T he nurse put her preferences in stark terms.
"I’d rather be a combat nurse in Iraq than scrub with Dr. Maxwell," she told me and my colleagues. She used the physician’s real name, however, which I’ve changed for this article.
We might have been tempted to dismiss this comment as dramatic hyperbole--after all, Dr. Maxwell is a highly respected staff and faculty member at a prestigious, nationally known teaching hospital. But we believed her.
For several days, we’d been hearing similarly pained comments from other professionals in the doctor’s department. They were all superbly trained and skilled and feared being belittled or verbally abused every time they were assigned to his service. His behavior may have been the most extreme, but it differed in degree rather than in kind from that of several other surgeons in the group, all of whom had devoted their careers to patient care, research and teaching at this outstanding institution.
The hospital’s leaders knew there were problems and recognized they had to change the workplace. The unit faced morale problems, staff defections, unsuccessful recruiting campaigns, bad publicity, potential liability and, worst of all, an adverse effect on patient care. But over the years, it became easier just to deny that surgical behavior was a workplace hazard rather than to actually get support to implement a broad regimen of change.
After we listened to the comments and spoke to the staff, the leadership asked us, in essence, to diagnose the problem and recommend a quick cure. I suspect our client’s representatives wanted us to provide an immediate answer that would get rid of the bad behavior and thus, in their minds, turn the whole department around. But with deeply ingrained cultural issues at play, there is no quick fix. As one of the surgeons told us, "Medicine’s not enough; this needs an operation."
As patients, we go to our doctors hoping that whatever health problems we have are minor or can be dealt with by some new pill or high-tech treatment. All too often, our hopes are tempered when we learn what the treatment will involve--time-consuming and costly therapies, complex procedures, powerful medicine or (often most difficult of all) new lifestyle and behavioral habits. Changing deeply institutionalized and abusive behavioral patterns, often common in surgical and other industrial workplaces, requires similar measures and commitment. This conduct is the result of habit and ritual, the unspoken way things are done and transmitted from one workplace generation to the next.
Put simply, it’s the culture, and Band-Aid solutions won’t change it. Delivering an online training course once a year, sending out a memo every other month, making an occasional speech to the surgical troops--what many often hope is enough--is, alone, a waste of time.
We learned that a standard had been created by previous generations--the current staff’s teachers and
In this institution, the problem was too serious and the culture, whose behaviors went back 30 years or more, too ingrained. We learned that a standard had been created by previous generations--the current staff’s teachers and mentors--who demonstrated outstanding clinical skills but outrageous behavioral interactions.
The not-so-subtle message: To succeed, to achieve excellence, this is how you behave. We also found that the organization’s leaders weren’t comfortable addressing improper behavior, that policies had been adopted but never applied and that no one would raise complaints. Again and again we heard, "Why bother? Nothing will be done." Nurses, anesthesiologists and staff members all told us that as long as surgeons performed their clinical work well, ultimately nothing else mattered. Or at least that was what they had inferred from the leaders’ lack of action. According to several accounts, all of this fits a common pattern in health care workplaces.
We told the institution’s leadership directly: The only effective cure starts with leaders prescribing clear standards, launching ongoing and credible communication and being willing to take action, even if that includes removing respected clinical members from the staff. And while the surgical setting may seem to be particularly susceptible to these kinds of problems, we’ve had similar conversations in a range of industrial environments. These same behaviors crop up in banking, pharmaceuticals, high-tech, utilities--in all types of job functions.
Almost always, our advice generates resistance from a few talented, often brilliant leaders. Some say the staff is too busy to change, that surgery (or other high-stress fields) engenders over-the-top behaviors, that there is no time to deal with behavior when they must be focused on clinical outcomes, and that this is how it’s always been (and, by implication, always will be). Clearly there is a cost-benefit analysis, perhaps unconscious, at the root of such thinking: We may have problems, but we get the job done, and get it done exceptionally well. This other stuff is an annoyance, an inconvenience, but not really a big deal. Let’s slap them on the wrist or make them go through a brief online course, some minor procedure that may or may not work but will at least make it look like we’ve done something.
Sadly, this reminds me of the approach taken by several of my close family members who knew that smoking might harm them but refused to quit, saying their habit was too ingrained. Too late, they finally stopped after a chilling diagnosis proved the harm of their habit exceeded whatever benefits they thought it brought them.
Across industries, my colleagues and I see a common pattern in which organizations finally react to outrageous conduct after high-profile scandals damage their enterprises. That’s when we hear new leaders talking about cleaning house, changing culture, spending whatever it takes to change the way things are done and installing new systems to encourage people to report what should have been recognized and addressed as toxic behavior. At that point, suddenly, time and money are not the issues--long-term culture change and the application of principled workplace values are.
Every day, patients are advised that prevention is preferable to cure. What I don’t understand is why health care leaders and their colleagues in other industries don’t take this practical advice and apply it to their own institutions. Prevention may not be the easiest route to take in the short term, but the results are worth it. Denial, wishful thinking, quick fixes and cheap remedies won’t stop a serious disease. Prevention, where possible, and aggressive treatment, where needed, are the best hope. In the workplace, the same advice applies, with this difference: Prevention is easier, less expensive and likely to be more successful than treatment after the fact.
Workforce Management, September 2005, p. 12 --Subscribe Now!