1. Cox, Sharon RN, MSN, Principal Consultant

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How often have you heard the famous catchphrase, "A picture is worth a thousand words?" I was reminded of this recently when listening to a frustrated group of nurse managers describing how hard it is to foster a sense of ownership and accountability at the staff level and sustain behavior change over time. I drew an iceberg on a nearby flip chart, and this led to a discussion about implementing behavior change in organizations.

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The iceberg analogy

At the top of the iceberg is the behavior we see on a daily basis. By reviewing the systems and structure we have in place, we begin to see ways to influence behavior. Staff behaviors are in direct response to processes we have in place, or the lack thereof. If we modify our systems or structure, we modify behaviors. Staying with the analogy of an iceberg, we can go even further by examining the beliefs and assumptions inherent in these systems and structures.


A classic example of this "iceberg analogy" is evident in the experience of middle managers at Genesys Regional Medical Center, Grand Blanc, Mich. After reviewing their policy on bereavement leave, they realized it was very parent-child and not in keeping with their adult-to-adult partnering philosophy. The revised policy was shortened from two pages to a single sentence that read, "If there is a death in your immediate family or your extended family, talk with your supervisor about the time you need." A year later, middle managers found that there was a 43% reduction in the time taken by staff. They developed a system in line with a basic belief, and when they changed the system, they changed behavior across the entire organization.


Connect the dots

As healthcare organizations across the country grapple with ways to create a more positive workplace, it's time to reflect on the iceberg analogy and see the connection between basic beliefs, systems and structure, and behaviors that manifest as the "tip of the iceberg." In doing this, we need to change some of our standardized ways of thinking.


At many organizations, there's a focus on monetary incentive systems to foster retention or improve staff morale. However, research shows that money isn't a primary motivator for many people, and is often much less important than career growth, challenging work, or being part of a great team of people.1 Another system that may warrant rethinking is the evaluation process. If a management team wants to foster staff ownership for career development, then a system that makes the employee the driver of their evaluation process is preferable to having the manager in charge of this process.2


The connection between beliefs, systems, and behavior norms is perhaps most obvious with our long-standing system for performance issues. With the policy of progressive discipline, the assumption has been that if we treat people bad, their behavior will get better. In reality, however, very few employees ever come back from a suspension with a good attitude. A number of hospitals have chosen to move away from a system that requires managers to act like police and instead use a system called positive discipline.


Fostering ownership

Positive discipline is based on the belief that employees should be treated as responsible adults. With this system, the employee is given a paid "self-assessment/decision-making leave" day to decide whether or not they want to keep their job. The employee comes back from that leave day with a plan they've developed to take ownership for getting back on track. If they slip back to their old behaviors at any time, they've willfully terminated themselves. This system gets the person's attention without punishing them.3 The approach has been shown to improve retention and morale.4


As we continue culture change efforts in healthcare, it's wise to remember the iceberg analogy. Examine your systems and structure, as well as the beliefs underlying them. If you're serious about sustaining a healthy workplace, a picture is worth a thousand words.




1. Atchison T. Exposing the myths of employee satisfaction. Healthcare Executive. May/June 2003. [Context Link]


2. Coens T, Jenkins M. Abolishing Performance Appraisals: Why They Backfire and What to Do Instead. San Francisco, Calif: Barrett-Koehler; 2000. [Context Link]


3. Grote D. Discipline Without Punishment. New York, NY: AMACOM; 1995. [Context Link]


4. Murray B. Positive discipline reaps retention. Nurs Manag. 2003;34(6):19-22. [Context Link]