1. 24 TD | February 2016
case in point
HEALTHCARE
W
e need look no further than the daily newspaper to see the power-
ful impact that a toxic culture can have on an organization’s vitality
and performance. In 2015, we witnessed the emissions scandal that
unfolded at Volkswagen and got a glimpse into the ruthless culture at Amazon
through a New York Times exposé. While it’s often large corporations that have
their negative leadership and workplace environments laid bare, there is another
more unassuming profession that is all too often characterized by a toxic cul-
ture: nursing.
A Healthy Culture
One hospital’s nursing department attempts to change its toxic
culture through confidential interviews and focus groups.
BY LINDSEY BINGAMAN AND FRAN JOHNSTON
PHOTOS: THINKSTOCK
Copyright ATD 2016

2. February 2016 | TD 25
Research during the past few de-
cades indicates that bullying, or
“horizontal violence,” is a major prob-
lem in peer-to-peer relationships
between nurses. Many nurses use
phrases such as “eating their young” to
describe the relational dynamics that
typify nursing culture. Some hypoth-
esize that this dynamic exists because
nurses are caught in the middle of a
hierarchy in the healthcare system
and because it is a traditionally female
profession.
Many also believe that the corpora-
tization of the healthcare industry has
compounded this dynamic through
increased nurse workloads and stress.
The toxic environments found in
many nursing departments are alarm-
ing, considering the impact they can
have on patients’ health and safety,
employees’ well-being, turnover, and
profitability, among other things.
The opportunity
One large metropolitan hospital, rec-
ognizing this dynamic within its own
system, sought to address its toxic
nursing culture head-on. In partner-
ship with a leadership consulting firm,
the hospital launched an action re-
search project in which 60 of the top
nurse managers and directors volun-
tarily participated. The process was
carried out over nine months, primarily
through four foundational meetings.
The process
The first meeting brought the nurse
“change agents” together as a group
to explain the purpose of the project
and to outline the process. The sec-
ond meeting focused on training the
nurses in a qualitative interviewing
method called dynamic inquiry (DI).
In this meeting, nurses learned how
to interview each other using open-
ended questions, how to probe for
deeper answers to the questions they
asked, and how to limit their biases
and maintain confidentiality during
interviews.
They practiced interviewing each
other and writing up their interview
notes. The nurses also were briefly
trained in thematic analysis, a tech-
nique they would use to analyze the
data after conducting the interviews.
Following this meeting, the nurse
change agents went out and inter-
viewed several of their fellow nurses
using broad and open-ended ques-
tions about their departmental culture
and leadership. One example of a
question they asked was, “In your
view, what sort of culture does our
department need in order to be suc-
cessful? Why do you think this?”
Another question asked was, “Which
aspects of this culture do you believe
are present and which are missing?”
After the responses from these in-
terviews were collected and analyzed
thematically, a comprehensive snap-
shot began to emerge of the group
culture as it was experienced by the
nurses.
One of the biggest challenges
posed by this interview process was
creating an environment in which
nurses felt comfortable speaking up.
For this reason, interviews were care-
fully arranged so that no nurse change
agent interviewed her direct reports.
Also, nurses were instructed to
stress confidentiality prior to be-
ginning the interviews. Finally, the
questions were designed so that
interviewees could bring up any issues
related to the culture without naming
a specific incident or person. These
precautions helped create an envi-
ronment in which participants could
freely share their perspectives on the
nursing department culture without
being forced to disclose information
that felt too risky or personal.
Prior to the third meeting, the proj-
ect sponsors working in partnership
with the nurses identified high-level
themes that had emerged from the
interviews and selected anonymous
quotes that spoke to each theme. Dur-
ing the meeting, the nurse change
agents worked in small groups to ana-
lyze this information and then reported
to the entire group what they believed
the themes said about their culture.
This was a powerful meeting. It
enabled the nurses to describe their
group behavior and norms in their
own words, which had until then been
unspoken. After the analysis and dis-
cussion, the remainder of the meeting
was spent talking through how the
group could collectively and individu-
ally address the negative aspects of
their culture.
By the end of the meeting, the
nurse change agents had identified
three commitments they would make
personally and collectively to begin
making positive changes to the culture:
• Personally, adopt a leadership
behavior that would resonate
with their peers and direct re-
ports (such as communicating
more directly).
• As a group, identify clinical prac-
tices that their teams did well
because of the leadership and cul-
tural practices around it.
• As a group, identify an issue that
they were currently working on
with their teams, one that involved
elements of leadership and cul-
ture (such as communication or
A VAST MAJORITY OF
THE NURSES REPORTED
HAVING STRONGER
COLLEGIAL RELATIONSHIPS
AS A RESULT OF THE PROCESS.
Copyright ATD 2016

3. February 2016 | TD 27
case in point
decision making), and try a new
approach with the results of the DI
process in mind.
A few months after the third meet-
ing, the group reassembled to discuss
their progress as well as any unsuc-
cessful efforts. This meeting also
brought the action research process
to a close for the time being.
The results
Following the fourth meeting, the
project sponsors surveyed the nurse
change agents to assess how success-
ful the action research process had
been. The nurses reported the fol-
lowing individual and group changes:
• Most of the nurses indicated that
the process had increased their
self-awareness, self-efficacy, and
confidence to speak up within
their nursing groups.
• A vast majority of the nurses re-
ported having stronger collegial
relationships as a result of the
process.
• Nurses said that the action re-
search process enhanced their
awareness of their department’s
cultural reality.
• The results from the survey indi-
cate that the process increased
the nurse change agents’ belief in
the need for behavior change in
their department and provided a
clearer vision for how the group
could realize that change.
Lessons learned
Several key lessons emerged from
this process. First of all, while the
group commitments were an impor-
tant outcome of the action research
process, the process itself was just
as powerful, if not more so, than the
solutions that were implemented
as a result. Including the nurses in
interviews, analysis, and solutions
building catalyzed the relationship and
communication changes that needed
to happen within the group. The
commitments then helped to per-
petuate the changes that had already
started taking place.
Second, employees need to un-
derstand the reality of their group or
organizational culture before they can
become willing change agents. Seeing
the words they used to describe their
own group norms and behaviors was
eye-opening for many of the nurses
and created an urgency to change.
Surfacing these negative aspects
of the culture through open dis-
cussion also set new patterns of
communication and interaction into
motion. It gave nurses an opportunity
to practice speaking out against be-
havioral norms in the group and gain
support from like-minded colleagues
who had previously remained silent.
There is no getting around the
fact that culture change is complex
and iterative, but this action research
process is a powerful way to catalyze
change and can be replicated in nurs-
ing departments around the globe.
Lindsey Bingaman is a consultant for
the Teleos Leadership Institute; lbingaman@
teleosleaders.com.
Frances Johnston is founder and CEO of
the Teleos Leadership Institute; fjohnston@
teleosleaders.com.
THE ACTION RESEARCH PROCESS ENHANCED NURSES’
AWARENESS OF THEIR DEPARTMENT’S CULTURAL REALITY.
Copyright ATD 2016

4. 1114027.31610
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