Leadership literature focuses on highlighting the types, ideals, characteristics, and habits of good leaders. Although healthcare organizations may endure less than ideal leaders, some reports indicate that toxic leaders comprise up to 20–30% of leadership. A distinctive set of characteristic behaviors separate the difficult and demanding leader from the toxic leader. Toxic leaders can be characterized as autocratic, manipulative, controlling, deceitful, and callous. Organizations must have a mechanism for identifying, monitoring, counseling, coaching, or even removing toxic leaders. Lack of development of good leaders, dysfunctional teams, loss of productivity, and low morale because of toxic leadership lead to a high burnout rate and turnover.
Personality development is a process common to all humans and encompasses an individual’s patterns of thinking, feeling, and behaving.(1) It is influenced by the combination of life experience and genetics. Consequently, there is significant variability in personality from person to person, as well as in levels of emotional intelligence, the employment of mature and immature defense mechanisms, and styles of interaction. No individual, including one aspiring to a leadership role, is immune from developing traits that can be viewed as maladaptive.
Most articles on leadership spotlight good leadership. This report highlights the extreme opposite: a situation in which an individual with maladaptive traits is installed as a leader and generates a destructive, toxic culture. What follows is a summary of the individual’s impact on the department and the organization, with recommendations for managing such an individual.
The word “toxic” is derived from Greek mythology and the word “toxikon,” meaning poison or arrow poison.(2,3) Twenty percent of Americans report hostility or feeling threatened in the workplace.(4) Bullying also occurs to some degree in many workplaces. A workplace poll by a large recruiting firm showed that 51% of respondents were bullied by their boss or manager and 39% by co-workers.(5)
A working definition of toxic leadership is “a series of purposeful and deliberate behaviors and acts of a leader that disrupt the effective functioning of the organization and are intended to maneuver, deceive, intimidate, and humiliate others with the objective of personal gains.”(6)
Toxic leadership is present across industries around the world, including healthcare. There is evidence that between 20% and 30% of leaders globally are described as toxic.(3) In a study of 400 leaders, 39% of whom worked in the healthcare setting, almost 95% reported encountering toxic characteristics in someone at work.(7)
No healthcare environment or medical specialty is immune to toxic leadership. Labrague studied the impact of toxic leadership behaviors among nurse managers on adverse events and quality of patient care using three different standardized scales to survey 1,053 registered nurses.(8) Nurse-reported adverse events, including reports of complaints, verbal mistreatment from patients and their families, patient falls, healthcare-associated infections, errors in administering medication, and decreased quality of care, were all strongly associated with toxic leadership behaviors in nurse managers.
A specialty division at a large private health system thrived due to harmonious relationships among employed physicians and staff, but was held back by poor financial performance. A 12-month search for a new division chief followed.
Although a search committee of physicians, nurses, and administrative staff was formed, previous hires in this and other specialties tended to be at the whim of the department head. The candidate selected was a model of good behavior and charm at the interview. The physician was hired for the role despite opposing feedback from a few physician interviewers who had concerns about the individual’s abbreviated tenure at his two prior employers and cursory information provided by those employers.
Within six months, the division’s culture rapidly deteriorated. Initial dissatisfaction among faculty, trainees, and the staff was noted and based upon intimidation, manipulative behavior, lack of empathy toward employees, and lack of ownership of poor decisions. As a result of this behavior over three years, many complaints directed at the division leader were filed with human resources. The department head dismissed these, presumably based in large part on the division’s improved financials over 36 months.
After four years and an overwhelming number of formal complaints to human resources, the department chair asked for the division chief’s resignation.
Task-focused leaders, especially those coming into a new job, may be given specific charges with a timeline to fix problems such as financial deficits, as in this case. The new leader may be single-minded in following the department head’s instructions almost to the exclusion of other facets, such as the relational aspect.
How goals are accomplished is just as important as what is achieved. In this case, financial gains were recognized, but they came at the significant expense of a supportive culture and psychological safety for team members. Further, the built-in safeguards — HR and the director’s supervisor — failed in this instance for almost four years. The director’s authoritarian style created a toxic environment through his use of bullying, aggression, intimidation, and manipulation (Table 1).
Other associated behaviors might include confronting with false accusations and assuming credit for the team’s success. It is also common for these leaders to exhibit the “kiss up and kick down tendency.”(9)
Given the harm done to organizations, why are individuals who create such toxic environments tolerated? Most often, subordinates fear retaliation if they voice concern, and superiors are focused on the achievement of specified metrics (e.g., research dollars, clinical revenue). In this case, the individual improved the financial status of the organization, but at a high cost.
Supervisors become passive enablers, observing the inappropriate behavior but not advocating for change. The HR department’s ability to implement change depends on the policies by which they abide; these can require the verification of complaints, internal investigations, placing the individual on a performance plan, or involving a coach over several months before the recommendation is made to terminate employment. In addition, HR and senior leadership may wish to avoid the prospect of legal action involving termination without a foolproof record of verifiable complaints and evaluations. The department and the health system may also be conflicted because the division is now profitable.
Operational Implications for the Organization
Toxic leaders may succeed and benefit the organization in the short term. However, because they are incapable of developing good leaders or well-functioning teams, their success is usually short-lived before they are forced to move on to another institution. Therefore, organizations must have a mechanism for identifying and monitoring or removing toxic leaders.
Most healthcare institutions have a top-down performance evaluation process in place, which allows such a leader to not only suppress any dissent, but also progress upwards in the leadership chain.(9,10) Their behavior affects the organization in many ways. Instead of authentic and nurturing leadership, toxic leaders erode the self-worth, dignity and “psychosocial well-being” of workers.(3)
Morale suffers as employees become unengaged or actively disengaged, impacting efficiency and productivity. Employees exposed to this leader may be noncommunicative and afraid to disagree with the leader. The pressure to watch every word and survive each day within the poisonous culture leads to a loss of creativity.
Other than those who are favored by the leader, faculty or peer relationships suffer as they go further into isolation. Unproductive teams do not manage the normal day-to-day conflict well, and there is decreased resilience, hastened burnout, and high turnover.
Although this behavior ruins the culture within the workplace, it is sometimes difficult for the leader’s supervisor to discern because these leaders usually present as confident and assertive; however, they often exhibit what is called the “dark triad.”(11,12)
First exposed by Delroy Paulhus and Kevin Williams in 2002, the dark triad of personality consists of narcissism, Machiavellianism, and psychopathy.(13) The narcissistic leader, sometimes exhibiting pathologic tendencies, focuses only on their own needs. The leader profiled in the case study had an inflated view of self-worth, exaggerated his scientific knowledge, and often quoted non-existing literature to appear more knowledgeable.
Machiavellianism is described as “strategic exploitation and deceit.”(11) These leaders will do whatever is necessary (manipulation, deceit, and exploitation) to accomplish their goal.
The final part of the triad is psychopathy, exhibited by callousness, cynicism, aggressiveness, and episodes of anger directed primarily at direct reports or trainees.(14) The leader in the case study was opaque about essential information, acted unpredictably, and intimidated people within groups to send a message.(15)
Another typical behavior of the toxic leader in our case study was that he hired and favored a small circle, and tried to drive a wedge between them and the pre-existing faculty. Faculty were never included in major decision-making.
Although the difference between a “tough” leader focused on the task and a toxic leader can be difficult to discern at times based on the situation, a constellation of signs is important to recognize (Table 1). Tough and sometimes difficult leaders may be intense, demanding, perfectionistic, and difficult to work with, but they are fair and understand the balance between achieving financial targets and crossing the line to personal attacks. They also show emotional maturity by exhibiting empathy, leading employees and peers to conclude that the leader’s behavior is never personal. Both types of leaders can bring success to the organization, but the disruption and impact on the culture associated with the toxic leader may not be sustainable.
During the hiring process, employers focus on candidates’ fit with the job and the organization. However, few hospitals go beyond conventional inquiries such as structured or unstructured interviews to match personality traits with job performance. A variety of leadership personality tests are available, but there is still uncertainty about the predictability of these tools as well as the cost associated with widespread use.(16,17) Selective use of personality and behavioral testing may be worthwhile for senior executive and critical leadership positions.(18)
Next Steps in Managing the Toxic Leader
Toxic leadership may be due to behavioral concerns and can also be rooted more deeply within personality. Strategies for managing the toxic leader involve several steps.
Supervisor/manager actions toward toxic leader’s peers and employees include:
Provide counseling for victims.
Reiterate core values repeatedly.
Establish a hotline to allow fearful employees to report abusive behavior.
Urge documentation of behavior and falsehoods.
Direct employees to avoid solo conversations.
Provide peer recognition and reward programs.
Facilitate team-building exercises.
Supervisor/manager possible actions toward a toxic leader include:
Involve human resources and, if necessary, the legal department.
Address modifiable causes of behavior (e.g., substance use, personal relationship challenges, health problem) or mental health disorder.
Disclose specifically how the behavior is affecting others and encourage positive change and monitor consequences.
Bring in an independent third party to evaluate the workplace.
Facilitate 360-degree behavior evaluations.
Ask the leader to accept responsibility.
Practice zero tolerance when necessary.
Impose sanctions if needed.
Ask for resignation or dismiss if appropriate.
The first step is to involve HR personnel, who may be able to gather the necessary information from all sources.
Causes of the behavior may include a stressful situation outside of work or another temporary situation. It is likely the embattled leader will ask for specific examples of behaviors that are at issue. Leaders may lack self-awareness and be surprised to learn how toxic the culture has become due to their behavior. Some leaders may recognize the problem or benefit when senior management demonstrates a commitment to addressing it instead of looking the other way.
A supervisor (CEO/physician supervisor/administrator) should refrain from judging the leader and instead offer HR assistance and advice. The supervisor may distinguish whether the leader is deflecting blame or accepting responsibility. The leader then needs to face potential consequences and be given a timeline and specific behaviors to implement that will be monitored.
The intervention should continue, with progress documented by HR, until specific milestones are achieved. The leader should also be encouraged to keep interactions within well-accepted professional boundaries. Supervisors who learn of the behavior must give supervised peers, trainees, and employees an opportunity to speak in a nonthreatening situation away from the leader. It is worth repeating that HR should be involved at every step of any advice or action.
Escalation of the intervention proceeds from an informal awareness meeting to a disciplinary intervention if necessary(19) (Figure 1). If the leader does not change behavior after several warnings, the supervisor may recommend counseling and a 360 survey, which seeks feedback on the employee from several sources such as supervisors, peers, direct reports, and self-assessments. A commonly used instrument in this context is called the DISC–Behavior Styles Purpose (drive, influence, steadiness and compliance).(20) This does not measure intelligence or skills, but provides feedback on behavior and emotions.
Figure 1. Flowchart of Steps Dealing with a Toxic Leader
HR staff should assist in this task, but they can only offer advice based on the documentation, interviews, and institutional policies and procedures. Decision-making rests with the leadership with input from the legal team.
Once the evaluation is completed, counseling sessions and coaching, followed by further evaluations, may then decide the toxic leader’s future. If there is improvement based on the intervention, as indicated by reports by a coach or counselor and supplemented by employees or peers, progress is documented, including attainment of specific goals. If not, the institution must make a decision about termination.
Although policies and procedures vary by hospital, most if not all hospital bylaws applicable to physicians refer to “disruptive” behavior allowing the hospital to initiate disciplinary proceedings. The legal team must follow each step as mentioned in the bylaws, protecting the physician’s due process accurately and within the time specified.
While there is a wide range of leader behavior, including demanding and tough bosses, a distinctive set of characteristic behaviors separate these from a toxic leader. Once this type of leader is identified, intervention consistent with hospital bylaws is necessary by supervisors and managers. This could range from informal conversations to disciplinary action, including termination.
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CNBC. One-fifth of Americans Find Workplace Hostile or Threatening. CNBC.com . August 14, 2017. www.cnbc.com/2017/08/14/one-fifth-of-americans-find-workplace-hostile-or-threatening.html .
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