IN 2020, the year of the nurse and midwife,1 health care leaders were called upon to lead their teams more than ever before. When the pandemic threat was introduced to the United States, the crisis became very real, almost overnight. Without advanced warning, leaders had little time to prepare for the significant challenges coronavirus-2019 (COVID-19) would bring. Leaders had their own concerns, anxieties, and fears about what was happening. Some also had children at home who needed home schooling, a spouse or partner who got laid off, or elderly parents who were at risk. Yet, when leaders crossed the threshold of their workspace, they had to put their game face on for their employees.
Leading a team pre-pandemic was not easy but it was manageable. After all, nurses have been caring for patients for centuries. However, leading a team through a global pandemic was something leaders were not equipped to do. Health care leaders, like all leaders, were caught off guard and are still dealing with the consequences. However, some leaders managed to handle the crisis well and build stronger teams because of it. What lessons can we learn from them? This article provides nursing leaders with best practices learned from successful leaders.
WHEN THE CRISIS HIT
When COVID-19 hit, leaders kept telling their staff that they were in this together; they were all going to get through the crisis as a team. “We got this” became their mantra. It is because they thought there was a finish line and that finish line was in sight—just a few months of crisis and they would go back to normal. Then the virus moved the finish line. While health care teams expected the virus to be a temporary interruption in normal workflow, caring for patients in a crisis became the new norm. Nurses quickly found themselves a part of the family unit, often stepping in as the last person to be with a dying patient, connected to their loved ones only by a cell phone. As a result, teams slowly lost their momentum to continue fighting the virus.
When the pendulum swung from crisis to the development of new norms, leaders faced a new challenge—the overwhelming rise in burnout and disruptive behaviors. With millions of cases of COVID-19 in the United States and no end in sight, nurses were getting beat up physically, mentally, and emotionally. As a result, the leaders experienced an uptick in disruptive behaviors—even among their “good” employees. COVID-19 had exacerbated an already troublesome problem in nursing, bullying and burnout, which have plagued the nursing profession for decades. Leaders had to shift from protecting employees by ensuring they had enough personal protective equipment (PPE) to protecting employees from burnout and bullying. These added another heavy burden onto the leader's already weakened shoulders.
CULTIVATING HIGH-PERFORMING TEAMS
In a 2020 study, researchers Dhingra et al2 suggested that during times of crisis a “purpose audit” helps team members determine how their work fits into the big picture. Bringing teams together and reminding them of their purpose help to build team camaraderie, carry them through the immediate crisis, and help to sustain the momentum after the pandemic is over. However, making sure employees had the best PPE became the top priority, while gathering employees together to build camaraderie around, a common purpose fell to the bottom of the list.
The significance of team purpose in building team success has been heralded by hundreds of studies on team effectiveness. In one landmark study, researchers Larson and LaFasto3 studied heralded teams including cardiovascular surgery teams, teams from the Centers for Disease Control and Prevention, mountain-climbing teams, the Space Shuttle Challenger investigation team, and even the McDonald's Chicken McNugget team. They discovered that all these successful teams had one common characteristic—a clear, overriding sense of purpose. When the COVID pandemic hit initially, health care teams intuitively knew their purpose was to act with urgency to triage, isolate, and care for patients suffering from COVID-19. The critical question is what did successful nursing leaders do to maintain the momentum as the crisis continued? We answer this question from both the research and our experience providing leaders with the skills they need to cultivate and sustain professional and respectful teams.
COMMON MISTAKES MADE DURING THE CRISIS
Managing a department within a health care organization requires mastering a select group of skills: managing performance, budgets, payroll, staffing, and compliance and building successful teams. Although not quite as commonplace, managers are also engaged in leadership development and taught how to be an effective leader. However, who could have predicted leaders would also be required to lead their teams during a global pandemic of epic proportions?
At the Healthy Workforce Institute, we equip health care leaders with the skills and tools they need to address disruptive behaviors by setting behavioral expectations and holding their employees accountable for professional conduct. As a part of our interventions, we engage individual, team, and large system change. This may include coaching, team building, performance management, and culture change initiatives. This affords us the ability to learn what leaders are experiencing so that we can customize our strategies to meet their needs. Sharing struggles with an external advisor also provides leaders with a safe place to talk. After engaging in conversations with more than 400 leaders throughout the COVID-19 crisis, we discovered 2 common mistakes from front-line leaders that contributed to increased dysfunction among their teams—losing trust and ignoring disruptive behaviors.
Broken promises leading to broken trust
Leaders shared that they too were caught off guard when the pandemic hit and were not sure how to address their employees concerns. It seemed, as though overnight, they had to completely shift their priorities from the typical day-to-day operations of managing their department to adding task force meetings to their already busy schedule, dealing with the threat of not having enough PPE for their staff, and the uncertainty of receiving COVID-19 patients. There was not time to figure out how they needed to show up differently as a leader to lead their teams through the crisis. Therefore, many leaders when faced with a team filled with anxiety and uncertainty tried to alleviate employee fears by making promises. However, by doing so, they lost trust with their team.
When the crisis hit, one leader promised her surgical center team that they would remain open and that nobody would be asked to cut their hours. One week later, she asked more than half of her staff to take personal time off because they were reducing their cases by 75%.
Another leader promised his staff that their department would remain intact as a medical oncology unit. One week later, he let his staff know they were converting their unit to a COVID-positive unit and the entire team had to go through urgent training, requiring them to work overtime and different shifts.
To make matters worse, leaders shared information during huddles about how new cases are being handled and what type of PPE is recommended when, in fact, they did not clearly understand but were expected to convey information with confidence. An hour later after returning from a COVID-19 task force meeting, leaders rehuddled with their teams and said, “Scratch everything I said an hour ago; we're handling them this way.” Staff became frustrated and started acting out because leaders kept changing the information.
Trust is one of the most critical elements for team success. Frei and Morriss4 found that there are 3 core drivers of trust: authenticity, logic, and empathy. When evaluating each in relationship to what the leaders shared with us, it is easy to see why some teams lost trust in their leaders.
- Authenticity—when team members believe they are engaging with the real you.
- Leaders also had their own fears and anxieties, yet felt that they had to put their “game face” on when communicating with their teams. They, in a sense, pretended that everything was okay. However, their staff could see that they were not being authentic.
- Logic—when they have faith in your judgment and competence.
- Communicating information that contradicted the previous information shared without also conveying, with confidence, the reason. Or saying, “Well, don't blame me. I'm just the messenger” undermines the leader's credibility.
- Empathy—when they feel you care about them.
Leaders were so focused on making sure they were staffed appropriately, that they had enough PPE for their teams, and that they were participating in the numerous meetings required by their organization, and that they had little time to spend with their teams. Many shared that they “flew in and flew out” of their departments all day and felt disconnected from their staff. Over time, their staff felt disconnected from them too and, therefore, felt that their leaders did not care about them.
Many leaders shared that they struggled delivering information that, at times, they did not agree with. They were told by their executives to make decisions that were in direct opposition to the information and, at times, promises they just made. Over time, leaders could not keep pretending that everything was going to be okay. As a result, staff did not see them as authentic, credible, or trustworthy. Teams lost faith in their leaders and believed they only cared about the organization's bottom line and not about them as individuals. These leaders had good intent but had unintentionally increased anxiety and stress for their staff and broken their trust.
Rising disruptive behaviors that were ignored
During the crisis we saw the best and worst in people. Even though health care professionals were recognized across the globe as heroes, there was a dramatic uptick in disruptive behaviors. Nitpicking, pettiness, and complaining increased. Leaders experienced a rise in disruptive behaviors even by their “good” nurses. The problem is either they did not have the energy to deal with it or they justified their employee's disruptive behavior, knowing how hard it was for their staff. As a result, they ignored their bad behavior.
One manager shared that he felt guilty reprimanding one of his nurses for overtly yelling at a respiratory therapist in front of a patient. He normally would address the behavior immediately, but when he approached her, he could see the angst in her eyes and marks on her face from wearing an N95 mask all day. He just walked away.
Another manager asked for help to address a nurse who grabbed 20 N95 respirators knowing they only had 60 total for everyone. The nurse manager previously told the staff to only take one at a time. When she confronted her, she stomped down the hallway (in front of patients' rooms) yelling, “This is so ridiculous! I guess we'll all get COVID, too!”
Another nurse leader said that he had worked extremely hard to establish a healthy workforce culture. He set behavioral expectations with his staff, confronted any incidents of disruptive behaviors, and worked with his human resources partner to hold people accountable for professional behavior. He was finally starting to see the fruits of his labor when COVID-19 hit. Very quickly, some of his previous “offenders” started acting up again. However, he understood that their behavior was based on stress, so he ignored it; he even justified their bad behavior because he also was too stressed and did not have the energy to deal with it. Now, he feels like his staff and he have resorted back to the way behaviors were before—dysfunctional and disrespectful.
Leaders tried to accommodate, defend, rationalize, or ignore disruptive behaviors when they showed up. Yet, numerous studies show the negative impact bullying and incivility have on employees and patient outcomes.
Disruptive behaviors can lead to the following results in many documented studies as identified in Table 1.
Table 1. -
Research on Disruptive Behaviors
Patient errors: 51% of nurses reported an increase in patient errors because of verbal abuse.5
Decrease in critical thinking: 57.6% of pediatric nurses reported a decreased ability to engage in critical thinking because of disruptive physicians.6
Circuitous medical interpretations: In a survey conducted by the Institute for Safe Medication Practices, 75% reported going to a colleague to interpret an order rather than interact with an intimidating provider.7
Medical errors could have been avoided: 71% reported a link between disruptive behaviors and negative patient outcomes; 75% reported these outcomes could have been avoided.8
Poor teamwork: In a study of over 9000 health care professionals in 325 settings across 16 hospitals, disruptive behaviors were significantly correlated with poorer teamwork and decreased patient safety (P < .001).9
Increased financial cost: Research discovered that 51% of targets of the toxic behaviors are likely to quit10; 12% do.11 Further, human resource metrics demonstrated that the replacement costs for employees who quit are 30%, 150%, and 400%, respectively, in each of the 3 categories—entry, mid, and high, respectively.12 And often those who quit may be your top performers!
As a result of being asked to lead without careful preparation, dealing with their own fears and anxieties, and competing with a finish line that keeps moving away, leaders did not have the skills and guidance to make good decisions or address disruptive behaviors well.
While these same challenges occurred in most health care organizations, some teams were able to pull together and become stronger while other teams pulled apart—same circumstance yet different responses. What was the common denominator with the teams that pulled together? It was the leader.
Team dynamics can ebb and flow depending on a variety of factors. At times, some teams backpedaled while others shot forward because they used the skills and tools already learned and applied them to a new situation. These teams were also led by an authentic, logical, and empathetic leader who consistently showed up inspiring confidence and commitment to doing what it takes to get through the crisis together. While talking with our clients, we discovered that the leaders who managed to pull their teams together and become stronger throughout the crisis exhibited common behaviors, as we identify in Table 2.
Table 2. -
5 Leader Behaviors to Build a Strong, Cohesive Team
Be honest about what you don't know
Be visible and “get dirty” first
Address disruptive behaviors
Focus on the present
Show your team you care
They were honest about what they did not know
They let their team know that the crisis was evolving rapidly and that they were sharing information with them as they were getting it. Therefore, the information they are giving them now might change in an hour and that they need to be okay with that. They admitted that they did not have all the answers and were learning just like their staff. They told the truth and increased the frequency of their communication.
These leaders prepared their teams to expect frequent changes so that, when it happened, it caused less anxiety and stress. For example, here is a quote from one leader that demonstrates this during her team huddle.
I need you to trust that our administrators, the leaders in our organization, are making the very best decisions based on the information that they have now. We know that this might change in an hour or three hours or tomorrow, and I need you to trust that we're doing everything that we can to keep our patients and you all safe.
They were visible and “got dirty” first
When COVID-19 hit, every health care organization immediately created task forces to prepare for the predicted surge in patients. Multiple meetings required leaders to spend the majority of time away from their units. As a result, many staff felt abandoned and alone. The leaders who managed to successfully lead their teams through the crisis made visibility a priority.
They rounded on their employees upon their arrival, announced when they were leaving to attend a meeting, let them know how long they would be gone, and let everyone know when they returned. By doing this, the staff gained trust that their leaders were not hanging out in meetings while they were scrambling to care for patients.
When the first COVID-19-positive patients arrived, they got dirty first. One leader shared that when her department received their first positive patient, the staff hesitated, were almost paralyzed with fear. She immediately gowned and gloved, took her nurse by the hand, and walked into the patient's room together. These leaders demonstrated, “We're in this together” in a powerful way.
They continued to address any incidents of disruptive behaviors
Dealing with bullying does not happen through osmosis. Especially during times of crisis, leaders need structured vehicles to erode bullying behaviors. It is about being intentional. Kusy13 has identified several intentional approaches to dealing with disruptive behaviors; the one at the top of the list is to share hard data with staff. Psychologists often pronounce that awareness is the first call to action.
One of the very first strategies to reducing incidents of disruptive behaviors is for nursing leaders to understand the deleterious effects of disruptive behaviors on patient care and share associated data—even during a crisis. Leaders who successfully addressed disruptive behaviors integrated data about the negative impact of disruptive behaviors into team discussions.
Leaders recognized that many times their staff were acting out because they were stressed. However, they were still willing to address any incidents of negative, unprofessional behavior in a way that showed they understood. They were honest, “It's not okay for you to behave this way.” And respectful. “Are you okay?” Further, when dealing with staff who are nitpicking and petty, successful leaders addressed it immediately and did so with respect. Sample scripts include:
During crisis, we see the best in people and the worst. Your coworkers and our patients need you to be your very best, because neither you nor I have any extra energy to give to pettiness, complaining or comparing. Not today.
Can I count on you to be your very best today?
Many employees forecasted into the future and all they saw is gloom and doom. They watched the news (on their phones), read every post on social media. Constant negative messages can affect an employee's productivity and performance.
Leaders reminded their teams that they had control over today and to focus today on doing the best that they could for their patients and for each other. It was not easy. And here is where some of the patient experience data we shared earlier in this article can come to roost. Remind your team how all our behaviors impact patients—positively and negatively. These data are easy to forget in times of crisis. Rather than come down on an individual by saying “Don't do that anymore” (metaphorically speaking), share how their behavior could impact patient care. And do not save hard data for just the negative incidents; share hard data for the good ones as well. For example, Harvard researchers Amabile and Kramer14 discovered that on a “good” day—when employees feel most alive, 76% of them reported that they received feedback on progress that they have made toward a goal. Interestingly, on a bad day people reported that they did not receive feedback on this progress goal. Leaders who strengthened their teams reminded them that unprecedented times call for extraordinary courage, compassion, and commitment day by day. It is during a crisis that leaders need to go overboard in giving positive and constructive feedback on progress toward a goal.
Leaders showed their team they cared about them
A primary essence of team development is not always about structure. It is often the caring relationships we build with each other. Leaders who strengthened their teams took the time to show they cared by giving them permission to express emotions and encouraging them to talk. They created forums or huddles to engage staff in productive discussions that impacted the present. They built trust and illustrated empathy and connection.
GIVE THEM PERMISSION TO EXPRESS EMOTIONS
Strong, courageous health care professionals at times do not think they should show emotion or vulnerability. After all, this is “what we do.” When in a crisis situation like an unexpected death of a patient or colleague, give them permission to be sad, to cry, to be angry. Courageous leaders took a moment to collectively honor someone's feelings before they go back to their work.
Successful leaders let their staff know that what they were feeling (guilt, anger, sorrow, etc) was normal. That it was okay to feel whatever they were feeling and not to necessarily fight it or bury their feelings, but rather to recognize them—give names to them so that they can deal with those feelings. Reassuring their staff that the situation was difficult, the leader was confident they had the right people to get through the crisis helps teams to manage negative emotions.
LET THEM TALK
When feelings are not expressed, they can sometimes get so repressed that they are released in very destructive ways. Give them a safe place to talk. Doing so can feel very cathartic and help to alleviate negative feelings. Sometimes leaders believe that they must come up with solutions if they allow staff to vent. Psychologists have noted that venting in and of itself can decrease stress and anxiety.
As the year of the nurse and midwife concludes, it will be the front-line staff and their leaders who will lead the way into the next year and beyond. We cannot do it all. We can only change our own leader behaviors one step at a time—what we refer to as “the baby steps of change.” Like the Phoenix who rises from the ashes, so will nursing leaders.