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Journal of Nursing Administration:
doi: 10.1097/NNA.0b013e318195a845
Departments: Prescription Positive

The Importance of Positive Culture in Hospitals

Huseman, Richard C. PhD

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Author Affiliation: Founder and CEO, Executive Development & Education, Oviedo, Florida.

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Correspondence: 670 West Palm Valley Drive, Suite 100, Oviedo, FL 32765 (

Reprinted with permission from Coaching Update newsletter. 2008; Summer:1-4. (

Are you a positive person? If you said "Yes," are you sure? To be certain, take the following test. Imagine that you are attending a banquet with 99 other people. You've finished the meal, and the banquet is coming to a close. As the toastmaster completes her announcements, she says, "And now for a special surprise. When you entered the room tonight, we wrote each of your names down on a slip of paper. The box in front of me contains all 100 names. I'm going to stir these names up and draw only one. The person whose name I draw will receive a $10,000 cash prize!" You now have 2 options:

1. Stand up and move toward the podium. The toastmaster is sure to draw your name.

2. Stay in your seat and say to yourself, "It probably won't be me. My chances are only 1 in a 100. I never win these things anyway."

If you are like most other people, you chose the second option. Realistically, your chances of winning are only 1 in 100. Realistically, you also have absolutely no control over whose name the toastmaster will pull from the box. Since you are now in such a realistic mood, let's offer another scenario.

You are now a prisoner in some far-off land. In fact, there are 100 prisoners in the room. It's about lunchtime, and the chief guard strolls into the room. He announces: "I've got some bad news for you. We have enough food for only 99 people. So I've written each of your names down on a slip of paper. The names are in this box. I'm going to stir these names up and draw one out. If I draw your name, we're going to take you outside and shoot you." You now have 2 options:

1. Stand up and walk to the door. The guard is sure to draw your name.

2. Stay in your seat and think, "It probably won't be me. My chances are only 1 in a 100. I never win these things anyway."

The irony in this illustration is that the odds in both situations are identical - 1 in 100. The amount of control we have is the same - none. If you forgive the pun…most of us think we will get the bullets and not the bucks.

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Negativity and the Ancient Brain

The human brain developed during a time when staying alive was the first priority for our earliest ancestors. Back in the Pleistocene Era, hominid brains were on constant alert to ensure survival: securing food and water, finding protection from the elements, staying alert for predators and other dangers, etc. Hominid brains were programmed to seek out potential catastrophe at every moment and around every corner.

You might pity our hominid ancestors and their "catastrophic brain" but their programming was the key to our successful existence and continuation as a species. And, despite the millions of years that have passed between their existence and our own, our brains still carry much of the same catastrophic wiring.

Excellent evidence of this catastrophic wiring is how the media attracts our attention today. Disaster, death, threats to safety and security, all trigger our catastrophic brains to pay attention and we become riveted to what the media presents as the latest potential dangers to our continued existence. Trying to stay positive and happy when we are inundated with these negative messages is quite a struggle.

Although most people would identify themselves as being "happy" and/or "positive," studies have repeatedly shown a strong tendency toward the opposite.

* We tend to remember failures more vividly than successes.

* We tend to react more strongly to negative stimulus than we do positive.

* We tend to trust negative information more than we do positive.

Many of us go through our day mostly blind to the good things in life and only pay attention when something goes wrong.

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The 6 Universal Emotions

Why do we as humans have such a strong tendency toward the negative? The ability to focus on negative emotions comes from our ancient danger/recognition system formed early in the brain's evolution. The pre-frontal cortex, which registers happiness, is the part used for higher thinking, an area that evolved later in human history. Consider the following list established by psychologists as the 6 universal human emotions: Fear, Anger, Sadness, Disgust, Surprise, and Joy.

Four of these emotions (bold italics below) are negative. Surprise is considered neutral, as it could be both a positive or negative surprise. Joy alone is positive. Psychologists tell us that this is due to our ancient mind. Each of these universal emotions alerts us to potential threats and suggests a different course of action.

* Fear tells us to run away when danger is near.

* Anger tells us to defend ourselves against aggressors.

* Sadness warns us to be cautious and save energy.

* Disgust urges us to avoid contamination.

* Surprise (good or bad) immediately heightens our awareness so that we can evaluate a situation.

Only Joy does not prompt a response. Joy simply tells us something good has happened and suggests that we do nothing, as our current situation is a good one. Unfortunately, however, it has been found that joy tends to be very short-lived. While negative emotions can persist over long periods of time, we quickly neutralize joy as we become settled into the status quo and then go back on alert for how our existence might be threatened.

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The Hedonic Treadmill

Our inability to maintain a sense of joy causes humans to be like a hamster on a wheel. We go round and round constantly seeking joy in our lives, but only achieve it for a short time before we move on to our next endeavor. Psychologists call this the "hedonic treadmill." We rapidly and inevitably adapt to good things by taking them for granted and then are forced to seek joy elsewhere. For example:

* The elation over a pay raise soon diminishes and work once again becomes a grind.

* The excitement over getting a new car barely lasts to its first oil change.

* The joy over a new computer or other electronic gadget lasts only as long as the next ad showing the more powerful and spiffy model available.

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The Impact of Negativity at Work

We spend a huge percentage of our lives at work. And if you think negativity is a dominant construct for an individual human mind, bring them together in community and the effect increases exponentially. Negativity is contagious and spreads quickly, especially within an organizational culture. "We engage in emotional contagion," states Sigal Barsade (1), a Wharton management professor who studies the influence of emotions on the workplace. "Emotions travel from person to person like a virus."

Recently, a study (2) of 1,100 employees and 300 senior human resource executives by Towers Perrin and their research partner, Gang & Gang, found that there is a huge difference between how people perceive their current work experience as opposed to their "ideal" work experience. In measuring the nature and intensity of employees' emotions about work, the study shows that on average, more than half of people's current emotion is negative at work and a third is intensely negative.

The top 5 reasons for this negativity are:

* An excessive workload

* Concerns about management's ability to lead the company forward successfully

* Anxiety about the future, particular longer-term job, income and retirement security

* Lack of challenge in their work, with boredom intensifying existing frustration about workload

* Insufficient recognition for the level of contribution and effort provided, and concerns that pay isn't commensurate with performance

Negative emotions at work not only impact productivity and performance, but also make retention a significant issue for many organizations. For instance, the study showed that among those who are intensely negative about their current experience, 28 percent were actively looking for a new job or poised to leave when anew opportunity arose. By contrast, those who felt strongly positive about their work only indicated that 6 percent were looking for a new job or were poised to leave.

Even more disturbing, lurking behind those numbers is the troubling fact that 25 percent of the intensely negative employees from the study plan to remain with their current employer. This implies that in many organizations, there is a potentially large group of negative workers coming to work each day with the simple intention of "hanging on" to their jobs. These workers are not only a problem in terms of their individual performance and productivity, but also their potential to adversely affect other employees and even customers with their negative attitudes and mindset. These workers are the carriers of the negativity virus that can quickly infect an entire organization.

Negativity in an organizational culture is detrimental not only to employees but also for customers. A negative employee attitude makes a huge impact on customer perceptions and satisfaction with an organization and/or its product(s). And, one bad experience is all it takes to damage and/or irreversibly impact customer loyalty.

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Scripting and Its Limitations

In an attempt to mitigate the impact of negative emotions and attitudes in the workplace, at least in terms of the customer experience, many organizations have adopted strategies for training employees to always present a positive "face" on behalf of the organization.

The advent of "scripting" has been a big part of this effort. Scripting is simply the organization's mandate for how employees communicate and interact with customers down to specific phrasing and/or terminology. The Ritz Carlton chain of hotels popularized scripting with their use of the phrase, "My pleasure" whenever responding to a guest's request. The phrase "My pleasure" has become so popular that it can now be heard uttered by those who serve us at fast-food drive-through windows.

However, many leaders have now realized that scripting can not eliminate negativity from employee/customer interactions. Just saying the prescribed words does not eliminate the fact that communication can be significantly colored by the general mood of the employee delivering the scripted lines - even if the employee is trying his or her best to be perceived as positive. "You may not think you are showing emotion, but there's a good chance you are in your facial expression or body language," says Barsade.1 "Emotions we don't even realize we are feeling can influence our thoughts and behaviors."

"Surface acting" occurs when a tired and stressed customer service agent forces himself to smile and be friendly, and it is almost always quickly detected by customers. For example, a nurse shares a story of when an elderly patient pushed his call button late one night. The nurse already felt as though she had too much to do and not enough time. When she went to the patient's room, she stated her hospital's scripted line of, "How can I make you more comfortable, Mr. [Patient Name]." Despite her words, the nurse's non-verbal behavior was screaming, "I don't have time for this!" The patient took one look at the nurse and said, "Never mind, I'll save my question for someone else. I can see you are in too much of a rush to be a good nurse." The nurse was so humbled by the experience that she tells this story as if it happened yesterday when it was a lesson she learned more than 20 years ago.

A final note on scripting is that in addition to its practice not necessarily improving employee/customer communication, many employees develop resentment toward it, breeding additional negativity into that organization's culture.

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The Need for a Positive Culture: The Challenge for Hospital Leaders

The consequences of a negative hospital culture are staggering not only in terms of productivity and performance losses among employees, but the implications for patient safety and satisfaction. Consider a recent study that showed that cardiac care units in hospitals where the nurses' general mood was "depressed" had a death rate among patients 4 times higher than on comparable units!

It would be a grand understatement to say that hospitals are stressful work environments. Hospitals face all the challenges of any large, multi-functional organization plus the demands of serving customers (ie, patients) who, for the most part, hoped they would never need to make use of the hospital's services in the first place. Ask anyone entering an emergency room or coming in for non-elective care if they actually want to be in a hospital and the answer will most likely be a resounding, "No!"

As such, negativity is actually bred into the health care mix. The very people whom hospitals serve often enter their experience with a negative predisposition. Frightened, ill patients with worried family and friends make tough customers for hospitals. From the perspective of hospital staff, to achieve any level of patient satisfaction is an uphill struggle to begin with. Add to this long hours, staff and equipment shortages, budget constraints, and lack of recognition for their hard work - is it any wonder hospitals battle negativity at every turn?

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Promoting a Positive Culture

Promoting a positive culture is absolutely essential for any hospital. Referring back to the Towers Perrin study,2employees identified 3 strong needs that drive their positive outlook, performance and dedication to their organization.

* The need to feel connected to and competent in their work

* The need to strengthen/develop their capabilities and build their careers

* The need for recognition

These 3 needs have a common line of contact: an employee's immediate leader all heavily impacts them.

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The Immediate Leader and Promoting a Positive Culture

The immediate leader at every level of an organization has the most significant impact on an employee's perception of their job. Leaders are the ones who can help fill the need for their employees to feel connected and competent at work. Leaders can develop and grow employees in their skills and careers. Most importantly, leaders can provide recognition for good performance.

In the sometimes-thankless world of healthcare, it is the leader who can show appreciation and praise employees for the hard work they put in each day. A relatively brief moment of genuine praise can counteract a day's, week's or even month's worth of negativity. Having leaders at every level of a hospital adopt a leadership style utilizing praise and recognition is one of the quickest ways to counteract negativity.

And, it is the virus of negativity that must be battled in order to help sick hospitals become well. Only a positive culture can secure the health and wellness for a hospital, its employees and its patients.

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1. Barsade SG, Gibson DE. Why does Affect Matter in Organizations? Academy of Management's Perspectives. 2007;February;36-59. Available at: Accessed September 26, 2008.

2. Towers Perrin. Working today: Understanding what drives employee engagement. Available at: Accessed September 26, 2008.

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