How Does a ‘Theory X’ Leadership Philosophy Contribute to Medical Error, Workplace Violence, & Poor Staff Morale?

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“I don’t think it’s too profound:  We all do better in a supportive environment”, states Dr. Lucian Leape, a founder of the national patient safety movement and a health policy analyst at Harvard School of Public Health in 6/18/12 Boston Globe interview with Karen Weintraub.  In the article, “Healthy Doses of Respect“, Dr. Leape advises, “If you want happy patients, you want a happy workplace.  The needs of the workforce have not really been a top agenda for the leadership of many health care organizations”.

As a Registered Nurse with over 25 years of experience, it is validating to hear a physician leader talk about the importance of respect and to associate the lack of it with high rates of injuries among nurses, mistakes by sleep-deprived doctors, and tendencies to not fully inform patients.

Thank you, Dr. Leape for your clear and progressive position that seeks to value healthcare workers and consumers. From a nurse’s perspective, having enough staff, time, and training along with supplies, equipment and technology designed with nurse input are all examples of respecting the work we do and the safety of our patients.

In graduate school I studied organizational behavior, emotional intelligence and group dynamics and recall being profoundly moved by Douglas McGregor‘s theories about human motivation and management.  In his book, “The Human Side of Enterprise” published in 1960 he examined theories on behavior of individuals at work, and formulated two models which he calls Theory X and Theory Y.

I remember being particularly struck by how the assumptions of ‘Theory X’ leaders resonated with my work experiences as a nurse, teacher, waitress, cashier and a variety of other employee roles over the years. Consider Dr. Leape’s concerns about respect and the lack of it evident in McGregor’s model depicting a philosophy where leaders who believe in ‘Theory X’ assume that people:

  • Have a genuine dislike for work.
  • Must be prodded, coerced, or threatened in order to be productive because work is so unpleasant.
  • Prefer to be closely supervised.
  • Avoid as much responsibility as they can.
  • Have little ambition.
  • Seek security above all else.

Such leadership is common in many employment settings and yet the repercussions in healthcare can mean life or death.  Perhaps there was a time in human history where controlling leadership was critical for survival, but it is an old way of being.

One of the biggest challenges that nurse, physician, and administrative leaders face is to balance the importance of developing collaborative teams, empowering patients, and ensuring action-based critical clinical interventions.Respect for self and others is a key leadership imperative.

Check out YouTubes for related info:

Why is Communication & Collaboration So Hard for Healthcare Professionals?

Interruption Awareness:  A Nursing Minute for Patient Safety!








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7 Responses to How Does a ‘Theory X’ Leadership Philosophy Contribute to Medical Error, Workplace Violence, & Poor Staff Morale?

  1. Pingback: Recognizing the ‘Art of Safety’ in a Complexity Science World!

  2. Beth_Boynton_RN_MS says:

    Hi Denise,
    Thanks for your supportive feedback!

    I would love to publish your story (other people’s stories for that matter) re: nurses saving your life. Or share your opinions re: people who abuse nurses and other healthcare workers? Write to me at

    If I’m not polite, I’m afraid I’ll get labeled as a complainer, a nurse with a negative attitude, and/or unprofessional making it easier to dismiss my points. That’s probably another article! Hmmmm, what happens to people when they speak up and are not listened too? Speak louder? Shutdown? Become overly polite? 🙂

  3. Denise A.Vincent says:

    I always love articles about respecting Nurses (Nurses Saved My Life!) and this was well written and touching. However, in my opinion, you are too polite. I have many loud and unattractive words to describe people who abuse Nurses (and other healthcare workers) and create unsafe environments. Many words. Words too strong for polite company and that won’t make it past the comment filter.

  4. Beth Boynton says:

    Pretty simple all in all, isn’t it?

    • Jim Murphy says:

      It is simple! And maybe that is what makes it so hard. Peace, justice and understanding are simple ideas, too, but civilization for thousands of years has been unable to put them into practice.

      In the decades since McGregor wrote (Abraham Maslow should also be noted in this connection), many others have carried these ideas forward. Robert Greenleaf’s servant leadership and Peter Block’s empowerment and stewardship are simple and fundamental ideas. Tom Peters made excellence, a simple idea, into a concept that is a fundamental management concept.

      Not only that, but numerous books have been written that show very clearly that organizations that put these ideas into practice are more successful than those that don’t. For example, First Break All the Rules, by Marcus Buckingham and Curt Coffman, is based a vast amount of survey research showing that good management makes for a successful company. Bruce Katcher’s 10 Reasons Why Employees Hate Their Managers spells out these ideas so clearly that anyone can understand them.

      So why are so many organizations still in the dark ages? Why are blogs like this, not to mention Dilbert, so popular?

      Maybe an answer by analogy can be given. Any child psychologist can explain how treating children with goodness and understanding will make them successful in life. The shelves of bookstores are full of titles on raising children that, just like those on management, show how good treatment works. Not one of these suggests that a parent should yell at a child or a manager should yell at an employee. Yet how many parents and how many managers do just that?

      • Beth Boynton says:

        Hi Jim,

        You are so right on re: simple stuff can be so hard and thank you for your provocative comment and inspiring resources. I don’t know how many parents or managers yell at their children/employees or find some other way of disrespecting them. I can’t help but wonder if our work to change organizational norms is paralleling work to change social norms?

        I think anything involving human behavior change is much harder than it looks. It involves individual differences and growth that include things like self esteem, motivation and self efficacy. Not to mention that changes have to take place in the context of relationships where others are learning too and there are big power differences, (perceived and/or otherwise). Knowing what could or should be different, the intellectual part seems like a very small part of the learning. Like, Just say ‘No’ to drugs…or unsafe sex or another donut all seem simple, right?

        I have to believe or at least operate from the belief that raising awareness is a vital part of the long long long process of change. I’d even go as far as to say that I think healthcare could be leading important changes that ripple out into many of our civilization’s problems like the big ones you mention, (peace, justice and understanding). I also think there is a connection between a nurse speaking up for her/him self AND patients that not only makes healthcare safer, but also builds more rewarding healthcare careers and impacts patients and families in all sorts of social and emotional learning beyond “medical” treatments and assessments.

        In healthcare, we are so entrenched in old heirarchal, patriarchal, controlling ways of being. I think their are places in healthcare where this makes sense…like during a code or emergency surgery. But, we seem to be in this “STAT” reactionary mode all the time and don’t ensure time for building and practicing the soft skills that promote communication and collaboration. It is like being at the fire all the time. The buckets may be leaking and carrying water more effective if we took the time and resources to fix them.

        Raising awareness about what respect looks and feels like has it’s own value. I trust this and leave, value but don’t wait for the researcher to prove it! There are 12 million nurses in the world and millions more consumers.

  5. “If you want happy patients, you want a happy workplace” he speaks the truth! So glad to hear some leaders are in touch!

What are your thoughts?