Fluff to Priority: Culture Change and Disruptive Behaviors in Healthcare

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Renee Thompson:
Plants thrive and grow in a peaceful, nourished environment, right? Well, it's the same with human beings, but what if that environment is not so peaceful? What if it's toxic? Welcome to Coffee Break: Breaking the Cycle of Bullying in Healthcare – One Cup at a Time. In this podcast, you'll get practical, evidence-based strategies to help you cultivate and sustain a healthy and respectful work culture by tackling an age-old problem in healthcare: bullying and incivility. I am your host, Dr. Renee Thompson.

Renee Thompson:
Hi everyone! Welcome back to another episode of Coffee Break: Breaking the Cycle of Bullying in Healthcare – One Cup at a Time. I am your host, Dr. Renee Thompson, and it's just an honor to be with you all today; whether you're listening to this podcast as you're getting for work in the morning, that's when I listen to my podcasts, or you're on your way to work, from work, or you know what, maybe you're just hanging out somewhere, having some me time listening to some really great podcasts out there. No matter where you are listening, we're happy that you're here. Today, I'm really excited to welcome a very special guest on the show, and that is Dr. Mitch Kusy. Mitch is an organizational psychologist, a researcher, and a professor in the PhD program at Antioch University. He has authored many books, including Why I Don't Work Here Anymore. I actually have that one on my nightstand. Seriously, I do, so good. And he has written numerous articles and is a Fulbright scholar in organizational development. And one more thing before I officially welcome him, very much like Diane Salter in a previous episode, Mitch is a valuable member of our team here at the Healthy Workforce Institute. Mitch and I do our consulting together, he is a fantastic keynote speaker, and is an excellent coach, especially with disruptive physicians. Yes, when an organization reaches out to us, and they say, Oh, we're struggling with some physician incivility, we send in Mitch. Today, we're going to talk to Mitch about making a case for culture change as a priority when you have so many other competing priorities. Welcome to Coffee Break, Mitch. Do you have your coffee?

Mitch Kusy:
I've got it. I've got it right here. Cheers!

Renee Thompson:
Cheers! Double cheers. Mitch, can you start by telling us what got you involved in culture change as an organizational psychologist? And in particular, how did it lead you down this path to being so good at addressing disruptive behaviors?

Mitch Kusy:
I'm chuckling when I hear that question, Renee, because I wish it were designed that I would become an organizational psychologist working in the area of culture change, but it really was more serendipitous than anything else. And let me share a story with you, and this happened many years ago in an organization in which I was working. And what ended up happening is I walked into an elevator, I smelled a special perfume, I still don't know what this perfume was, and Renee, I got sick to my stomach. And I didn't, I just wondered, what was happening? I didn't make a connection to the perfume, until about a year later, it happened again to me, the same perfume, and then it clicked. This was the perfume worn by a highly disrespectful, toxic individual, and it affected me viscerally, and this is now 20, 25 years ago. I said to myself, I wonder if there's something to this. And this is at a time when people weren't researching disruptive behaviors and organizations very readily, and I went on a saga to try to discover more and started doing some research and helping other individuals understand: what are these disruptive behaviors, why do people get away with bad behaviors in organizations, and what's the system that's preventing individuals engaged in respectful ways?

Renee Thompson:
I think that when you think about how that all happened, that the smell of someone's perfume made you sick to your stomach, it just makes me think about the negative impact, disruptive behaviors, especially behaviors like bullying, that they have on an individual, not just immediately, but the long-term negative impact. You said even a year later, when you smelled that perfume, you had the same response and then figured it out. And it's so important that we recognize it's not maybe just in the moment, but these behaviors, when they go unaddressed, they can impact somebody for the rest of their lives. And I hate to say I'm glad that happened to you, Mitch. I'm glad you got sick to your stomach. But it really, as you said, took you on this path to learning more about it, and now you're considered an expert in really dealing with disruptive behaviors. And as you said, what's going on in the system that is permitting or allowing these toxic people to continue?

Mitch Kusy:
What's really interesting about what you said in terms of the long-term impact, there are three primary impacts in organizations, our own personal well-being, the performance of the team, and ultimately the bottom line, and in healthcare, the bottom line is the patient experience and patient safety. Back to personal well-being, before I started studying this, I said to myself, thinking back, Gosh, there must have been something wrong with me. Why this happened to me, I must have to correct something I'm doing so this doesn't happen in the future. And sometimes that is true, often it is not.

Renee Thompson:
And we personalize it. I know, myself, when I was a new nurse, and I would have some of the other experienced, very competent nurses criticized me, were incredibly rude, disrespectful. A lot of the reasons that I do this work is because of my own experiences, but I internalized it, and I thought, I'm not a good nurse, I should quit right now. Because they made me feel that there was something wrong with me, and now, in retrospect, it wasn't me. It was, not to say it wasn't me, it was them, but it was the way they behaved that I internalized it and felt that I wasn't a good nurse. And it's so sad that happens, and it's happening every day. It's happening as we speak, I'm sure.

Mitch Kusy:
Yeah, I remember at a book signing event, this was when my book, Why I Don't Work Here, came out, after the event, and during the book signing, this woman started crying. She said, Would you autograph my book, Dr. Kusy? And I said, why are you crying? She said, up until now, I always thought it was about me. Now I realize it's a systems issue, and that's why we go into organizations.

Renee Thompson:
I'm happy, again, that in a way, that this happened to you because, just like me, a lot of people get involved in a topic like this because of their own personal experience. And the goal is, Mitch and I feel very much the same way, we don't want anyone else to go through what we went through, and that's why we do a lot of the work that we do. It's really to serve the leaders and their teams and equip them with the skills and tools that they need to actually address disruptive behaviors, hold people accountable, and ultimately cultivate a healthy work culture. And one of the things, this Mitch, there are a lot of organizations we know they need our help. However, they don't always make culture change a priority, and they think it's fluffy stuff. They think it's just about being nice. And I remember it was at this one organization, and we were about to start doing some work in the emergency department, and they wanted me to speak to their medical director of their ER, and he sat in a conference room on the opposite side of me, and I was to explain to him what this culture change initiative was all about. Talk about body language. He turned his chair completely sideways, didn't even look at me while I was speaking. And then, when I was finished, basically said, so you just want us to be nice to each other? Is that what this is all about? And I was like, okay. My inside voice wanted to, my inside person wanted to smack him. But this is something, Mitch, that we see all, very frequently. So how do you convince people that this is not a soft skill, this isn't a fluffy topic, this isn't just about being nice to each other? It's way more than that. So can you talk to us a little bit about that?

Mitch Kusy:
Oh, I'd be happy to. One of the, I'm smiling when you were speaking, Renee, because one of the discoveries that I've made in talking, in particular, with physicians and physician executives and healthcare executives, is that I get it's about being nice, and you're just going to send us to charm school. And one of the things that I have discovered in many of the physicians and physician executives that I work with, they've been through charm school. They've gone through training, and that alone does not work. You need to look at the system and the consequences that allow people to get away with bad behaviors. Let me talk about some of the strategies then that I've found really effective, and I'd like to give you three of them.

Renee Thompson:
That'd be great.

Mitch Kusy:
Yeah, and the first strategy, and I would say this to the listeners and, out there, is first of all, don't try to go it alone. And in terms of improving the culture, if you're a leader in your organization, think about how you can engage others in this process of recognizing that this is a problem. One of the things that so many people, in the goodness of their hearts, try to do is they try to make this change of bringing about a culture without key stakeholders along the way. So my first tip, don't go in alone and be sure to start with the problem or opportunity. And the problem is not one person is getting away with something, the problem is that we have an endemic in this organization. The problem is that it's affecting the patient experience. And when more than one individual goes in and tries to help the system understand what's going on, best to do it with other key stakeholders, ideally from different disciplines.

Renee Thompson:
You're so right because there are so many times a leader will reach out, and they will say, We need help. There's bullying, there's incivility, we're losing people, but my boss or the people above me don't think there's a problem. And I actually heard this. I was having a call, somebody had reached out and said we could do some help. And they actually shared with me that their medical director, their key physician, he actually said that bullying is made up, that it's not real. And I thought, oh, so that's what you're fighting against, or people that don't think it's an issue, they think it could be something made up. Now, I've never heard of that before. I've never heard anybody say, oh, that bullying, that's not real, that's made up, that doesn't really happen. But the mistake leaders make sometimes is that they think they have to be the ones to actually convince everyone else. And I so appreciate your point, don't go at it alone. Chances are there are other leaders in your organization who have also recognized that it's a problem. And that's something when leaders reach out, and they say, okay, this is an issue. I always ask, is there anyone else in your organization who also thinks that this is an issue?

Mitch Kusy:
Right on, and with that, someone else or those other individuals, bring those individuals in to the conversation. When you're trying to convince someone else that this needs to be a culture change initiative, that's key. You hit the nail on the head, and you stole my thunder just slightly with the second strategy note. I think it might have gone over our heads, but the second strategy is use the evidence that's out there, and it is amazing. The number of people who are afraid to use documented evidence. Most people will take the evidence from within their organization, which is one form of evidence. So the evidence is the recent culture survey pointed to the top three things that we need to focus on are the following. Or they say, You know what? We've had some turnover, and in the focus groups we've run, we discovered that nurses are leaving in droves because of X, Y, Z. That's one whole cadre of evidence that I call internal evidence. The kind of evidence that most individuals don't engage is what I call external evidence. Are you aware that the, in a recent survey that was done by McKinsey, that number one, in 15 countries with 15,000 employees, the number one cause of burnout is toxic behaviors in the organization? That makes an impact when complemented with the internal evidence.

Renee Thompson:
I actually, believe it or not, never really thought of it in that way, that you have internal evidence and external evidence. When I think data doesn't lie, show them the numbers, show them the studies. I always think of external, yet at the same time, most organizations, they do have some internal data. And I remember, as soon as you brought that up, I thought, yes, hello, this was years ago, I had heard from a colleague of mine. She was in a meeting with their CMO, they just received survey results on why 50% of their new graduate nurses were quitting, and the reason is bullying, or was bullying. And I love this story, he said, now that we know we have a problem, we have to do something about it. Does anyone know an expert in bullying and incivility? And my friend was there. She, that would be my friend who happens to be about a half an hour from here because she's visiting, doing some work, and we're actually meeting for dinner. And I was able to go and meet with the CMO, and then that established a long-term relationship with him and the organizations that he's been to. And I don't know, though, Mitch, do you think a lot of organizations are collecting that internal data?

Mitch Kusy:
I think a number of organizations have some data. Maybe it's not totally contemporary, and that's where the external evidence comes in, because maybe your internal evidence isn't up to snuff. And maybe that's one of the things that, one of the core actions is we need to do a better job of assessment before we make the determination of the culture change, and you and I know this because we do assessments with the organizations. So some organizations have it, some don't. And I think what's really important about the external evidence is that you gear it to the group. For example, I was working with a recent, I was recently working with a group of physicians, and I shared a study that, and they were just amazed as, I can't believe, first of all, people are doing these studies, those surgeons with more colleague complaints had 14.3% higher complication rates in surgery. So, bottom line is you got more complaints if you're a surgeon, you're going to have more complication rates. This really hit them hard, and that's that third piece of the bottom line. And the bottom line is in healthcare, one of them is patient safety. They said, you know what? We're going to put a stake in the ground now and need to do something about this.

Renee Thompson:
You're so right, and that's the one thing that I so appreciate about you. You are so quick to pull out a study in the moment. And sometimes, when we're having conversations with executive leaders, they'll say, okay, do you have any references for this, or what's the evidence, or do you have any citations? And I say, hold on. Mitch has 27 that he could send you in 30 seconds because you're a researcher, and you appreciate not just a group doing a study, you appreciate good studies that are well-designed with an adequate sample size. Just because somebody did a study doesn't really mean that it's a study that you want to use or especially if you're trying to, again, going back to convince the key stakeholders that this is an issue that we need to address, you have to be very mindful of what studies you share. And to your point, if you're trying to convince a group of physicians, use studies that focus on physicians; if you're trying to convince a group of nurse executives, use studies that reflect what's happening in nursing right now. HR, take a look at retention. Take, so be very mindful on the studies that you're sharing.

Mitch Kusy:
Yeah, speaking of HR, because I bet there's some HR listeners, talk about pulling studies out of my hat, and one that relates to particularly for HR professionals is that there were several studies done. Bottom line, they discovered this: anywhere, depends on the study, 65 to 70% of individuals said that they would stay in the organization and not leave if the organization had a respectful culture, and here's the rub, and 70% said better pay would not even be tempting. So subsequently, many of our clients will say maybe we need to pay people better, but we don't have the money. I said, You know what? You, 70% said money doesn't matter.

Renee Thompson:
Yes, and I think it's just maybe short-term thinking versus long-term thinking where they want to have a short-term solution. So they think just throwing money at people will make the biggest short-term improvement or difference, and what they fail to see is the long-term impact that has, and they're failing to recognize and utilize the data. You just mentioned earlier about the McKinsey report, when that report came out, and I think it was November of 2022, the number one, and actually the article was basically the title was something like, you got burnout all wrong. Okay, like the solution.

Mitch Kusy:
That's right.

Renee Thompson:
Do you think the solution to burnout is not the solution or the cause? And it was, yes, the number one cause of burnout and intention to leave, so turnover, is toxic workplaces. So it's, I think you have to be a very strong leader to identify that this is what's happening. We have the internal data, we have external data, this is something that we as an organization need to do, and take a look at this from a strategic priority considering the long-term impact that this has, not just the short-term.

Mitch Kusy:
Totally agree. It's, this kind of stuff doesn't happen via osmosis. You've got to prepare, and you have to think about these kinds of conversations you're going to have to get people to be elucidated in a culture change initiative.

Renee Thompson:
Yeah, you're so right. So I know you said three strategies.

Mitch Kusy:
Oh, you've caught me. Yes, the third. The third is when you're trying to get engagement, people want to know the, one of the top questions that people want to know is how are decisions going to be made related to this engagement? Often when you share that you're going to have a culture change initiative, and we want to engage people, interpret and misinterpret because the leader didn't do their due diligence, misinterpret engagement with input, and you're going to do what I say. And so here's a little strategy. When you are in a decision-making mode, like we're going to proceed with this culture change initiative, we want to do an assessment, etc., you need to outline the decision-making parameters. It could be something like, you know what, you're going to give me input as a leadership team, and the team will make the decisions. This sounds simple, Renee. People don't say these things. It's, the one is input to the leader. Another, which is actually a better model, but it does depend upon the context is one based on consensus, and it is fascinating to me, most people misinterpret consensus to mean agreement and it does not; be in consensus and not be in agreement. So back to the strategy, you need to define what consensus means if you want support, and consensus means, in fact, do this exercise with a large group. How long does consensus typically go on in your organization? They say it never ends, typically, and I say that's your fault as a leader. So here's the thing, put a time parameter on consensus. We're going to be in consensus with just support for the next 15 minutes for the next two weeks. And here's the rub, if we can't achieve consensus, let people know the default mechanism, how the decision will be made, the decision be made by majority rule. The decision will be made by a leadership team, we'll decide this, etc. And those discussions are really important. And the problem, Renee, with majority rule, the research shows it has a tendency to polarize the group into winners and losers. Think about what happens after a major election. So what's really important is that you define how the decisions are going to be made, and it could be input to some leadership team, it could be consensus. Those discussions are critical. So that's the third strategy.

Renee Thompson:
You know what, Mitch? It really helped me to think also about whose decision is it ultimately, and this is where sometimes I think we can get into power struggles, especially as an interprofessional team. Is it nursing's decision? Is it the physician's decision? Is it the CEO's decision, the COO's decision? Especially when you're looking at investing in resources for something like culture change. Who, is it HR's decision? Who ultimately makes that decision? And what I've learned over the years and understanding the true power of a leader is that they create an environment of engagement, as you said, and they actually sit in a room with people having the discussion about, say, in this case, it's culture change, and they just listen. They listen, they ask input from everyone. We say this with culture change, it's top-down, bottom-up, and everything in between. It can't just be a group of leaders sitting around a conference room saying, okay, how are we going to make things better here? And it starts there with, Are we going to make things better? Are we going to tackle this? But then at that point, it's really about engaging everyone in the process. Even that housekeeper who's working the night shift needs to have a voice. And when I think about, I love the structure, it's, what does consensus look like? How do we know that we've gotten there and what's the timeline for this? But then if we can't come to some type of agreement, who will ultimately make that decision? And that is important. However, whoever needs to make that decision needs to be part of the conversations and do more listening than talking.

Mitch Kusy:
I agree. Here's a little exercise your listeners can engage in, whether or not you're in a culture change initiative or not, you're all leaders, you run team meetings, etc. Go to your next team meeting where you're leading it and a major decision that has to be made and ask the group on a sheet of paper to document how the decision will be made. I will bet you will come up with 3 to 4 different ways that people perceive the decision will be made, and that's the leader's fault by not sharing and having this discussion up front ahead of time for engaging in decision-making.

Renee Thompson:
Yes, we could actually take that advice that you gave and apply it to a thousand other situations. … Deciding up front, okay, we've started doing this and you know this, Mitch, with the meetings that we have on our team, why are we meeting? What's the purpose of this meeting? Is this a meeting that is a meeting to make a decision or is this a meeting to discuss? We just want to have a discussion about this first. And I think, especially when it comes to something like culture change, when you're asking people who aren't convinced there's no bullying out there, it's a made-up term. Maybe that first conversation is just that, a discussion, and the sharing of the evidence. But then at some point, it's the, okay, my recommendation or our recommendation is that we do something about this and then what does that look like? So I think all points, very well taken. And so, Mitch, would you mind just, as we start to wrap up, just giving a recap of your three strategies?

Mitch Kusy:
Love to do that. Here's a simple way to think about it. For strategy one, don't go in alone all the time. And related to that, where you're bringing in key stakeholders who have a stake in the success of the outcome, be sure, related to this strategy, you start with a problem or opportunity, so that's the first. The second strategy is bringing the evidence, bringing the evidence from two perspectives, bringing the evidence from an internal perspective, if there are opportunities for that, and bringing some external evidence that are from documented research studies, maybe some benchmark organization, a critical benchmark organization is, hey, this is what Mayo Clinic is doing. If Mayo Clinic is doing it, there's a high probability it's going to be successful, so it doesn't have to always be researched. So that's the second strategy. And the third strategy is to identify what the decision-making strategy is before you engage in the culture change initiative. Is it that individuals are going to provide input to a leader or a leadership team, and that team decides, or that individual decides? Is it going to be based on consensus and consensus about support? Be sure you place a time parameter on consensus, and if consensus isn't achieved within this time parameter, here is how the decision will be made. Those are the three strategies.

Renee Thompson:
I think, especially if you're on the executive team and you're listening to this, very powerful, especially when it comes to decision-making. So I so appreciate your fantastic strategies, Mitch, and your insight into this issue. And again, going back to why we were having this conversation, we know that a lot of people, they don't think that culture change is important, that they think it's, oh, you just wanted us to be nice to each other. It goes so far beyond just being nice, and I always say, I want people to be nice to each other, but that's not what this is about. We have hard evidence that actually shows, improves disruptive behaviors and the negative impact that they have on pretty much everything. So as we wrap up, I always like to ask our guests, can you tell us one book? What book are you reading right now? What are you reading?

Mitch Kusy:
I'm reading a book that's called, actually two books. One, it's called After the Miracle. And its subtitle is The Political Crusades of Helen Keller.

Renee Thompson:
Really?

Mitch Kusy:
This is, I can't put this book down. I have discovered some things about Helen Keller. She had some social causes she was adamant about, and this is in the early 1900s. She graduated from Radcliffe College, which was then the women's college associated with Harvard. So essentially she graduated from Harvard. She speaks several languages. It's just amazing. So whole 'nother view of Helen Keller.

Renee Thompson:
Okay, I'm going to have to definitely put that one.

Mitch Kusy:
After the Miracle. It's, truly is an amazing book. And the other book is one by Dr. Deborah Myerson called Tempered Radicals, and essentially it's her research on how individuals make change in organizations in quiet ways. And you've heard me talk about my own organizational change motto, and the motto is, The most successful organizational change is not always about a bold stroke, but a long, steady march. And that, in her book, Tempered Radicals, demonstrates how individuals in small ways bring about major change in organizations.

Renee Thompson:
You know what, Mitch? I actually think I read that book when I was working in a corporate position, and I was encouraged to think like a tempered radical. I'm going to have to look at that to see if that's the same book, because it sounds…

Mitch Kusy:
Here's a classic example that Deborah Myerson, 15 seconds, and I know we're way out of time, someone at a meeting, a woman says something about, here's the strategy I think we should engage. And I know, when I relate this story to many women, they get it. And then, a gentleman at the meeting says exactly the same thing, and everybody goes, yeah, when it was the woman who initiated this conversation. So the tempered radical does this. Dave, I want to thank you for bringing forth Renee's great idea that she initiated. Thank you, Renee, and Dave, thank you for reinforcing Renee's idea. That's a tempered radical.

Renee Thompson:
I love it, because most people, they wouldn't say anything, but they would talk about, oh my God, … Dave.

Mitch Kusy:
They talk about it. That's a whole 'nother topic, gossip.

Renee Thompson:
Yeah, exactly. No, I definitely want to check that book out because I think I read it, but I'm not sure. And if you can just, if there's one leadership book that you would recommend to all leaders out there, what would it be?

Mitch Kusy:
Ash, let me think.

Renee Thompson:
Other than your.

Mitch Kusy:
Tempered Radicals. No, not my books. Tempered Radicals is really an incredible. I'd actually have to say it's the tempered radical book because that is one that focuses on what leaders can do in the immediate sphere that they have rather than these theoretical types of books. So I would recommend Tempered Radicals.

Renee Thompson:
All right, There you have it. Thank you so much, Mitch. And as we wrap up, I just want you to know that we'll have links to these books in our show notes, which you can actually find on our website, HealthyWorkforceInstitute.com/Podcast. And I just want to end by thanking you so much, Mitch, for being on our show and just keep up the great work that you're doing to cultivate and sustain a healthy work culture. Thanks, Mitch.

Mitch Kusy:
Thank you, Renee, and I adore working with you. So thanks so much.

Renee Thompson:
Thank you for listening to Coffee Break: Breaking the Cycle of Bullying in Healthcare – One Cup at a Time. If you found these practical strategies helpful, we invite you to click the Subscribe button and tune in every other week. For more information about our show and how we work with healthcare organizations to cultivate and sustain a healthy work culture free from bullying and incivility, visit HealthyWorkforceInstitute.com. Until our next cup of coffee, be kind, take care, and stay connected.

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