Since 2006, our nurse-led healthy work environment research team at a large academic medical center has studied the impact of disruptive behavior on the work environment and, specifically nurses and patients5-7. After several years of focusing on the causes and negative consequences of disruptive behavior, and evaluating the impact of a positive-psychology intervention in nursing units, the team had a transformative insight: the lens through which we view the issues profoundly alters not only what we learn, but our capacity to respond. What we see is determined by where and how we look. When focusing attention and conversations on challenges, problems and egregious behaviors, we are choosing a scarcity (or deficits) lens. This choice impacts what we discover. Albeit unintentionally, when we focus on identifying, understanding and reducing the factors that negatively impact our work environment we reinforce four incorrect perceptions: (1) these negative factors are normative/usual; (2) there is more wrong with us than right with us, (3) the problems are beyond our control, and (4) most nurses are not senior/powerful/respected enough to influence positive change. In 2013, focus groups about job enjoyment with frontline registered nurses and nurse managers throughout the institution revealed pervasive narratives about perceived lack of power and influence to improve their work environment. These fell into two groups: “nurses are not (fill in an adjective) enough” and “nurses do not have enough (fill in a noun)” to influence the work environment. Concerned, the team committed to learning the reasons for these perceptions.
Even though focus group discussions identified most of the negative factors described in the job satisfaction literature,8 without exception the greatest threat to nurses’ job enjoyment was perceived or real harm to patients and families. Qualitative analysis also revealed discordance between nurses’ clinical confidence and ability to problem-solve on behalf of their patients, and their perceived helplessness to change their own work environment. Specifically, the team noted that although nurses knew what needed to change, they could not describe how it would happen; often resorting to comments such as: "that's above my pay grade", negative non-verbal expressions or silence. This led us to look at what was not being said, and revealed that the foundational issue underlying job enjoyment was the presence or absence of specific trust-building behaviors in their work environments. Although nurses seldom used the word trust, the stories they told clearly described the impact of trust behaviors on the work environment. Specifically, we learned what is possible when trust building behaviors are present in the work environment, and what is compromised when they are not.
Given that trust is a complex construct, often difficult to understand and describe, the team’s major recommendation was that nursing leadership adopt a trust framework to engage nursing staff in conversations about trust and trust building in the work environment. Nursing leadership committed to using the Reina Dimensions of Trust: The Three Cs model®, 9 and deployed the Reina Team Trust Scale® 10 throughout nursing. To facilitate the Reina’s strengths-focused survey debriefing process, we trained a cohort of volunteer Trust Ambassadors, who reminded us how challenging it is to keep work environment-related conversations focused on strengths.
Together, we identified five reasons for adopting a strengths-focused approach: (1) Humans are biologically programmed to identify and remember threats and scarcity, (2) nurses are trained to be vigilant for errors and threats to patient safety, (3) institutional leadership’s response to surveys is to focus on areas of weakness, (4) we initiate root cause analyses when things go wrong – not when they go well, with the result that (5) our comfort and skill with strengths-focused conversations and root cause analyses is limited.
The survey debriefing experience taught us that although nurses responded favorably to the strengths-focused debriefings and found conversations about their strengths encouraging; overcoming the scarcity-focus bias will require clear direction, tools and practice. Leadership must be vigilant for the presence of conflicting messaging to avoid reinforcing the negative narratives.
In this presentation, we will describe both completed and ongoing work to build a strengths-focused culture including: development of a strengths-focused integrated debriefing process that has been used to debrief all institutional surveys involving nurses since 2015; developing nurse leaders’ self-mastery to notice and mitigate physiological response to stress, fear and scarcity; and training in inquiry to build trust and support generative conversations about nursing’s strengths and resilience.
Adopting a strengths-focus does not discount the many real challenges nurses face, but changes the way we understand and respond to these. Developing a strengths-focused culture is not quick or easy, but it is an important investment in creating and sustaining healthier work environments.