In a recent podcast conversation with Kevin Pho, MD, we talked about the importance of assertiveness in health care, including the ability to say “No” and the significance of culture in supporting it.
One of the topics we touched on was the influence of both top-down and bottom-up factors, which I want to elaborate on here.
Organizational culture refers to how and why things are done at work and the rules that guide them. The culture can be either healthy or toxic, and the rules can be implicit or explicit. The way people interact, how tasks are accomplished, and the emotions evoked by observers are all by-products of workplace culture. The quality of communication in an organization reflects the quality of the culture.
In an ideal health care culture, such as in a hospital or primary care practice, individuals give their best, teams function with a clear and common purpose of providing safe, quality care, and everyone has the resources and skills to succeed. Communication, emotional intelligence, and behavior among staff are characterized by:
- Open, honest, respectful exchange of ideas.
- Requests for help, offers of assistance, or setting appropriate boundaries.
- Timely and compassionate responses to patient needs and requests.
- Maintaining healthy professional and therapeutic boundaries.
- Actively giving and receiving constructive feedback.
- Taking ownership of mistakes and showing a willingness to teach and learn respectfully.
In such a culture, professionals can freely seek input because they trust that their opinions will be respected, and ongoing learning is an organizational-wide expectation. Interactions contribute to everyone’s knowledge base, critical thinking, and moment-to-moment decision-making. Power dynamics within the hierarchy are healthy, and a culture of respect prevails.
On the other end of the spectrum, a toxic culture refers to one where the opposite qualities prevail. For instance, communication may involve gossiping, bullying, or other disrespectful patterns. There’s a tendency to blame rather than learn from mistakes, unhealthy boundaries exist among professionals and/or with patients, and conflicts are avoided, contributing to resentments and fears.
In such a culture, professionals may choose to ignore some colleagues while favoring others, information exchange is limited based on personal alliances, and trust is selective. Symptoms may include door slamming, talking behind others’ backs, and passive-aggressive or aggressive behaviors that hinder cooperation and teamwork. Informal and formal power dynamics influence the hierarchy in unhealthy ways, and disrespect is pervasive.
Whether healthy or toxic, the difference is palpable to all stakeholders.
Ultimately, leaders of an organization are responsible for creating clear and consistent expectations for communication and behavior in a culture. However, for success, all staff must possess the skills and emotional intelligence to contribute to and sustain it. Leaders who have attempted to change a culture where unhealthy informal power dynamics (passive, passive-aggressive, or aggressive interactions) are pervasive can likely attest to the limitations of a top-down approach that doesn’t include a foundation for healthy bottom-up work as well.
Medical improv training is an effective way to build such communication skills and emotional intelligence. Therefore, it can be a valuable tool for leaders who aim to reinforce a healthy culture or provide support for a culture change initiative.
Beth Boynton is a nurse consultant and author specializing in research, training, and writing about emotional intelligence, communication, teamwork, and complexity leadership. She’s a pioneer in developing medical improv as a teaching modality for health care professionals and the founder, Boynton Improv Education. Find out more about upcoming open events, videos, and articles related to medical improv. She can also be reached on Facebook and LinkedIn.