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Last week, I wrote about the ways in which toxic leadership behaviors generate toxic work cultures. The other two factors that were found to predict toxic workplace behaviors are toxic social norms and flawed workplace design. So, this week, I wanted to tackle the subtle ways in which toxic social norms may show up in our work environments.

But before I do, I want to clarify the use of the word ‘toxic’ in this context.

What Is Toxic

For many of us, the word ‘toxic’ conjures images of noxious substances, so we might balk at thinking of our work cultures in those terms. When I write about toxic work cultures, I’m not suggesting poisonous environments full of willfully malicious dealings. According to the Oxford dictionary, another definition of the word toxic is ‘very harmful or unpleasant in a pervasive or insidious way’. This alternate definition better captures the essence of what we’re speaking about in regard to workplace cultures. It’s about addressing the pervasive or insidious structures that make our work environments unpleasant or even harmful. Harmful in the sense that they undermine our ability to perform an important role and rob us of our motivation and drive by making us feel small, invisible or irrelevant.

Toxic social norms are the negative behaviors that color our interactions at work. When we think of toxic social norms, the ones that immediately come to mind are things like verbal abuse, bullying, racism/sexism/ableism/ageism, inappropriate jokes, or malicious gossip. But not every toxic social norm is this obvious. Below are a few subtler patterns I’ve seen permeate work culture in the hospital.

Sensitized Communication

A friend recently related an incident in which she was handled bluntly by a colleague in a meeting. As someone who is not easily frazzled, my friend didn’t make much of it at the time. But when other colleagues who had witnessed the interaction approached her to express their concern, my friend realized how uncomfortable her colleague’s tone made people. While she had no prior history with this colleague that would have made her interpret the exchange negatively, others clearly did, and it changed their assumptions around what the interaction expressed.

Communication comes across very differently depending on how a team has been sensitized. One person’s candor can be seen as refreshing directness or as highly confrontational depending on the receiver. But when multiple people on a team have a strong negative reaction to types of communication that might otherwise be perceived as neutral, it speaks to an underlying lack of psychological safety within that team. If the baseline assumption is that you are being attacked, it’s worth looking at where those assumptions are being generated, particularly when multiple team members share that interpretation.

Unfortunately, this type of sensitization within a team can extend to all communication even if it originated from one individual. This seems to be particularly true when that one individual is in a position of leadership (see The Subtle Signs of A Toxic Work Culture- Part One on toxic leadership). Sensitization within teams or departments comes at a great cost to communication, inhibiting the exchange of ideas and healthy debate around complex issues.

Zero Sum Game Thinking

In my experience, few things undermine growth and progress within a team or department as fundamentally as zero sum game thinking. In a past role, I was once approached about the option to participate in an intensive training along with one or two other members of the team to enhance our technical skills in a highly specialized procedure. Seeing this as an opportunity to improve outcomes and better manage complications, I enthusiastically brought it up with my supervisor. The immediate response was: If everyone can’t go, then no one should.

My supervisor’s reaction stemmed from a scarcity mindset that is common in toxic work cultures. It’s the idea that there just isn’t enough to go around. Not enough opportunity for everyone’s advancement, not enough support for everyone to contribute, not enough access for everyone to be heard, not enough power for everyone to become empowered. When we think of opportunities for growth as slices of a limited pie, we propagate the mindset that only a few can get ahead and the others will, by default, be left behind. This pattern can manifest as toxic leadership and/or as a toxic social norms. The irony here is that this scarcity mindset becomes a self-fulfilling prophecy. Instead of viewing individual opportunities as a chance to give rise to new possibilities and embracing the forward momentum this generates for the entire team, we essentially cut off our nose to spite our face.

Unfortunately, zero sum game thinking is bred into physicians from the early days of our medical training. Medical school is selective, residency and fellowship spots are highly competitive, and we are inundated with messages that only those at the top have a shot at success. We quickly internalize the idea that we are in constant competition with those around us, rather than in a collaborative venture in which one person’s successes elevates everyone. Over time, zero sum game thinking erodes the very foundations our work is built on. People hold on even more tightly to means of advancement. They become less willing to share knowledge, skills and resources. They shut the doors they’ve walked through behind them. As a result, everyone’s growth stalls and the environment that is so highly competitive internally is no longer competitive externally.

Undermining Competence

There is a related subtle sign of toxic social norms and it’s been present to some degree in every hospital I’ve ever worked or trained in. It’s the casual undermining of each other’s competence. Undermining competence is the natural extension of zero sum game thinking. It assumes that we cannot all shine, and by taking away some of your light, I become brighter by comparison.

You may recognize this pattern from your own encounters with it. It’s the colleague who deliberately changes all of your orders when they assume care of your patient. Or the nurse who doesn’t bother to understand the reasoning behind the management plan of a patient but vocally dismisses it on rounds. Or the ICU doctor who scoffs at the fact that your patient isn’t already intubated with an arterial line in place when they acutely require escalation of care. Or the flippant comments of the day team about how a difficult case was managed overnight.

To be clear, I’m not referring to open and vigorous debate around best management concepts, which provides an opportunity to improve outcomes. I mean the offhanded, no-discussions-had dismissal of other people’s work, knowledge and skills. When these behaviors are widespread in a department, the summative effect on the team is a constant underlying tension and the sinking feeling of being set up for failure rather than success. It also breeds defensiveness, which may deter individuals from actually addressing gaps in knowledge or opportunities to optimize care.

Equating Fear with Weakness

Somewhere along the line, an image has emerged of the competent physician as one who is always confident, makes no mistakes, and is consistently fearless in the face of calamity. That image may look great on TV, but it has next to nothing to do with reality. Beyond the fact that every single one of us errs on the regular, many of the of the most experienced and capable doctors I have worked with have never lost a healthy dose of fear in their clinical work. The self-awareness that we as doctors are not all powerful is a mark of maturity. When patients’ lives are the currency you are dealing in, it is a sign of good judgement to feel some fear at the very real possibility of stumbling, of being unable to find a solution, of not knowing enough.

I’m not ashamed to admit that even as a NICU hospitalist attending dozens of deliveries daily, my heart would pound and my hands would sweat almost every time I was paged to a neonatal code. And I loved that job! But I also knew that there are limits to what I can do in an emergency, some related to my level of skill and expertise and some simply out of all of our control.

Unfortunately, rather than normalizing and embracing this fear as a safety mechanism that keeps us from overplaying our hand, many hospital work cultures suppress and even mock any expression of fear. I’ve heard colleagues speak derisively about a peer whose hands shook during a resuscitation, laugh at an attending who asked for help with a procedure they hadn’t performed very often, ridicule residents who asked for someone more senior to take a look at an acutely ill patient- the list goes on.

When expressing fear or uncertainty is viewed as a sign of weakness it discourages healthy judgement, empowers overconfidence, and falsely equates bravado with competence.

Isolation and Disconnect

The common denominator of these toxic social norms is that they all ultimately lead to isolation and disconnect in the workplace. When we lack the psychological safety to bring up our questions, ideas and needs in the team, we end up trying (and often failing) to work through them alone. Zero sum game thinking pits us against each other in an imagined contest in which it is each person for themselves. Undermining competence alienates us from each other by forcing us into defensive armor. And viewing fear as weakness divorces us from the shared experience of grappling with the limits of our knowledge and power.

It’s important to realize that none of these behaviors are inevitable. Each of us has the power to either sustain them or diminish their footprint on our work cultures. Where there is sensitized communication we can gently ask: ‘How do you mean that?’ Where there is zero sum game thinking we can share opportunities and find ways to create more of them. Where competence is regularly undermined we can become vocal about praising each other’s management decisions around complicated issues. And where fear is mocked we can push back by openly admitting to our own fears. It’s by choosing these responses that we disrupt the cycle of toxic social norms that holds all of us back from achieving what we are truly capable of.

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Next week I’ll be concluding this three part series on toxic work culture by addressing flawed workplace design. Hope to see you back here!