Julie has been the executive director of the Maternal-Newborn Service for 5 years and reports to the chief nursing officer (CNO). The four other executive directors of service-li

Principle 1: Know Thyself 

For the leader of an organization, the most important rule for minimizing dysfunction is to know what he or she stands for and what behaviors he or she finds unacceptable. Barrett (1995) makes the point that whatever a person identifies with, that person cares for. When people identify with 

family members, they give them support. When they identify withtheir environment, they protect and nurture it. When they identify with their organization, they give it their very best. Further, when they enlarge their sense of self by identifying with their organization, they develop a greater sense of responsibility toward it and link its welfare with theirs.

Knowing yourself is more than identifying your patterns of decision making. It includes identifying your values, your outlook on life, and the importance you place on integrity and the work ethic. The leader who believes that employees are basically honest, hard working, and optimistic about the future is quite different from the leader who believes that employees will do only what they absolutely must, tend to be less than truthful, and are typically negative about the future.

Leaders need to listen to what others have to say about them and to look carefully at their style of communication and the way they treat point-of-service workers. The words that others say about them are not always easy to swallow but cannot be ignored. As leaders, they are honor-bound to respond and make the changes necessary to improve their reputation. Interestingly, most leaders will listen to negative feedback up to a point and will permit some change. The goal, however, is to pass through a make-or-break threshold of anxiety about having to change, trust others, and renounce autocratic behavior. Getting through this threshold helps everyone in the organization, whereas backing away from making the necessary changes allows the damage to continue.

Leaders should look at themselves, confront their emotions, and acknowledge the pain and resentment of employees. How much of the pain are they accountable for? When an intimidating senior manager says to an employee, “I want to know how you see me,” the employee might still be reluctant to answer honestly out of fear of retaliation. If a leader discovers that others are afraid of being open, he or she must make the effort to eliminate the toxic behaviors that cause their fear, such as yelling, criticism, and negative feedback. Personal assessment often allows leaders to gain an appreciation of unexplained discrepancies between how they are viewed by colleagues and by family and friends. At work, even though people look the same, what they become in the eyes of others is seldom the same as how they are perceived in their personal life. It is possible, for example, for an individual to be considered competent outside of the workplace but incompetent at work— or vice versa. Although self-assessment and dialogue with others can clarify paradoxical perceptions, they cannot eliminate the disparities.

As leaders journey through the self-assessment process, they may find that meditation is useful for relaxing and regaining a healthy balance. Relaxation is not just the relief of tension but the foundation of self-healing abilities. By learning to relax, people build confidence in their ability to control their body, feelings, and thoughts. They become aware of having more choices in how to react and how to feel. They also become more aware of what kinds of things, people, and thoughts tend to produce tension—an important first step in learning to deal with these sources of tension constructively. In addition, relaxation interrupts habitual negative thought patterns and clears the mind.

Principle 2:Walk the Talk 

The second rule for reducing toxicity is to walk the talk—or act in accordance with expressed values. If leaders did in fact walk their talk and consequently did listen to employees, would it be necessary to have suggestion boxes? If they really had an open-door policy, would they have to sell it so emphatically? Building trust between two individuals requires the words and actions of each to be congruent. The trust that leaders are able to acquire by walking their talk will encourage innovative behaviors by employees, minimize the potential for discrepancies between expectations and reality, reinforce their  perceived integrity, strengthen the confidence that employees have in the appropriateness of future interactions, and reinforce the bond between the leaders and employees.

In times of chaos, the importance of constancy of values increases. Although the healthcare environment and marketplace present regular challenges for health professionals, the mission and values of health care remain unchanged. The values of respect, compassion, confidentiality, patient advocacy, accountability, competence, continuing knowledge development, supportive work environments, and collaboration remain constant beacons of light for those who work in the field.

Creating a team (or committee) to act as conscience of the organization could serve to assist all employees in evaluating their success at walking the talk. The committee, an extension of the traditional ethics committee, would provide an ongoing critique of leadership decision making to ensure that the decisions arrived at were consistent with the values and norms of the organization. In addition, it could give careful consideration to potential conflicts between formally stated organizational values and unavoidable financial or business pressures as well as issues related to all types of harassment, coercion, and discrimination.

As an example, recent downsizing efforts, despite the organizations’ professed respect for the dignity of all individuals, resulted in a significant loss of dignity by the employees who were laid off. If instead these organizations had used their power appropriately, acted to protect human rights and dignity, and taken organizational and societal issues into consideration at the outset of their decision making, they could have responded to the financial pressures in a way that minimized the negative impact on employees and thus minimized the resulting organizational toxicity.

Given that the traditional compact between employers and employees—in which long-term job security is traded for loyalty—is becoming extinct, a new compact needs to be fashioned to ensure that employees are not victimized or wind up working in a trustless environment. In other words, the employer-employee relationship needs to be reconceived. Although it is true that promises of long-term employment and associated benefits are inappropriate in the current marketplace, employers and employees should openly and honestly discuss the nature of the work, expected changes that will impact the work, and ways in which employees can remain useful to the organization. If an employee leaves the organization, the termination of employment should be the result of a mutual decision rather than a unilateral act by either the employer or the employee.

Principle 3: Be Willing To Listen

Listening, active listening, is not just a matter of hearing, for instance, employees’ feelings of loss, anger, or survivor guilt; it also encompasses taking these feelings to heart and not dismissing them as merely trivial. The leader who is an expert at listening believes that every employee is a source of unique information critical to the organization’s success.

Shared leadership is one leadership model that is especially conducive to active listening— and to healthy dialogue. Also conducive to active listening is the horizontal organizational model, in which teams of individuals are involved in organization wide, cross-functional core processes.

Listening is an essential part of effective problem solving and decision making. Leaders in quantum organizations use active and critical listening skills to gain a full understanding of problem situations. To acquire the depth of understanding they need, they must explore multiple issues and gather myriad data, both of which tasks begin with critical listening.

Principle 4: Value the Truth of the Whole

The power to be gained from understanding both sides of an issue often goes unappreciated. Instead, an individual will strive to have others believe and support a particular point of view—his or her own. In the quantum organization, understanding multiple perspectives and balancing differing 

opinions is particularly helpful for arriving at optimal decisions. The chal-lenge for the quantum leader is to cherish the fruitful opposition between order and creativity and to escape the grip of either/or thinking. Multiple perspectives are essential for under-standing the whole. Often, the whole truth is a paradoxical joining of apparent opposites, and if the whole truth is desired, the opposites need to be embraced as a unit . Finally, the leadership team should have room for a whole constellation of personality styles to ensure the effectiveness of its decision-making practices. Healthy organizations typically seek to include a broad variety of leadership personality styles so that multiple perspectives can be considered and no single one can dominate in the creation of strategies and structures, thereby minimizing the potential for group think.

Respect for individuals is paramount. Microaggression are the everyday verbal, nonverbal, and environmental slights, snubs, or insults, whether intentional or unintentional, that communicate hostile, derogatory, or negative message to target persons based solely on their marginalized group membership. These must be eliminated and respect must prevail if we truly value the truth of the whole (Druck et al., 2019).

Principle 5: Empower Employees

Leaders of quantum organizations work to empower employees and ensure that they have the freedom to make suggestions, grow and mature, and become sensitized to them-selves and others. The corporate social democracy they practice is much different than the corporate elitism associated with centralized power. Instead of the chief executive and managers thinking for everyone, all individuals in the organization think. Instead of a mission statement being handed down, all employees should participate in the creation of the organization’s vision, mission, and values, because they do the work and deserve the right to define these critical elements. Leadership expertise is easily identified in action but difficult to describe in its richness. The wisdom of leaders is similar to the clinical wisdom of clinicians described by Benner, Hooper-Kyriakidis, and Stannard (1999). It includes the essential skills of grasp (comprehension), inquiry, and forethought. It is this wisdom that leaders who want to serve as transformers need to acquire.

Obtaining these skills requires significant leadership experience. Leaders who have this level of experience become expert at problem identification and solving and are able to act in situations that are ambiguous, underdetermined, unexpected, and/or markedly different from their preconceptions. Grasping involves making qualitative distinctions, doing detective work, recognizing changes, and developing relevant knowledge bases. Inquiry involves knowing what questions to ask. Expert leaders learn to use their knowledge, experience, and intuition to anticipate crises, risks, and vulnerabilities that may affect the organization or its employees. For example, in implementing a program, the timing of events is often crucial to success. During a period when employees are demoralized from downsizing in other local organizations, a wise leader would not choose to reduce benefits and cause additional stress. Although it is possible to view this decision as motivated by expedience, political cowardice, or unrealistic optimism, it is more likely to be based on a grasp of the organization’s entire context and a realization that traumatizing employees further will be counterproductive in the long run. Forethought is another component of leadership wisdom that emerges after significant experience dealing with common situations as well as unanticipated events. It is basically the ability to anticipate likely eventualities and to take the appropriate actions—an ability seldom articulated despite the fact that it is pervasive in the everyday actions of expert leaders. These leaders subconsciously project possible situations that may result from particular conditions. Then, by being extra attentive and using their ability to recognize pat-terns and sense the relevance of events, they are able to prepare the organization for the most probable of these situations. Empowering employees is a career-long journey of mentoring. The goal is to transfer leadership wisdom not only to aspiring leaders but to all employees. Along this journey, expert leaders provide tools for employees to do their jobs well and to help them feel successful. They try to create a culture of respect based on the belief that employees who feel successful and appreciated in the workplace will truly leave their work, both physically and mentally, at the end of the day and will thus be better able to manage their time and achieve and maintain a healthy balance between work and personal life.

Principle 6: Build Relationships on Respect

Each and every interaction between employees and between employees and patients should be directed toward achieving therapeutic outcomes. No relationships characterized by disrespectful behavior, insulting language, or emotional harm can be tolerated. Respect for employees is an expectation that is never open to discussion. No individual ever has the permission to be rude or abusive to any other individual. The fundamental right of every person to be treated in a manner that reflects the inherent value of human beings is theguiding principle of all human relationships.

Following are rules that leaders should keep in mind to help ensure that their relationships with employees and the relationships between employees are essentially therapeutic:

•Behave so as to preserve every person’s dignity.

•Encourage employees to talk with each other to learn more about each other’s opinions before reaching a conclusion.

•Encourage self-improvement.

•Give employees feedback on their performance.

•Be open to new ideas.

•Encourage employees to do their best.

•Compensate employees fairly for the work they do.

These next rules apply to the relationships between care providers and patients. Because their purpose is likewise to help ensure that these relationships are fundamentally therapeutic, they need to be followed by the care providers:

•Probe to uncover the rationale for any decision that a patient makes.

•Recognize that family members and friends can have a significant impact on a patient’s ability to manage his or her own health.

•Consider a patient’s cultural beliefs before providing care.

•Consider a patient’s spiritual beliefs before providing care.

•Empower patients to avoid unnecessary dependency or overtreatment.

•Recognize that clinical and behavioral outcomes affect each other.

•Support a patient’s choice to use culturally based healing practices.

•Be fully present and listen to each patient.

•Assist each patient to develop or sustain his or her ability to cope with life situations.

•Identify each patient’s feelings about his or her illness and expectations for recovery.

•Encourage patients to participate in self-care programs.

•Recognize that a patient’s choices should guide the plan of care.

Principle 7: Act as an Agent of Transformation

Quantum leaders encourage employees to be self-reliant and to take charge of their careers, not only their current jobs. They assist employees in overcoming the negative effects of career entrenchment or entrapment, such as dissatisfaction and ineffectiveness. Quantum leaders also:

•Encourage employees to voice concerns and work collaboratively to identify and ad-dress dissatisfaction.

•Do not threaten retaliation when employees express negative emotions or opinions.

•Recognize that there can be discrepancy between ideal career progression and reality.

•Seek to transform career pathways into a progressive career management program.

•Recognize that employee loyalty has advantages and disadvantages (e.g., loyalty can be merely passive and result in skill atrophy, boredom, and depression).

In addition, quantum leaders encourage employees to engage in extra-role activities that are not directly compensated but can decrease employee stress while simultaneously benefiting the organization. Acting as a mentor outside the organization is an example of extra-role citizenship work that can decrease the frustration of entrenched employees while reducing stress and meeting affiliation needs.

Quantum leaders understand that entrenched employees who attempt to cope with their career issues through loyalty or by acting as a constructive voice do contribute to work force stability and reduce turnover costs. These employees often can be jarred from their entrenchment by giving them the opportunity to be involved in special projects, by per-mitting job rotation, by facilitating downward or lateral moves, by training them in cross-functional roles, and by allowing temporary reassignments.

Career development programs can assist employees in using the “constructive voice” approach to dealing with career entrenchment. Retraining and redeployment programs further assist employees in managing their careers and thereby help the organization sustain its viability. Employees in organizations that avoid career management are less likely to discuss career issues affecting their performance. Finally, when all else has failed, it may be necessary to remove an employee who has retired on the job. Employees who have lost the motivation to develop and grow become increasingly less productive and focus on non career activities at the expense of the organization. They therefore need to be counseled to seek employment opportunities outside of the organization.

Principle 8: Screen Job Candidates for Dysfunction

New employees represent a significant investment for the organization, and job candidates require more scrutiny than they currently receive. To help in screening job candidates, leaders should identify specific dysfunctional behaviors that have a negative impact on organizational performance and, with the assistance of human resource experts, should develop new approaches to interviewing and selecting employees. The 10 principles for minimizing toxic behaviors under discussion in this section are likely to be useful in these endeavors. In addition, these questions are appropriate for ongoing use to prevent or decrease dysfunction among current employees. Getting regular feedback from employees about their assignment preferences and cur-rent frustrations assists leaders in developing a good working relationship with them.

Principle 9: Expect Accountability

Accountability is more than the background against which everyday decisions are made. In fact, the way in which accountability is created, negotiated, communicated, and evaluated lies at the heart of an organization’s operations. Unfortunately, years of entitlement philosophies have created workers who park their brains at the door and are comfortable with being rewarded for simply showing up. According to Connors, Smith, and Hickman(1994), the concept of accountability has been poorly defined in the popular press and in the literature on business. Consequently, most people think of accountability as something that happens to them or is inflicted upon them. They perceive it as a heavy burden, al-though they also view it as something that is applied only when something goes wrong or when someone else is trying to pinpoint the blame for a problem. Connors, Smith, and Hickman suggest that instead accountability should be defined as an attitude of continually asking “what else can I do to rise above my circumstances and achieve the results I desire?” It is the process of seeing it, owning it, solving it, and doing it. It requires a level of ownership that includes making, keeping and proactively answering for personal commitments. It is a perspective that embraces both current and future efforts rather than reactive and historical explanations.

Accountability systems, to function properly, require the clear delineation of individual behaviors and supporting management practices. Both individual accountability and sys-tem accountability are necessary to support the values of integrity and transformation and to foster therapeutic relationships. Individuals in a quantum organization are not threatened by the expectation for accountability but rather need accountability to perform at a high level.

Principle 10: Reward Value-Adding Behaviors

The opportunity now exists for leaders to shift the focus from return on investment to cost-effectiveness and create new rules that lay the groundwork for value-based reward and recognition programs. First and foremost, health care leaders are called on by the economic community to use resources in a way that ensures health care value. No longer can care providers give the best of everything without any financial accounting.

Health care leaders and providers are now required to examine services within the value equation. If resources are limited, does every patient symptom require intervention, particularly if little or no improvement in the patient’s clinical condition is likely to result? Just to ask this question is a challenge for providers and leaders schooled in an environment characterized by increasing growth of and access to the health care system. Provision of as many services as possible was the sign of the successful leader. Unfortunately, there was no accountability and no control in the fee-for-service payment system. The result is well known—the exhaustion of resources.

Health care services need to be appropriate to the conditions being treated, focused on outcomes, and consistent with the wishes of the patients and families being served. The buyers and users of health care 

want to know they are getting value for the resources expended. They want to know that something good or better will happen because of the purchase of health care services—that the users’health will be improved. They also are demanding that the choices made by care providers are rational and based on evidence.

Given the expectations of buyers and users, health care leaders need to create an organizational context that will support the desired services and direct the rewards and recognition of the organization toward efforts that will be able to meet these expectations. In addition, the success of care providers in improving the health of patients or community members and in managing their own health needs to be recognized and rewarded.

In a quantum health care organization, the care providers work to ensure that the patients

•experience an improvement in their clinical condition, possibly including increased physical functioning, greater tolerance of activity, improved ambulation, and/or reduced pain

•improve their ability to care for themselves, including performing wound care, taking medications on schedule, maintaining a nutritious diet, and eliminating properly

•learn more about their condition and its treatment, including their own treatment regime, appropriate procedures, potential complications, and emergency interventions

•are aware of the elements of a healthy lifestyle, including proper nutrition, weight management, activity, stress management, sleep, safety, infection control, and disease screening

The main tasks of the leaders of a quantum health care organization include

•hiring and developing a work force capable of achieving the patient outcomes listed above

•retaining and continuing to develop the care providers needed to meet the organization’s future needs

•creating a system in which providers and leaders can influence the context of care pro-vision based on their understanding of what is needed and what they are capable of doing (e.g., providers and leaders both need to be able to actively intervene to improve communication, understand potential situations likely to unfold, and alter the context as necessary)

•fostering therapeutic relationships between leaders, providers, and patients that focus on the values and beliefs of the patients, develop the inner capacities of the patients and providers, involve patients in decision making, and make room for self-responsibility

Organizations might find it helpful to use the topic of organizational toxins and ways of minimizing behavioral dysfunction as the theme of a leadership retreat. In such a retreat, the participants could be challenged to identify toxins in their department or the organization as a whole and then consider strategies to reduce the toxicity using the above de-scribed principles.

CONCLUSION

To counteract the toxicity that currently exists in health care organizations, leaders need to return humanity to the workplace. There is nothing easy, however, about creating the proper context for providing health care services. An organization is an open system consisting of inputs, throughputs, and outputs, all of which can be healthy or toxic. The work of delivering care is complex and emotional. Care providers deal with human beings at their most vulnerable, requiring of the providers a high level of personal involvement and commitment.

What is terrifying about dysfunctional organizations is that employee emotional pain is accepted as a natural phenomenon. Employees are expected to live with discomfort as a condition of employment. The real mystery is the continual denial by leaders of a connection between employee pain and service quality. It seems to escape many leaders that employee dissatisfaction leads inevitably to patient dissatisfaction and that, conversely, there is a correlation between contented employees and gratified patients. Even when they accept this correlation, leaders find it difficult to create the conditions and practices that increase both employee and patient satisfaction.

The aim of leadership is not to create a workers’ paradise but rather to engender an organizational culture that allows for organizational transformation and for the employees’ performance to live and grow. It is the obligation of the leader of a health care organization to push toward organizational health so that the will of the patient is respected. To do this, the leader needs to demonstrate a willingness and ability to cultivate self-transformations as well as transformations in others on a continuing basis. The obligations of leaders and employees are interconnected. Neither group can be successful without both of them meeting their responsibilities. Leadership is never an either/or situation.