1. Tye, Joe MBA, MHA

Article Content

In the early months of the pandemic, people celebrated frontline heroes and a "we've got this" spirit suffused healthcare organizations. More recently, as we've spoken with healthcare leaders and asked how their staff members are holding up, the words we most often hear are anxious and exhausted. The challenges faced by healthcare leaders are mirrored by what's happening in our nation overall. The CDC reported that symptoms of anxiety and depression are up by three to four times over what they were just 1 year earlier.1 Public opinion polls show that a substantial majority of Americans believe our country is headed in the wrong direction.2 And a study published by McKinsey found that "behavioral health is among the top workforce health concerns with nine out of 10 employers surveyed noting that COVID-19 is affecting their workforce behavioral health and/or productivity."3 As a leader, what can you do?

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

This article explains how high anxiety can lead to flawed leadership decision-making and why fostering a spirit of everyday courage is the antidote. We share 13 strategies for being a more effective leader and promoting a positive culture in the midst of the unprecedented challenges facing today's healthcare environment.


The dangers of high anxiety

In his classic book, On the Psychology of Military Incompetence, Norman Dixon found the key distinction between highly capable commanders and their inept counterparts was that the latter hadn't developed the capacity to manage anxiety.4 Uncontrolled anxiety can cause disastrous military blunders by inducing paralysis or panic. On the business front, Jim Collins, in his book, How the Mighty Fall, concluded that decisions made in response to fear often create a self-fulfilling prophecy bringing about that which was feared.5


Consider the following examples from the airline industry. On March 27, 1977, Captain Jacob van Zanten was in a state of high anxiety. His KLM 747 had been diverted from its intended destination to a tiny runway on the island of Tenerife. He knew that if he didn't take off within several hours, his crew would time out, meaning that KLM would have to send a replacement aircraft and accommodate hundreds of passengers, all at great expense. On the other hand, he knew that if he took off after his crew had timed out, he would risk losing his pilot's license. Adding to his worries, a dense fog had rolled over the island, cutting visibility to less than 200 m. Overriding concerns expressed by both his copilot and flight engineer, van Zanten accelerated down the runway. Seconds later, his aircraft slammed into another Pan Am 747. With 583 fatalities, it was the deadliest aviation catastrophe in history. There had been no equipment failure; it was human error by a pilot in a state of high anxiety.


On January 15, 2009, following a routine takeoff from LaGuardia Airport in New York City, US Airways flight 1549 flew into a flock of birds, which instantly shut down both engines. Over the next several minutes, pilot Chesley "Sully" Sullenberger maintained constant communication with air traffic control, his copilot, and the flight attendants in the cabin. He calmly told air traffic control that he would be unable to make it to their suggested alternate landing site and would be landing on the Hudson River. Despite the catastrophic mechanical failures, all 155 people aboard walked away.


Van Zanten, a highly experienced pilot who was also the senior safety officer for KLM, was overwhelmed by anxiety and experienced what Daniel Goleman, in his book Emotional Intelligence, described as "emotional hijacking."6 As a result, hundreds of people lost their lives. Sullenberger, an equally experienced pilot who was also a senior safety instructor, kept a tight rein on his emotions when confronted with catastrophic equipment failures. And as a result, all passenger and crew lives were saved.


The antidote: Everyday courage

During the COVID-19 pandemic and ensuing economic dislocation and social disruption, nurse leaders have been called on to work harder and longer than they ever have been before. They've been challenged in ways that were inconceivable only a year ago, challenges for which nursing school couldn't have prepared them. On top of these professional challenges, most have also been faced with challenges on the home front like everyone else. For many, though, the most significant challenge-and the most important duty-has been sustaining staff morale.


Novelist Robert Louis Stevenson said, "Keep your fears to yourself, but share your courage with others." For the leader, this sometimes means sharing courage that you may not feel yourself. The following 13 practical strategies can help you promote everyday courage every day. We aren't talking about medal of honor sorts of bravery. We're talking about the everyday courage of the environmental services worker who cleans a room after a patient with COVID-19 has been discharged, the nurse who sits with a dying patient whose family must remain outside the room and see their loved one through a window or on a screen, and the pediatric nurse who volunteers to work on an adult critical care COVID-19 unit. And we're talking about showing up every day even when you would rather crawl under the bed and close the door behind you.


Strategy #1: Emphasize a commitment to values

The first responsibility of nurse leaders is to be clear about their own values and make a concerted daily effort to ensure that these values are reflected in the attitudes they bring to work, the way they treat people, their approach to dealing with conflict, the criteria they use for making decisions, and how they deal with obstacles and setbacks. The second responsibility is to help the people whom they lead do the same thing. This quality, more than any other, defines the heart of a nurse leader.7


It has often been said, "Don't waste a crisis." How can this crisis help us all to be clearer about the values that define who we are and what we stand for? How can we as healthcare leaders challenge the people who look to us for leadership to honor those values?


Strategy #2: Focus on purpose

Helping people remember why they joined the healing professions-reminding them why they care-is the best antidote to anxiety and fear. The only reason people experience fear is because they care; if you didn't care whether you were rejected or failed, you wouldn't fear rejection and failure. Remembering why you care will help you find the courage to ask even though you risk rejection and to try even though you risk failure.


A real-world example: Last September, Hurricane Laura battered southwest Louisiana with 140 mph winds. Windows were shattered, buildings were flattened, and the community lost power and water. The area was evacuated, including most patients and staff from Lake Charles Memorial Hospital. Among the few people who remained behind were 20 caregivers in the hospital's neonatal ICU. Disregarding the personal risk, they stayed to care for 19 premature infants who couldn't be moved. Had these caregivers been asked to stay behind in the kitchen to make sure that the freezers weren't looted or to stand guard over computers that housed accounts receivable, they would've thought the request was preposterous. Nobody cares enough about those things to risk their lives for them. They stayed because they cared for their patients.


It's just as important for you as a leader to remind yourself why you care for the people for whom you're responsible. Chris Van Gorder, president and CEO of Scripps Health in San Diego, Calif., puts it this way: "If you truly care for the people you have the honor to lead and they can see and sense that, those same people will give the same back to you many times over and in so doing, will give you the stamina and even courage to persist over an extended period of time. But the caring must be genuine and not manufactured or your people will see right through it."8


Strategy #3: Be present

In J.R.R. Tolkien's fantasy classic The Lord of the Rings, Gandalf the wizard was known for showing up where he was most needed and least expected. That's an essential element of courageous leadership during a crisis. As J. Larry Shackleford, CEO of Washington Regional Medical System in Fayettesville, Ark., put it in real-world terms: "As leaders during a time of crisis, it is vitally important to keep an eye on the emotional and mental well-being of your management team ... That leadership style manifests itself in...being visible and accessible to staff, including those on the front lines. It means putting on personal protective equipment and rounding in the critical care and COVID-19 units on nights and weekends."9


Strategy #4: Be confident

In the movie U-571, an American submarine crew sets out to hijack a German U-boat, but everything goes awry. The American captain is killed, leaving his executive officer in command of a skeleton crew on a German submarine they don't know how to operate. The new commanding officer honestly tells the men that he doesn't know how he'll get them out of the mess. Shortly thereafter, a seasoned submariner tells the young officer, "You're the skipper now, and the skipper always knows what to do whether he does or not."


This is a pretty good metaphor for the responsibility of a leader in troubled times. You may not know what you're going to do, but you must believe in your ability to do something. More important, you must make those who look to you for leadership believe that you're capable of doing something while reassuring them about the decision.


Strategy #5: Be transparent

During the Vietnam War, Admiral James Stockdale spent more than 7 years in a prisoner of war camp. He developed the philosophy that Jim Collins, author of Good to Great, termed the Stockdale Paradox: "You must never confuse faith that you will prevail in the end-which you can never afford to lose-with the discipline to confront the most brutal facts of your current reality, whatever they might be."10


People want to be treated like adults and they want to know the truth that will affect their job and their future. The surest way to earn trust is to tell them those truths, and the surest way to lose trust is to try to convince them that everything is just fine when they know it isn't. But you must share those truths in a way that doesn't erode the faith that you'll prevail in the end.


Strategy #6: Make it personal

We define a transformational leader as someone who helps you achieve goals you didn't know you could achieve by helping you become the person you didn't realize you could be. Because culture doesn't change unless and until people change, your focus should be on helping individuals achieve their goals by living their values. As more people make this commitment, a stronger culture of ownership will evolve. Improved patient satisfaction, reduced RN turnover, and significant cost savings are just some of the organizational outcomes that can result from people making culture personal.


Strategy #7: Make it fun

In her book, No Ego, Cy Wakeman wrote that the average employee spends 2.5 hours per day on drama.11 Trying to eliminate drama by implementing rules and policies against it, or by holding people accountable for creating it, is more likely to increase the level of drama than it is to reduce it. Consider the Pickle Challenge for Charity, a lighthearted approach to inspire people to turn complaints into charitable contributions. We've seen decorated pickle jars, pickle parades, people dressed up in pickle costumes, and hundreds of other great ideas for eliminating toxic emotional negativity from the workplace. To date more than $100,000 has been raised for charities by turning nearly half a million complaints into contributions. More important, the impact on the workplace environment is immediately visible and comes at no financial cost to the participating organization.12


Strategy #8: Enforce zero-tolerance behaviors

You can't drive fear out of the workplace if bullying behaviors are tolerated. As a leader, you must enforce a zero-tolerance policy for abusive and disrespectful behaviors. Renee Thompson, one of the nation's leading authorities on employee bullying in healthcare, told us that the problem of bullying has gotten worse since the start of the pandemic. She believes that the biggest mistake healthcare leaders can make is to rationalize away abusive behaviors because people are under pressure. She suggests that leaders use this script for confronting bullying behavior: "You can be angry, frustrated, or scared, but you can't be cruel. Neither you nor I have the time or energy to be anything other than our very best today."13


Strategy #9: Reach out to your community

In his book, Building a Vibrant Community, Quint Studer wrote, "Healthcare systems should go beyond their role of providing direct patient care and invest in keeping their community healthy and vibrant."14 In today's challenging environment, healthcare leaders can promote everyday courage in their communities by offering expanded mental and behavioral health programs, especially for already underserved populations. As one example, Children's Hospital New Orleans recently opened a new 51-bed behavioral health unit that's providing enhanced services for young people across the Gulf region.


Strategy #10: Protect your people

Jeffrey Doucette, senior vice president and CNO at Thomas Jefferson University Hospitals in Philadelphia, Pa., reports that a colleague told members of his team: "We're all in this boat together, but I'm the captain of the ship and my most important job is helping you get through the storm safely." Doucette said that "this simple statement was an affirmation that although you may feel lonely leading your team, you're never alone. It's important to learn the difference."15


Kit Bredimus, CNO at Midland Memorial Hospital in Texas, noted that as the coronavirus pandemic wore on, his staff members were increasingly being subjected to negative comments and criticisms in the press, on social media, and by email and text. He wrote an editorial that was published in the local newspaper asking people to send a message of support to a healthcare worker. He told us that since the editorial was published, there has been a significant positive shift in community attitudes toward hospital staff.16


Strategy #11: Foster a support group culture

Support groups exist to help people cope with shared challenges. When a support group meeting ends, the patient with cancer still has cancer, but he or she leaves with a little more hope and inspiration and, quite often, with new friends. Bullying and abusive behavior simply isn't tolerated in support group meetings. Imagine that sort of spirit in your workplace-a spirit in which people are willing to ask for the help they need and to help coworkers who ask for their help.


One way to do this is to encourage people to adopt the Golden Rule in reverse (the Nedlog Rule): Anything that you would be willing to do for others if they asked you, be willing to ask for the same help when you need it yourself. As a leader, seek to create an atmosphere where people are encouraged to ask for help when they need to refill their own pitchers.


Strategy #12: Do more to recognize your people

In our experience, nonmonetary recognition is as or more motivating than money can be. Especially when social distancing requirements make it more difficult to practice management by walking around, it's important to create other ways of formally and informally recognizing people for their hard work and accomplishments. Bonnie Barnes, cofounder of the DAISY Foundation, told us, "During the COVID-19 surges, we heard repeatedly from CNOs that sustaining the ritual of recognition for their nurses, especially during healthcare's most stressful time, was culturally critical. By shining a bright light during dark days and nights, nurses found the strength to come back the next day and do this very tough work all over again."17


Strategy #13: Sustain a sacred hope

In his classic book, The True Believer, Eric Hoffer wrote that anyone who would change the world, or their corner of the world, must be able to "kindle and fan an extravagant hope."18 Especially in troubled and turbulent times, one of the leader's most important imperatives is kindling that sort of hope. Jacque Camp, executive director of patient experience and strategy at JPS Health Network in Fort Worth, Tex., told us, "We use evidence-based practices that include caring for the mind, body, and soul, which our team members can use for their own well-being. When you see your teams using these same loving techniques with their patients, you realize the sacred hope we all have is a gift worth sharing."19


The ultimate test of leadership

In times of crisis like those we've experienced over the past year, it's essential for leaders to invest more, not less, in building a positive culture of ownership. As retired Admiral Eric Olson put it: "Culture and morale and standards all depend on the leader, and none of those can be sacrificed in a crisis. A culture left untended will go someplace the leader does not want it to go, and once it does, it's impossible to get back."20


Dave Altman, chief operating officer of the Center for Creative Leadership in Greensboro, N.C, told us: "In the future, when we look back on the challenges presented to us in 2020, the best leaders will remember the hard lessons they learned and applied, and they'll embrace their current-day challenges as fuel for charting a new course into the uncertain future."21 When a hospital or health system begins a values and culture project with a values coach, they're given a large banner that reads, "Proceed until apprehended: Leadership doesn't require a management title." This mindset-the commitment to take action when it's needed and ask for help when you need it-is the ultimate benefit that comes from inspiring your people with everyday courage in these extraordinary times.




1. Czeisler ME, Lane RI, Petrosky E, et al Mental health, substance use, and suicidal ideation during the COVID-19 pandemic-United States, June 24-30, 2020. Centers for Disease Control and Prevention. 2020. [Context Link]


2. Brenan M. Satisfaction with US direction lowest in four years. Gallup. 2020. [Context Link]


3. Coe E, Enomoto K, Gupta A, Lewis R. National employer survey reveals behavioral health in a COVID-19 era as a major concern. McKinsey & Company. 2020. [Context Link]


4. Dixon NF. On the Psychology of Military Incompetence. New York, NY: Basic Books; 1976. [Context Link]


5. Collins JC. How the Mighty Fall: And Why Some Companies Never Give In. New York, NY: HarperCollins; 2009. [Context Link]


6. Goleman D. Emotional Intelligence: Why It Can Matter More Than IQ. New York, NY: Bantam Books; 1995. [Context Link]


7. Dent B, Tye J. The Heart of a Nurse Leader: Values-Based Leadership for Healthcare Organizations. Solon, IA: Values Coach; 2018. [Context Link]


8. Van Gorder C. Personal correspondence. October 6, 2020. [Context Link]


9. Shackleford JL. Wartime leadership in the battle against COVID-19. Arkansas Hospitals. 2020. [Context Link]


10. Collins JC. Good to Great: Why Some Companies Make the Leap...and Others Don't. New York, NY: HarperCollins; 2001. [Context Link]


11. Wakeman C. No Ego: How Leaders Can Cut the Cost of Workplace Drama, End Entitlement, and Drive Big Results. New York, NY: St. Martin's Press; 2017. [Context Link]


12. Tye J, Dent B. Pickle Pledge: Creating a More Positive Healthcare Culture-One Attitude at a Time. Solon, IA: Values Coach; 2016. [Context Link]


13. Thompson R. Personal correspondence. October 12, 2020. [Context Link]


14. Studer Q. Building a Vibrant Community: How Citizen-Powered Change Is Reshaping America. Janesville, WI: Be the Bulb Publishing; 2018. [Context Link]


15. Doucette J. Achieving work-life effectiveness. Nurs Manage. 2020;51(10):56. [Context Link]


16. Bredimus K. Personal correspondence. October 12, 2020. [Context Link]


17. Barnes B. Personal correspondence. October 8, 2020. [Context Link]


18. Hoffer E. The True Believer: Thoughts on the Nature of Mass Movements. New York, NY: Harper & Row; 1951. [Context Link]


19. Camp J. Personal correspondence. October 13, 2020. [Context Link]


20. Olson E. The war on the coronavirus: three top military leaders offer lessons from the front lines of managing deadly crises. McKinsey Quarterly. 2020. [Context Link]


21. Altman D. Personal correspondence. October 7, 2020. [Context Link]