July 8, 2020

Psychological Safety and Toxic Culture in Nursing Shared Governance

I recently received the March 2019 issue of American Nurse Today, the monthly magazine of American Nurses Association. The Leading the Way section includes a brief article entitled “4 steps to repairing a toxic culture.” The article’s author, Rose O. Sherman, EdD, RN, NEA-BC, FAAN, is a professor of nursing and director of the Nursing Leadership Institute at the Christine E. Lynn College of Nursing at Florida Atlantic University in Boca Raton. Of particular interest to me at this time is the author’s comments on psychological safety in nursing culture.

In a previous nursing position, I have had the opportunity to serve my colleagues as either chair or co-chair of three different tiers of my organization’s shared governance structure. In those roles, I found myself occupying a middle ground between management and bedside staff. I was not a member of unit leadership; I was a bedside nurse. On the other hand, I became a sounding board and comment box for many of my fellow staff, and I knew they were eager for positive results.

Sherman cites Building a Culture of Ownership in Healthcare by Joe Tye and Bob Dent to introduce the idea of toxic culture, which can develop when negative emotions and behaviors persist unchecked. A number of signs of toxicity are listed, but I’d like to focus on lack of psychological safety. This sign of toxicity amounts to the sense of risk associated with certain interpersonal exchanges within the culture, a common one being the sense that it is not safe to express one’s viewpoint.

Consider the following points of interpersonal risk: asking a question, requesting feedback, reporting an error or concern, and offering a suggestion or new idea. At which points have you experienced sufficient risk to think twice before speaking?

As a shared governance officer, I had many opportunities to discuss unit issues with staff one-on-one or in small groups as well as during official meetings. What I came to realize was that there can be a disconnect between the meaning of shared governance and actual cultural practices in nursing.

Despite the fact that there was an easily accessible comment or suggestion box available to staff, there were few who actually used it. For the most part, shared governance topics were proposed directly to me, and I simply wrote them down for reference at the next meeting. In fact, the majority of staff contributions came in this form.

There were constructive comments, to be sure, but there were also criticisms. At the time, it was generally the case that members of the unit leadership team attended every shared governance meeting in its entirety. As you might expect, I had staff tell me that bedside staff felt no one could speak freely with unit leadership present. In addition, it was frequently the case that conversations that took place during shared governance meetings were not open, round table discussions. Instead, they often took the form of bilateral negotiations with bedside staff on one side and unit leadership on the other.

Framing discussions in this way seemed to degrade the collegiality of staff. To the extent that this took place, we were not unit members of equal status contributing to the “governance” of our unit in a “shared” manner, implying mutual ownership of unit culture. Instead, we were equally disempowered, tied together not by mutual respect and professional integrity but by common grievances most felt themselves not at liberty to express.

Building confidence among staff in the existence of psychological safety on the unit is a crucial aspect of mending a toxic culture. During one shared governance meeting, a colleague verbalized the opinion that “you can’t change a culture.” I disagreed, positing an alternative: It’s not that you can’t change a culture, it’s just that it’s very costly and there are few people willing to pay that cost.

What is that cost? No one can state upfront exactly what the cost will be for any given unit because each unit culture is distinct. However, the cost involves willingness to accept interpersonal risks, to support the vulnerable staff member who chooses to verbalize what many are already thinking. The cost also involves contributing on an individual level to a cultural rejection of retaliation toward those who take the interpersonal risks.

Who pays the cost? Ultimately, it is the burden of all unit staff to share the cost of culture change. However, unit leadership bear much of the responsibility in the form of their relationship with bedside staff in the context of shared governance. Shared governance is not collective bargaining; it’s not a strategy to enable a union of staff to obtain what they want from management. Shared governance is a paradigm of mutual ownership of vision and values that plays itself out in staff interactions and collective behaviors that lead toward the realization of those values.

While unit leadership are represented ideally in the collective “sharing” of “governance,” because of their positions of organizational authority they may wish to consider recusing themselves from certain decision making processes and excusing themselves from certain meetings to allow staff in general to speak freely. With respect to routine shared governance meetings, this might mean unit leadership are only present for a brief portion at the end of each meeting to be presented with the consensus of the bedside staff present.

Again, changing a toxic unit culture is costly, but the cost can be shared by all staff members to build a more resilient culture. In your nursing sphere of influence, how can you contribute to positive change in this area?

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