Engaging Nurses in Culture Change Efforts with the Key to Pandora’s Box

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Any trainer or facilitator that has ever presented to a group of nurses can likely relate to feeling some resistance from them.  Folded arms, scowling faces, and an unwillingness to participate or even hostile participation is not uncommon when groups of nurses gather for inservices. It is easy to understand why  nurses may have a bad reputation when it comes to change management efforts.  Yet understanding the resistance and making room for validation is an extremely powerful opportunity for healing and engagement.

What makes nurses angry and resistant to change?

Nurses are the biggest workforce in healthcare.  Over 3 million in the USA and over 12 million worldwide.  Our roles in delivering service interface with every aspect of our healthcare system.  Nurses must make it through rigorous training and education to practice a profession that is extremely demanding intellectually, emotionally and physically.  We must pass a difficult examination to obtain become licensed to practice and then maintain credentials through continuing education.

Despite these extremely demanding accomplishments, most nurses I know can relate to a culture shock experience from the world of academia into the world of work.  Sadly,  initial enthusiasm and commitment are often met with work cultures that lack respect.  This can manifest in horizontal and vertical violence, unreasonable workloads, mandated overtime, relentless stress, chronic under-staffing, high rates of work-related injuries, and/or schedules that can be incompatible with raising families or having a healthy work-life balance.   Additionally, nurse input in the day to day provision of care is often dismissed, ignored, and/or invalidated.  Nurses work in environments where constant change impacts their work and have little control or at least little perceived control over the work they are the experts in and expected to do.  Is it any wonder that resentments, mistrust and bitterness become familiar feelings among nurses and huge disconnections between frontline caregivers and management become entrenched?

Even progressive leaders who are trying to engage nurses in respectful dialogues may shake their heads in confusion as they try to empower staff, but are met with a lack of trust that presents as disengagement.  Some nurses are angry, some have shut down and some have accepted being disrespected as OK.  Leaving an organization may not be an option.  Assertiveness may have been eroded, tentative, or never established.  The skills to practice with respectful professionalism have been damaged by a complicated array of individual and organizational experiences.

There is Hope

Assuming that genuine empowerment of frontline staff is a goal, change agents can turn this resistance into engagement with a fairly simple, cost-effective, and powerful process of honesty and ownership.  It is called validation! Making room for the feelings of resentments and anger by acknowledging them and allowing some time to discuss along with a clear expectation that moving on is critical.  Some leaders may worry that a discussion along these lines will lead to a ranting and raving session making things worse or that a loss of power may ensue with a riotous mob of angry nurses.  Being genuine about building respect, setting a time limit, and staying in charge will minimize this kind of energy.

Here’s an example of how a leader might begin a meeting:

I want to announce our organizational initiative to create a Safe Culture here at ABC Hospital.  This is going to require learning, growth, and hard work from every one of us.  I understand that there may be some anger or resistance from some of you because of the way you have been treated or perceived to have been treated.  I know that moving on means building trust.  I want you to know that you deserve to be respected.  I’d like to spend a half hour now talking about some of the obstacles that you have experienced over the years. 

At this juncture allow for some brainstorming where answers can be recorded and visible. Remember, you don’t have to agree or disagree,  just listen.   You might consider using the recorded input in a letter to staff,  newsletter or poster.  Don’t underestimate the power of using staff input verbatim.  It is validating!

And how a leader might ensure moving on:

Thank you for your honesty.  I can see we have many obstacles to overcome.  I’d like to know if you are willing to work with me towards a new culture where our work is collaborative, respectful and most of all, safe for our patients?  Look around the room.  Make eye contact.  Offer any additional support such as an Employee Assistance Program, (EAP) or open door policy, and/or pause for Q & A.   Make next steps clear, look for opportunities to invite and utilize input, and get ready for an exciting new energy coming from your nurses.

Some Examples of  Empowered Nurses Engaged in CHANGE

Dignity Health and NICU Nurse

Leadership Students at New Mexico University

RN Movers and Shakers

Seattle Children’s Hospital Nursing Queens & 1st Rate Teams

Interruption Awareness:  A Nursing Minute for Patient Safety [embedplusvideo height=”281″ width=”450″ standard=”http://www.youtube.com/v/PGK9_CkhRNw?fs=1″ vars=”ytid=PGK9_CkhRNw&width=450&height=281&start=&stop=&rs=w&hd=0&autoplay=0&react=1&chapters=&notes=” id=”ep7805″ /]


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3 Responses to Engaging Nurses in Culture Change Efforts with the Key to Pandora’s Box

  1. Melissa AuClair says:

    Excellent article Beth! I think if more managers and administrators took the time to follow your advice and listen to their staff before being in a rush to implement a new program, there would be much more acceptance- not by all, but by many nurses. I think the attitude of “you’re a problem that needs to be fixed” is a common communication from upper management to staff. It may not be how management really feels about the staff, but it is how they communicate the new program. Thanks for another great post.

    • Thanks Melissa. I think so too. Middle managers are in a tough position and must be able to advocate for resources while inspiring and setting limits with staff. Often there is a gap between senior leaders and frontline staff where middle managers may feel stuck and lack the communication skills to do this dance. Also, some senior leaders may not have or be willing to get resources necessary to ensure safe care etc. It is hard to know whether some middle managers don’t have the skills or have given in to a hierarchal power base that favors the top or do have the skills but not a supportive senior leadership. (One nurse manager wrote to me recently saying she was resigning after years of trying…very sad.) They may also be fighting a lot of informal power that staff have when cultures are toxic. A very complicated picture emerges that makes one wonder whether senior level staff really “get” the work nurses do and want to ensure supports or not. Closing this gap of understanding seems crucial to long-term meaningful change!

  2. Lucy Pilon says:

    Hi Beth…awesome posting! I am working on a position paper for my EdD and find this topic fits right in with my topic of incivility in nursing and nursing education. Your suggestion of dialogue for a meeting to start the process of creating change and improving the working environment is excellent. Sometimes I think it just takes someone like you to guide the rest of us with realistic examples – to know where to begin! I enjoy reading your posts and must apologize for not responding to this one sooner! Lucy

What are your thoughts?