Workers take little accountability and have an “everyone-is-out-to-get-me” mentality. They seem insensitive and indifferent, with low regard for one another—and, in healthcare settings, for patients. You can feel the tension as soon as you set foot in the workplace.

Quadrant 3 (Q3) behaviors. Q3 behaviors are submissive and responsive. The Q3 workplace radiates warmth and feels comfortable—at first. Workers seem cheery and pleasant. The predominantly passive approach to accomplishing tasks creates an environment where people are happy but don’t accomplish much. The need to maintain harmony overrides the need to get things done, so workers tend to give only positive feedback. Patients may view the staff as nice but not meeting their needs.

Quadrant 4 (Q4) behaviors. Q4 behaviors are both dominant and responsive. Task accomplishment is balanced by regard for others. Workers treat each other as valued team members and challenge one another in a positive sense. Each worker takes responsibility for his or her actions rather than blaming others. Vigorous debate among staff is valued. In a Q4 healthcare setting, employee satisfaction scores are high and patients give high marks to the care they receive.

Using the Dimensional Model
When using the Dimensional Model to assess your culture, first identify task accomplishment behavior. Focusing on observable cultural norms, ask yourself how work gets done in your workplace. For example, is it constantly running out of I.V. pumps and commodes because no one calls for more supplies when they’re low (as may happen in a Q2 culture)? Or does a staff member request more supplies as soon as someone notices that only a few are left (as in a Q4 culture)?

Once you’ve identified task accomplishment behaviors, evaluate relationships among employees. For example, are new staff members “eaten alive” by peers as a rite of passage (as in a Q1 culture)? Or do employees coach and mentor new team members to give them a chance to become integrated into their new roles (as in a Q4 culture)?

Important: Focus on the behaviors you observe most often. Although a culture can contain a mixture of behaviors from all four quadrants, typically a single behavioral style predominates.

AACN’s six essential elements
The American Association of Critical-Care Nurses (AACN) has proposed six essential elements for establishing and maintaining a healthy workplace. These standards reflect evidence-based and relationship-centered principles of professional performance:

• Skilled communication. Nurses must be proficient in communication skills.
• True collaboration. Nurses must pursue and promote collaboration relentlessly.
• Effective decision making. Nurses must be committed and valued partners in making policy, directing and evaluating clinical care, and leading organizational operations.
• Appropriate staffing. Nurses must advocate for staffing that ensures an effective match between patient needs and nurse competencies.
• Meaningful recognition. Nurses must be recognized by others and must recognize others for the value each brings to the organization.
• Authentic leadership. Nurse-leaders must embrace the principle of a healthy workplace, must live it authentically, and must engage others in achieving it.

To assess your workplace culture, you may wish to use these six essential elements in conjunction with the Dimensional Model.

Other assessment tools
Other tools you can use to assess workplace culture are your organization’s guiding vision and mission statement. The vision identifies an extraordinary goal, whereas the mission statement identifies how the organization intends to accomplish this goal. A strong mission statement clearly identifies the organization’s objectives, its nature and direction, traits that distinguish it from competitors, desired financial outcomes, types of employees it wants to attract, and its culture and values.

Nurse leaders are responsible for articulating to staff members how their behaviors support the organization’s vision and mission. To articulate these, you need to have a thorough and ongoing understanding of the culture of your floor or unit. Successful leaders take advantage of every communication opportunity with staff, helping them “connect the dots” between their actions and the organization’s mission. Doing this reinforces behaviors that have a positive effect on patient care and enables staff to understand how their actions support the organization’s mission.

Circulating productive behaviors
Assessment is a critical first step in changing the workplace culture. Effective assessment ensures that when you initiate your “rescue breaths,” you meet as little resistance as possible. In turn, as you pump “air” (new workplace processes) through the environment, you circulate productive behaviors in which workers take care of both patients and each other.

Selected references
American Association of Critical-Care Nurses. AACN standards for establishing and sustaining healthy work environments: a journey to excellence. Am J Crit Care. 2005;14(3):187-197.

Lefton RE, Buzzotta VR. Leadership Through People Skills: Using the Dimensional Model of Behavior to Help Managers. New York: McGraw-Hill; 2004.

Schein EH. Process Consultation, Volume II: Lessons for Managers and Consultants. Reading, Mass: Addison Wesley; 1987.

Cindy Lefton, PhD, RN, is Director of Performance Consulting at Psychological Associates in St. Louis, Mo. She also works as a staff nurse in the Emergency Department at Missouri Baptist Medical Center in St. Louis.

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