Leading an organizational culture change? Consider an apology first. [PODCAST]

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“While patients, the workforce, and key outcomes are way better off in a culture of safety, the process from toxic to healthy culture requires a challenging shift from relationships rooted in distrust to trusting ones. To ensure long-term meaningful change, leaders must steadfastly create a foundation of trust.

An apology that acknowledges poor behaviors have occurred, are hurtful, and will not be tolerated will help build trust and open hearts and minds to new ways of being. It will also model ownership and create rich opportunities for listening. All are integral to healthy cultures.”

Beth Boynton is a nurse and consultant.

She shares her story and discusses her KevinMD article, “Leading an organizational culture change? Consider an apology first.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today on the show, we have Beth Boynton. She’s a nurse and a consultant. We’re going to talk about her KevinMD article, “Leading an organizational culture change? Consider an apology first.” Beth, welcome to the show.

Beth Boynton: Thank you, Kevin. I’m happy to be here. I just found out that you were also in New Hampshire, on the Seacoast, so we’re practically neighbors.

Kevin Pho: We are, just about an hour away. So we’re going to talk about your article a little bit, but first off, briefly share your story and journey to where you are today.

Beth Boynton: So I studied biochemistry before I went to nursing school. I went to nursing school in my late 20s and discovered, “Wow, this is really a rigorous program of study.” I got out of nursing school and started working in the typical hospital settings. I got into occupational health and home health, where I really enjoyed those places, I think because I had a little more autonomy. I got in a serious relationship, bought a house, got a dog, and had a kid. I was in that relationship for about 10 years, and then my partner left me, and so that was a difficult, painful point in my life and career.

It got me into counseling, where I started to realize that I gave up my voice in relationships. As a nurse, I was a really good advocate for other people, but I wasn’t very good at advocating for myself. So I started going down this path of learning to identify my own needs and desires and how to express them respectfully. Also, I was taking improv classes as kind of a hobby, and I discovered there that some of the things, like self-expression and confidence, I was learning about in therapy, but I could actually practice them in improv, and it was more fun than some of the personal work.

And then in my career, as I started to become more assertive for myself, I discovered that it was really hard to be in the environment that I was working in. A quick example: I would be asked to work overtime, and I’d say, “I can’t. My son’s with me.” My boss would say, “There’s the door.” My peers would say, “Well, I had to do it,” or, “Can’t you do just one weekend?” And that kind of stuff. So there was a point around the turn of the century where I was fed up. I felt like I couldn’t be healthy as a nurse, so I was like, “I’m going to go to graduate school. I’m going to study something in organization and management.”

I used improv. I developed a model to teach emotional intelligence and communication to kids. I got out of graduate school and started building a business that way. And then I was asked to teach a course to graduate students in contemporary issues in health care, and that’s when the Institute of Medicine was publishing To Err Is Human and Crossing the Quality Chasm. We were discovering, “Oh, we’re making a lot of mistakes,” and a lot of those mistakes have a basis in communication.

So I realized the stuff I was teaching using theater games with kids, I could use with adults. I started developing a consulting business teaching communication and writing about communication, and I started to use little experiential activities from improv in my workshops. And I was like, “Oh, that’s what works.” I can talk about listening until the cows come home, but if I can give somebody an experience where they get to practice listening with their peers and then debrief it with their peers, that’s when the light bulbs go off. So more and more, I’ve been integrating improv and focusing on improv as an experiential teaching modality.

And I’ve also been honored to write a couple of books. I’ve written a textbook called Successful Nurse Communication, and the revision that’s coming out by F.A. Davis this December is Complexity Leadership. I was asked to co-author a third edition of that book. And so I have this very academic part of my career, and then this other part that’s a little bit more informal in terms of how I approach education. So that’s kind of the story.

Kevin Pho: Now, this isn’t the first time I’ve heard about that intersection between improv, improvisation, and health care. Go into a little bit more detail. Give us a story or an example about how improv skills can help us with communication skills in the health care setting.

Beth Boynton: Sure, I’ll give you a couple of examples. One is an activity called Same Time Story, and that’s where one person is telling a story and another person is supposed to try to tell it at the same time, which sounds like it’s impossible, a story mirror. But what happens is this person has to slow down, and this person has to really pay attention, and they can’t actually be thinking of 20 other things, which we tend to do, and which interferes with our listening. So that’s a fun activity. People are a little silly with it, but then we debrief: “How was that activity for you?”

And in fact, I had one nurse tell me once that was the first time she ever felt heard. And so when I hear that, I think, “Oh my gosh, how are we ever going to expect her to be a good listener if she doesn’t know what it feels like to be heard?” So that’s one example.

Kevin Pho: So let’s talk about your KevinMD article. It’s titled “Leading an organizational culture change? Consider an apology first.” Now, for those of you who get a chance to read your article, just walk my audience through it, and share the story of why you decided to write it.

Beth Boynton: Yeah. We know that we need to create cultures of safety, and we’ve known that for a long time. And I think one of the things that gets lost is that we don’t realize that trust, broken trust, is at the bottom of many of these toxic, bullying, or blaming cultures, and that if we’re really going to change them, we have to rebuild trust.

And so in the article, I talk a little bit about how mistrust becomes ingrained in our relationships. It’s like, “I don’t trust you. You don’t trust me.” We form alignments, we form relationships that are based on mistrust rather than on trust. Instead of learning from each other, we might blame each other for an issue, or we might withhold information. So we don’t have trust. We have all the gossiping, blaming, bullying, and withholding, things that we hear about all the time but don’t necessarily change. So I talk a little bit about that.

And then I talk about why, if we really want to change them, one of the important things to start with is to acknowledge that inappropriate behavior is not OK. It never was, and it isn’t going to be that way from now on. But to make having an apology part of that message, so that you can own it. It’s almost like modeling ownership of the problem. And so in the article, I write a sample letter, “Dear staff,” and I’m writing as a CEO, “This is what the new expectation is, and I want you to know that it wasn’t OK and it won’t be OK, and these are some steps that we’re taking.” And that is not going to be changing the whole culture right there, but it’s a place to start building trust.

Kevin Pho: Now, when you said that a lot of relationships in the hospital and health care setting are sometimes based on mistrust, where are those divisions? Are we talking about nurses and clinicians? Are we talking about administrators and health care staff? So tell us about some of the divisions that you see in the health care setting.

Beth Boynton: Kevin, I think they’re throughout. They can be. I mean, there are healthy organizations out there, and all the power to the people that work in them. I think there are mistrusts among nurses. I think between doctors and nurses, between senior leaders and managers, between managers and staff, and between nurses and nurses’ aides. I just don’t think we have a solid foundation of trust in many places.

Kevin Pho: So when you say, “Consider an apology first,” that speaks to a person’s or an entity’s humility, right? And I agree with you that that is one of the best ways that we can build trust. So from a clinician standpoint, if we wanted to change a culture, start with an apology first. So give us some advice in terms of how we can do that, how we can present that apology and reach out with that olive branch.

Beth Boynton: Well, I think it probably starts with self-reflection and ownership, like, “What’s my part in this issue?” And so if I can take a deep breath and not be defensive and try to consider the other person’s perspective, then I can get to a place of having some ownership and understanding. That’s like clinician to clinician.

Kevin Pho: I think that’s a little bit hard, right? Just having that self-reflection. Now, if we can do that in our society, it would be much less politicized and polarized, right? It’s very hard. You have that background in improvisation and things like that, so give us some advice, because you make it sound so easy, just have this self-reflection, but in the moment, it’s actually very difficult. It’s very hard. How do you advise us to do that?

Beth Boynton: And I think it’s even harder in our profession, because we are under this constant, relentless pressure, and it’s always high stakes. So how are we going to change? It’s a behavior. How are we going to change behavior when we have this constant stress? And I think the place to start is, “I’m going to respect myself, and I’m going to respect you. I’m going to respect the limits that I have. I’m going to respect the limits that you have.” I think that’s a really good place to start. And if doctors and nurses and all the clinicians in the world can do that, we can have a serious impact on the cultures that we work in.

I mean, right now, and this might sound a little flippant or something, but I think the tail is wagging the dog. And I think you had a post on LinkedIn recently about the importance of doctors’ voices, and I say the same about nurses’ voices. And if we can come from a place of respect for ourselves and each other, and clearly state what we need and what we want to have in terms of a safe, respectful environment with the resources that we need, and to be able to say, “No, I can’t do that. I have to go home. I have my family. I have my improv class,” or whatever other self-care piece. That makes me think of the other point, about self-care, because maybe that fits in with self-respect. I think that’s really important for us.

Kevin Pho: So give us an example where this particular technique that you mentioned, the humility, leading with an apology first, moved the needle and changed a culture. A case study, or give us an example.

Beth Boynton: Well, I remember a time I was working as a nurse on a locked unit, on a dementia unit, and there were two adjacent units. A nurse’s assistant came to me and said that somebody on the other unit had a skin tear, and that I had to take over. And I was like, “What do you mean? That’s on that other unit.” She said, “Well, you’re supervising me.” And I was like, “I did not know that I was supervising you.” I had my hands full with my own unit. I went through the process and did what I needed to do that night, but I went home, and I was so angry and frustrated. And I felt like, “I have to go in and talk with the scheduler. I have to own my concern and my limitation.”

And it took me, like, two days. Like we were talking about, it’s hard, right? So that was just so hard, what was going on for me internally, because I felt like, “Was I inadequate, that I couldn’t just rush over and fix that problem?” Anyway, I went in and I talked with the scheduler, and he said, well, he couldn’t make any promises. And I took this deep breath, and I said, “Well, I have to talk with the director, then.” And I went up the long staircase into the director of nurses’ office, and I said, “I’m sorry that I can’t do what you’re asking me to do. If that’s an expectation of me, I just can’t do it.” And we had a very nice conversation, and she actually ended up saying, “OK, we can revisit this in six months,” which allowed me to exhale.

I mean, if it was me, if I was inadequate and needed more training or more time than was reasonable for a registered nurse to have, then I could look at those areas of growth. And maybe the director could look at the area that maybe we don’t have enough people to do what we’re asking you to do, or maybe it’s an excessive workload. And I think that’s often part of it when we go to try to fix staffing issues. If we don’t have respectful conversations that may lead to new ideas, and may lead to, “Well, this might not be a good job match,” which had to be something that I had to at least look at, then we just stay in these power struggles. So that goes back to your point, I think, Kevin, about how hard self-reflection is. It’s scary. It’s emotionally risky. I don’t want to be inadequate.

Kevin Pho: We’re talking to Beth Boynton. She’s a nurse and consultant. Her KevinMD article is titled “Leading an organizational culture change? Consider an apology first.” Beth, tell us something that you’re passionate about that you’re working on right now.

Beth Boynton: Thank you for asking. I am very passionate about how medical improv can help us in health care, because it is a teaching modality that can be used to decrease stress, to improve communication, to help us have positive relationships with each other, and to help with emotional intelligence. Because it can help with all those things, and it can also be done in a fairly short amount of time, I’m really excited about some collaborations I have.

I work with Ellen Schnur and Jim Mecir of Improv Talk. She’s a former corporate trainer, and he’s a former Major League Baseball pitcher. He was born with a clubfoot. They have an improv business, and together the three of us just did a workshop with Ball State University faculty and students on medical improv to help with interprofessional communication competencies, and that was very successful. So it’s like, we just get people in the room and do these activities, and some people learn to listen, some people develop confidence, and some people become more trusting. So I’m very passionate about that.

I’m passionate about some train-the-trainer. I do these short, hour-long sessions that I’ve just been doing, one activity at a time. So what I’m trying to do is, if I can help other team leaders and managers know these short, simple activities and do, like, five minutes here, 10 minutes there, we can start to create a rippling effect where we can all develop those hard skills and practice them with the people that we work with.

Kevin Pho: So what’s one improvisational technique that I can use in the exam room to help me become a better physician communicator?

Beth Boynton: Well, the primary principle of “yes, and.” If you stick with that, just note that that means that, yes, you’re going to validate the person first. It’s really a listening skill. So whatever somebody says to you in the exam room, if you just validate them as a separate experience, that can be extremely transformational.

I like to use the example, going back to people with dementia: Mrs. Smith wants to set her hair on fire. Sometimes we tend to say, “Well, you can’t set your hair on fire. That’s dangerous, blah, blah, blah.” But her wanting to set her hair on fire, validate it: “You want to set your hair on fire? Tell me about that.” We get to have a different relationship, and it is OK. She can want to set her hair on fire all she wants. She’s just not going to be able to do it in the nursing home. So first we validate, and that’s what the yes is all about.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Beth Boynton: We deserve to work in environments where we feel safe and respected, where we respect each other, and where we have the resources that we need to do a good job, at least most of the time. I think that we deserve that. So that’s what I’m going to say.

Kevin Pho: Thank you so much for sharing your time and insight, and thanks again for being on the show.

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