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transforming culture resiliency teamwork

Transforming culture through resiliency and teamwork

By: Tammi P. Hicks, DNP, RN, CEN, NE-BC; Melissa Sullivan, MHA, BSN, RN, CPPS; J. Bryan Sexton, PhD; Kathryn C. Adair, PhD

Support positive relationships and value each team member.


  • A resilient workforce is the foundation for positive change within an organization.
  • When healthcare organizations make resilience intentional, they can create a culture of well-being for their teams that positively impacts patients.

transforming culture resiliency teamwork coverIf you can answer yes to any of the following questions, this article is for you.

  • Have you ever been misunderstood at work?
  • Have you ever been frustrated with poor communication or teamwork?
  • Have you ever changed your personal plans due to work?
  • Have you had trouble sleeping because of work stress?
  • Has stress become your norm?
  • Have you fantasized about quitting your job or even switching careers?
  • Have you lost your zest for nursing?

In 2014, many of our nurses at Duke Raleigh Hospital were answering these questions with an emphatic yes. We found they were experiencing stress, had low resilience, and some were burned out.

Like many healthcare organizations across the country, we’re committed to improving our safety culture, which depends on the resilience of nurses and other healthcare staff. We began by working with experts to help us better understand resilience and burnout and find tools and activities to help us strengthen resilience. We then developed interprofessional processes and programs to ensure ongoing efforts at building resilience across the organization. Our end goal was to prepare our staff for a change in our organizational culture to promote the safety of patients, families, and staff.

Resilience first, then change

The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®) steering committee, an interprofessional team led by the chief nursing officer (CNO) and leaders from patient safety and education, collaborated with resilience researcher Dr. J. Bryan Sexton, who pointed out that work settings with the greatest opportunity for improving their safety survey performance were too burned out to adopt change successfully. To address this issue, he helped us develop resilience activities and tools—such as Three Good Things—that team members could incorporate into their daily lives. (See Three Good Things.)

Three Good Things

Three Good Things is a simple tool for training your brain to focus on positive emotions throughout the day. Before going to sleep each night, write down three good things that happened that day and reflect on the positive emotions you felt. Start by doing this every night for 2 weeks. You may struggle to find three good things in the beginning, but eventually you’ll start looking for those positive moments in the day.

Learn more about Three Good Things at myamericannurse.com/three-goothings-build-resilience-and-improve-well-being/

In prior research, participants who completed the Three Good Things exercise showed significantly improved happiness and fewer symptoms of depression than the control group for 6 months. Dr. J. Bryan Sexton was inspired by this work and modified the exercise for use in healthcare.

Sexton also worked with the teams to cultivate positive emotions, such as awe. Feeling amazed by the world around us becomes more difficult when we’re caught up in the rush of daily activities or burned out. He taught our team members, using a simple tool, to allow themselves to stop and appreciate moments of awe throughout the day—a beautiful sunrise or a special moment with a patient, friend, or loved one.

Sexton also has researched the benefits of expressing gratitude. We often think of expressing gratitude as a simple thank you, but Sexton taught us that writing down feelings of gratitude has lasting benefits. He encouraged team members to write gratitude letters regularly to people who had a positive impact on their day, in a particular situation, or in their overall lives. Once a week, we dedicate time in our nursing leadership meetings to write thank-you notes to our staff and mail them to their homes. After giving our team members the tools to build their personal resilience, we began our TeamSTEPPS implementation in a phased approach. (See Step it up.)

Step it up

Team training improves interprofessional communication and organizational learning from errors and near misses. Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®) is an evidence-based program designed to enhance communication and teamwork. Developed by the Department of Defense with the Agency for Healthcare Research and Quality, TeamSTEPPS focuses on four principles:

  • communication
  • leadership
  • situation monitoring
  • mutual support.

The program creates a common language for communicating patient safety concerns, encourages a flat organizational structure so all team members feel comfortable speaking up for safety, and enhances teamwork across the organization.

For 2 years, we provided resilience training to all clinical and nonclinical team members in our organization as we worked toward our goal of using TeamSTEPPS tools to improve communication and safety. Focusing on resilience before implementing TeamSTEPPS facilitated engagement and buy in, and we found that team members were open to learning and using the tools in their everyday work, enabling an organizational culture change. We are continuing with this model for all new employees.

As our implementation journey progressed, we observed the positive impact the resilience work had on our team. Inspired by stories from individuals and teams about how the activities helped improve their wellbeing and team performance, we decided to make resilience a continual focus for our organization.

Building positivity

Building resilience is an ongoing process, and we’ve continued to develop ways to enhance positivity in the workplace. Dr. Barbara Fredrickson, a psychologist who’s completed extensive research in positive emotions, focuses on the 10 positive emotions that support happiness: love, gratitude, inspiration, pride, joy, serenity, interest, hope, awe, and amusement. We’ve incorporated these emotions in our efforts to improve well-being at work.

Initially, we partnered with departments to create a customized plan to improve resilience based on their team needs. We identified staff to attend a 2-day resilience workshop provided by the Duke Patient Safety Center. The workshop focused on the science of resilience and in-depth tool application.

After the workshop, attendees partnered with department leadership to develop plans to improve resilience. The education department initiated Wellness Wednesday, dedicating 20 minutes each week to participate in a wellness activity like yoga, stretching, mindful breathing, and walking. The radiology nursing team found that many of them were struggling with sleep issues. Team members completed education on healthy sleep habits, used their phones to set daily bedtime reminders, committed to not consuming caffeine after 3 PM, created a 15-minute awareness window by communicating a shift end so team members can help each get out of work on time, and used sleep-tracking logs. The team successfully improved their sleep at night, which allowed them to be their best possible selves at work. They reported feeling more alert and ready to face the challenges of the day and experienced improvements in their follow-up safety survey scores.

Interprofessional effort

In an effort to make building resilience continuous and extend it across the organization, we developed an interprofessional team to brainstorm ideas for organization-wide resilience activities. We recruited team members from human resources, education, patient safety, service excellence, and communications to develop specific activities we would do simultaneously throughout the entire organization. For example, we created interactive bulletin boards in each unit with activities for building resilience and positivity. The bulletin boards are placed in the employee lounges with supplies attached for team members to add their input, offer advice to others, or simply share their personal experiences. We also encouraged team members to post pictures to tell their story.

One bulletin board focused on cultivating positive emotions throughout the year, with a theme and activity for each emotion. (See Show your pride.)

Show your pride

We created a series of bulletin boards and other activities to promote positive emotions (love, gratitude, inspiration, pride, joy, serenity, interest, hope, awe, and amusement). We started with pride to align with the upcoming award season.


With the pride board, which we called “Fridge-worthy,” we encouraged team members to post their pride using supplied sticky notes or to add pictures to show their team members what makes them most proud. These fridge-worthy moments helped team members learn more about each other and encouraged conversations. They shared pictures of graduations, their children riding a bike for the first time, the finish line of a long race, and even feelings of pride related to being part of a great team.

We launched the Fridge-worthy boards during award season, when we surprise employees with recognition for their hard work and dedication. We held multiple celebrations for award recipients and shared articles highlighting the stories related to the awards.

Candy grams

To promote gratitude and pride, we held a free candy gram activity in the café. Anyone in the organization could choose from four different candy grams that they could send to team members to acknowledge their hard work or an achievement. For example, one option was an image of a life preserver with the words “You’re a lifesaver!” in the middle, along with a roll of Life Savers® candy. The candy grams were delivered to the recipients on their units the next day.

transforming culture resiliency teamwork show pride

Another bulletin board asked team members to share their “Prescription for well-being.” Staff shared activities they enjoy doing outside of work, including “being grateful,” “snuggle time with my little ones,” “pedicures,” “eating cake,” and “spending time with family.” We encourage leaders to discuss the board themes with all of their team members during staff meetings and to give everyone an opportunity to share additional ideas.

To help enhance joy and serenity at work, we developed a bulletin board asking, “What fills your cup?” with a coffee-mug theme. We provided paper coffee beans and tea bags for team members to write what brings them joy. The corresponding activity was traveling around to the units with a cart of tea, coffee, and aromatherapy to pass out to team members during their shift.

Each time we change the bulletin board theme, we create a kit that includes all the necessary components of the board and a photo of a completed version for leaders to replicate on their unit. This is an important part of our sustainability plan; it encourages participation without requiring too much time away from other duties.

Make resilience intentional

Focusing on personal resilience and improving teamwork has been extremely rewarding for individual team members and the organization. Since launching focused resilience education in coordination with team training, we’ve seen significant improvement in resilience, teamwork, and safety climate in our organizational culture surveys. The feedback on each of the bulletin boards and activities has been positive, and the managers appreciate the kits we provide. We plan to repeat several of the popular activities at various points throughout the year. All of the activities are low cost and easy to replicate in any organization.

We’ve learned that a resilient workforce is the foundation for positive change within an organization. By focusing on personal well-being, we’ve seen our culture shift into one that supports positive relationships, values each team member, and accepts that none of us are superhuman. Knowing that teamwork is essential for safe, high-quality care, we strive to foster a positive environment coupled with providing staff with a common language through team training. By making resilience intentional, healthcare organizations can create a culture of well-being that positively impacts patients, their loved ones, and the team members who care for them.

Tammi P. Hicks is the administrative director at Duke University Health System in Raleigh, North Carolina. Melissa Sullivan is manager of patient safety at Duke Raleigh Hospital. J. Bryan Sexton is the director of the Duke Patient Safety Center at Duke University Health System and associate professor at Duke University School of Medicine. Kathryn C. Adair is the assistant director of research at the Duke Patient Safety Center at Duke University Health System.

Selected references

Agency for Healthcare Research and Quality. About TeamSTEPPS®. April 2017. ahrq.gov/teamstepps/about-teamstepps/index.html

Fredrickson BL. The role of positive emotions in positive psychology: The broaden-and-build theory of positive emotions. Am Psychol. 2001;56(3):218-26.

Hall LH, Johnson J, Watt I, Tsipa A, O’Connor DB. Healthcare staff wellbeing, burnout, and patient safety: A systematic review. PloS one. 2016;11(7):e0159015.

Moss M, Good VS, Gozal D, Kleinpell R, Sessler CN. A Critical Care Societies collaborative statement: Burnout syndrome in critical care health-care professionals. A call for action. Am J Respir Crit Care Med. 2016;194(1):106-13.

Rippstein-Leuenberger K, Mauthner O, Bryan Sexton J, Schwendimann R. A qualitative analysis of the Three Good Things intervention in healthcare workers. BMJ open. 2017; 7(5):e015826.

Seligman ME, Steen TA, Park N, Peterson C. Positive psychology progress: Empirical validation of interventions. Am Psychol. 2005; 60(5):410-21.

Sexton JB, Schwartz SP, Chadwick WA, et al. The associations between work-life balance behaviours, teamwork climate and safety climate: Cross-sectional survey introducing the work-life climate scale, psychometric properties, benchmarking data and future directions. BMJ Qual Saf. 2017;26(8):632-40.

Tawfik DS, Sexton JB, Adair KC, Kaplan HC, Profit J. Context in quality of care: Improving teamwork and resilience. Clin Perinatol. 2017;44(3):541-52.

Weaver SJ, Lubomski LH, Wilson RF, Pfoh ER, Martinez KA, Dy SM. Promoting a culture of safety as a patient safety strategy: A systematic review. Ann Intern Med. 2013; 158(5 pt 2):369-74.

Welp A, Meier LL, Manser T. Emotional exhaustion and workload predict clinician-rated and objective patient safety. Front Psychol. 2015;5:1573.


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1 Comment. Leave new

  • Terri Heningburg-Douglas
    September 28, 2020 11:02 pm

    After reading this article, I realized the efforts made to promote well-being in my work environment. As I visualize my surroundings at the hospital, I reflect on bulletin boards, cold water, and newspaper services provided by the volunteers—calendars for nurses week with pictures of the nurses showing pride in their work. Zumba, Thai Chi, and mindfulness exercises are offered by mental health to reduce stress. These programs exist and are needed to support the team and promote well-being.


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