Listening to human resources expert Laura MacLeod, LMSW, describe the dysfunctional work cultures she has observed in healthcare and other industries, one is immediately reminded of the truism: “Every system is perfectly designed to get the results it gets.”
Nurses, for example, sometimes fall into a toxic work culture full of mistrust and unexpressed resentments. But too often they lack the supportive leadership and tools to communicate openly to defuse conflict and reinforce positive interactions, explains MacLeod, founder of the From the Inside Out Project® (http://fromtheinsideoutproject.com/). She teaches conflict resolution in the workplace, problem-solving, and listening skills using a method that addresses human interactive challenges.
“In all workplaces, there are very basic issues that are not being addressed,” she says. “A lot of issues directly affect the culture, customer service, employee relations, and productivity of the business. [These issues include] the specifics of communication, relationships, bullying — the way people are dealing with conflict, or not.”
Hospital Employee Health asked MacLeod for some tips and strategies to improve the work culture among nurses and in healthcare settings in general.
HEH: We have written articles previously on the potential for an unhealthy culture among nurses, which can affect worker mental health, impair patient safety, and even set the stage for violence. What is your take on this phenomenon when you look at nursing?
MacLeod: Simply the circumstances they are in — working in a hospital, working under high-stress conditions, surrounded by pain and trauma, disease and death — all of these things are very difficult on their own to handle. Then I think there are a lot of other layers. In the last several years there have been a lot of budget cuts, which means fewer people on the floor, fewer hands, fewer people doing all the work that needs to be done. That adds a number of stressful pieces to it — “Am I going to lose my job?” — plus the stress of having to pick up the slack. You used to have 10 people doing this work, now the work is the same but you have five people. Those are all factors.
The other thing is that hospitals have gotten into a kind of customer service [emphasis]. They are doing patient surveys and they are looking at things and pushing employees to take more of a kind of hospitality slant to their patients and patient families. That’s a whole other skill set. You are a nurse and you know that [field] — now you are supposed to be like a greeter in a restaurant. That is another pressure that has been added to the workplace.
HEH: Medicine has also had an engrained hierarchy and some lingering gender issues between the traditional predominance of male physicians and female nurses.
MacLeod: Then you have the things that frankly I see everywhere where there is race, hierarchy, seniority, and those kind of things that tend to put people in cliques. I believe in a hospital situation the hierarchy and the way things work is different and more stressful. You have the doctors, physicians coming down on the nurses. The nurses are unable to do much about this because they are in a subordinate position. So they take their stress on the nurses’ aides or each other. So you have basically a circle of dysfunction.
HEH: Nursing work culture is rife with a bullying, hazing atmosphere have given rise to the infamous phrase, “Nurses eat their young.”
MacLeod: I feel like there’s this feeling that nurses are not nice people, they’re bullying, hazing or harassing and all of these things. But it’s not because they are not great nurses and professionals. All of these factors that I just described — it’s a lot. And I think there are no [tools] for them if nobody is really putting anything in place to manage these stresses. Therefore, they are just behaving in the only kind of dysfunction they really know, which is this dysfunctional culture that has been going on forever.
HEH: Do you have any tips or thoughts on how to defuse these situations before they worsen, perhaps some kind of open communication or transparency about the issue?
MacLeod: Certainly transparency, communication — those things are extremely important, particularly for management, administration, anyone in a position of setting expectations and communicating them. Expectations need to be made absolutely crystal clear. For example, one of the things that comes up with nurses is with the managing clinical nurse in charge of scheduling. Sometimes that person shows blatant favoritism in giving people the hours they like, the best shift, vacation time — that kind of thing. There are some instances where those types of managers even cover for employees who are coming in late on a chronic basis — kind of looking the other way.
This type of thing sends a horrific message and creates infighting. It is clearly a management issue, a matter of [emphasizing] the rules that, for example, vacation goes by seniority and here’s how we are going to do these things [equitably]. It may be a union issue if they have certain things in place. But the expectations have to be made clear and then followed up on. If I know I am at the bottom and I am not going to get the vacation that I wanted, OK, that’s fine. But those have to be clear-cut rules. Whatever your rules and policies are need to be clear and followed.
HEH: Can you say a little more about the “specifics of communication” you mentioned earlier?
MacLeod: It may seem small, but one way to make a difference and start to improve things is for someone to model direct communication. And what I mean by that is, say there is something you’re confused about — a supervisor, a coworker — something that is upsetting to you and you don’t understand why they did that. Say something. This is not an easy thing. Nobody likes conflict, but confront things immediately in a rational way. You might say directly to that person, “Earlier today I didn’t like the way you spoke to me in front of a patient, it felt a little dismissive.”
Have that conversation as opposed to what is happening now, which is that people let it go and it festers and they are angry. Now it is just going to escalate. The person who was dismissive may not even realize that it came off that way. Maybe they were just trying to get the job done and they didn’t realize their words offended you. But if people model [direct communication] it continues on because if you see it or it is done to you then you are going to get it.
The other thing I would say is as simple as showing appreciation and thanking people. One complaint from patient care assistants is that they are treated like servants. Many of them are highly skilled and may come from other countries where they might have been a high-level professional. A nurse may be in a rush and tell them to go clean up a room or whatever, but you can come back to somebody and say, “Thanks so much for helping me with that when I needed it.” It can make a huge difference.
HEH: When you go into a worksite, do you recommend these approaches to hospital leadership or talk to workers in a group setting?
MacLeod: I recommend these sorts of things to administrators. It can be difficult get nurses together because of their schedules, but I also like to work with a group of employees and get them to talk about what is going on [in their work culture]. This is a deeper piece. It takes some time and a building of trust, there are confidentiality issues, but the idea is to get to what is going on. There is resentment and old grudges from years ago that haven’t been addressed. There may be a passive-aggressive kind of behavior pattern where everybody is very defensive.
This would be a meeting only with employees — not with management or anybody else but me. My goal is not to put a Band-Aid on it, but to talk about these things and find a constructive way as a group to problem-solve. What we try to foster in these groups — especially for a group like nurses — is the idea of how much better it would be if I actually trusted and looked to my colleagues for help and support when it was needed. The idea of breaking all this down is to foster some kind of a mutual support system. I model and teach that in problem-solving. The way to deal with things is to confront them immediately and deal with them directly. It’s great and it is the best way to resolve things quickly, but not everybody does that and not everybody knows how to do it. That’s where the modeling and teaching comes in.