Changing Nursing Culture- Why Is It So Hard?

If nursing is consistently ranked as the most trusted profession in America…
Why do so many nurses feel unheard inside their own workplaces?

That question has been on my mind.

On this podcast:

 We talk about burnout.
 We talk about staffing.
 We talk about leadership.

But underneath all of it is something deeper — culture.

And culture is hard to change.

Not because nurses don’t care.
Not because leaders don’t try.

But because culture isn’t just policy.

It’s identity.

There are many layers to uncover here, so let’s get into it.

Notes on Nursing: What it is and What it is Not, by Florence Nightingale

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Transcript

[00:00] Michelle: If nursing is consistently ranked as the most trusted profession in America,

[00:05] why do so many nurses feel unheard inside their own workplace?

[00:11] That question has been on my mind. On this podcast, we talk about nursing,

[00:16] we talk about burnout,

[00:18] we talk about staffing, and we talk about leadership.

[00:22] But underneath all of it is something deeper,

[00:26] and that's culture.

[00:27] And culture is hard to change.

[00:30] Not because nurses don't care,

[00:33] not because leaders don't try,

[00:35] but because culture isn't just policy,

[00:38] it's identity.

[00:41] There are many layers to uncover here, so let's get into it.

[00:58] So the first layer is that culture is inherited.

[01:04] Modern nursing identity is heavily shaped by several things. First of all, Florence Nightingale.

[01:12] Florence was all about obedience, morality, devotion and duty.

[01:18] And if you would like to learn more about Florence Nightingale, I did a nine part minisode series on Florence's book, Notes on Nursing: What It Is and What It Is Not.

[01:27] Just search my library and you'll find it.

[01:31] The American Nurses association introduced professionalization and standards to modern nursing.

[01:39] The Joint Commission,

[01:41] they introduced compliance culture and hospital hierarchies were built on physician dominance.

[01:51] So from this history, we inherited an identity built on self sacrifice,

[01:58] following the rules,

[02:00] being nice,

[02:03] endurance as a virtue. And I will go more into that in a moment.

[02:08] And silence as professionalism

[02:12] That identity helped nursing survive,

[02:15] but it also keeps nurses small.

[02:19] Professional identity lives in language such as,

[02:24] that's just how it is,

[02:26] We're short, but we'll make it work,

[02:29] Patients come first,

[02:31] I don't want to rock the boat.

[02:34] If nurses define themselves primarily as helpers,

[02:39] they will tolerate some degree of harm.

[02:43] But if they define themselves as leaders,

[02:46] they will challenge it.

[02:49] So changing identity requires us asking,

[02:53] who do we think we are? Who do we believe we are?

[02:57] Are we caretakers?

[02:59] Are we martyrs?

[03:01] Are we task rabbits?

[03:03] Or are we clinicians,

[03:06] strategists and designers of care?

[03:12] We need to stop confusing suffering with virtue.

[03:16] I think that would take us so far in nursing and changing the nursing culture,

[03:23] and I think it's already happening. I've spoke with many nurses that refuse to suffer.

[03:30] They change things instead of suffering in silence.

[03:35] One of the most entrenched parts of nursing identity is endurance.

[03:40] I interviewed leaders Brandon Young and Blaine Smith, who wrote the book Perseverance Is Greater Than Endurance.

[03:47] And that distinction applies directly here.

[03:51] Endurance says,

[03:53] I'll survive this,

[03:55] but perseverance says,

[03:58] I will change this.

[04:01] If nursing continues to glorify burnout,

[04:04] moral injury,

[04:06] and overwork as proof of dedication,

[04:09] our identity won't shift.

[04:12] We have to stop applauding exhaustion.

[04:16] We have to ask ourselves,

[04:18] what story are we telling about ourselves?

[04:21] Who does that story serve?

[04:24] And what would it take to tell a new one?

[04:29] Remember, identity is a story and stories can be rewritten.

[04:38] The next layer is hierarchy,

[04:41] and hierarchy is structural.

[04:44] So nursing developed inside a health care system that was never designed by nurses.

[04:50] And what I mean by this is hospitals were built around medical power.

[04:55] The modern hospital model grew through physician governance structures,

[05:00] fee for service, reimbursement models,

[05:03] expanding insurance, and regulatory frameworks shaped largely by medicine and administration.

[05:11] Organizations like the American Medical association shaped professional authority early and effectively.

[05:18] Nursing professionalized later through bodies like the American Nurses Association.

[05:25] But by then, the architecture was set.

[05:28] Chain of command,

[05:29] billing priorities,

[05:31] credential hierarchies,

[05:33] decision pathways.

[05:36] Nurses entered as essential labor,

[05:39] not as system architects.

[05:42] Organizations like the American Nurses association advocate for professional autonomy and influence,

[05:48] and they've made real progress.

[05:51] But at the bedside, many nurses still experience limited authority in decision making.

[05:57] We've been taught to think critically,

[05:59] but oftentimes there's pushback, either from individuals or institutions.

[06:07] Now, let's talk about shared governance.

[06:10] This might be a jaded comment, but shared governance sometimes feels performative.

[06:17] And let me explain.

[06:19] I'm sure many of you who work in hospitals,

[06:22] maybe you've been curious to see what this shared governance committee is all about.

[06:27] Or maybe you were invited to serve on the shared governance committee.

[06:32] Maybe you were voluntold by a manager, or you just needed the points for your annual raise.

[06:39] And don't get me wrong, many great changes have come from shared governance committees. I consider them essential.

[06:46] But the process is long and tedious and often met with resistance from within our own circle.

[06:54] And by circle, I mean within our own profession and among allied health professionals such as physicians.

[07:01] I was a nurse for 36 years, and I served on several shared governance committees and was part of trying to affect change within our scope of practice, only to have it thwarted by physicians who wanted no part of our change and were told to go back to the drawing board and try again.

[07:22] And we wonder why things take decades to change in healthcare.

[07:28] Culture doesn't shift just because we create committees.

[07:32] It shifts when power shifts and power is uncomfortable to talk about for many nurses.

[07:39] Shared governance only works when shared power is real.

[07:43] Otherwise, culture stays intact.

[07:47] Then there's the other layer we don't always name, and that is trauma.

[07:53] Trauma is chronic understaffing, moral distress,

[07:57] workplace violence.

[07:59] When people survive trauma together, coping mechanisms become tradition.

[08:05] And those coping mechanisms are dark humor,

[08:09] emotional shutdown,

[08:11] hyper independence, and I always think of the night shift when I hear this word.

[08:16] They are dependent upon each other,

[08:20] but individually they are each very hyper independent because they know there's nobody there that's going to back them up. There's no managers, there's no administration.

[08:32] They're pretty much on their own.

[08:35] And I think that's why they develop such tight teams.

[08:39] They have interdependence within their own group.

[08:43] But like I said, individually they're very independent.

[08:50] Coping mechanisms such as eat your young dynamics,

[08:54] those are sad, but they're often more about self protection than being cruel. And survival. Cultures resist change because change feels really scary and even destabilizing.

[09:08] And I want to talk about change for a moment in relation to culture.

[09:14] When I was working as a pediatric nurse in the early 1980s,

[09:20] early 1990s,

[09:23] I worked in a rural hospital and we had a very small pediatrics unit.

[09:29] We had a nurse come to our unit from the Bay Area and she had experience working at Stanford,

[09:39] at Lucille Packard, which is a pediatric hospital for very sick kids.

[09:44] So she had a lot of experience.

[09:46] She worked with us for a few months before she started trying to impart some of her wisdom.

[09:53] And her wisdom came from her experience caring for very sick children.

[09:59] Most of us pediatric nurses in our unit, we had kind of grown up in our valley, we had grown up in our institution and we didn't have a lot of experience outside.

[10:16] And so this nurse,

[10:18] she went about it in such a great way.

[10:21] When I, when I look in retrospect,

[10:24] even though she was not effective in creating any kind of change, but she would, if we were doing a certain procedure, she would say,

[10:33] you know, at Stanford we would do it this way, why don't we try it?

[10:37] Or at Stanford, you know, this was our protocol.

[10:42] What do you guys think about that?

[10:44] And at that time we didn't have any shared governance committees. We were very resistant to this nurse.

[10:52] We felt like, oh wow, you came from Stanford, so you're so smart, you know so much more than we do and you're trying to stuff it down our throats.

[11:03] And we were not receptive to her message

[11:06] As gentle as it was.

[11:08] We were not interested in changing because we said this is how we've always done it and this works for us.

[11:18] Even though it really wasn't working for our patients,

[11:22] it worked for us as nurses.

[11:24] And I just think how many times do we do things in nursing to make our lives,

[11:30] our work easier

[11:32] but it doesn't make the patient's experience any better.

[11:37] The corporate layer. Let's talk about the corporate layer. We know anybody that's been in healthcare for a minute knows that healthcare today is deeply corporate.

[11:49] I would even say it's big business.

[11:52] For example, last year in 2025, HCA Healthcare reported a total revenue of almost $76 billion,

[12:03] with a profit of over $6 billion.

[12:09] And large systems like HCA Healthcare and others operate at scale.

[12:14] And with scale comes metrics.

[12:17] Again, anybody that's worked in a hospital is familiar with metrics.

[12:22] Throughput,

[12:23] which is a critical key performance indicator used to improve efficiency and maximize profitability.

[12:30] Patient satisfaction scores,

[12:33] documentation, burden and cost efficiency, or as I like to say, doing more with less.

[12:42] Now, none of those are inherently wrong.

[12:45] But when productivity becomes dominant,

[12:49] culture bends towards efficiency, not humanity.

[12:55] Nurses have seen it, and nurses feel it.

[12:59] When the highest praise you get is "you moved patients quickly" rather than "you mentored someone,"

[13:07] or "you advocated" or "you slowed down to listen."

[13:12] Culture forms around what gets rewarded.

[13:16] We'll have some questions that we can ask ourselves a little bit later.

[13:21] Now we're at the layer of resilience and man,

[13:27] that is a bad word in my book. And it never was before COVID, but during COVID we were asked to do so much with so little,

[13:40] and then we were told that we needed to be more resilient.

[13:45] Let's talk about the resilience myth,

[13:48] because there's a narrative that we just need to be more resilient.

[13:53] We need more self care,

[13:55] more mindfulness,

[13:57] more pizza parties,

[13:59] more gratitude boards.

[14:02] But resilience can't compensate for misalignment.

[14:06] We don't have a resilience deficit.

[14:10] We have a systems alignment problem.

[14:15] So what actually changes culture?

[14:19] Culture changes when incentives change.

[14:23] It changes when staffing models reflect reality.

[14:27] I've said this before,

[14:29] that I'm so fortunate to have lived and practiced in a state that has safe staffing levels.

[14:38] Culture changes when psychological safety is modeled.

[14:43] Culture changes when leaders admit uncertainty. And for all the leaders out there, it's okay to say, I'm not sure. I don't know what's going to happen.

[14:52] It's okay.

[14:53] New nurses are socialized into advocacy,

[14:57] not silence.

[14:58] And boundaries are respected instead of quietly penalized.

[15:03] Culture shifts when what gets rewarded shifts. And that takes time and it takes courage.

[15:11] So let's reflect on culture change.

[15:15] If you've ever tried to change something in your workplace and it felt like the needle barely moved,

[15:22] you're not imagining it.

[15:24] Culture feels immovable because it's invisible.

[15:29] It's built from daily choices.

[15:31] What we tolerate, what we praise, what we ignore and what we model.

[15:36] Culture isn't just leadership.

[15:39] Culture is us.

[15:41] And maybe the question isn't why is it so hard to change the culture of nursing?

[15:47] Maybe it's what part of the culture am I unintentionally reinforcing?

[15:53] And that's not blame.

[15:55] That's agency.

[15:57] And agency is where change starts.

[16:01] So let's ask ourselves what behaviors are quietly rewarded in my unit?

[16:09] What behaviors are quietly punished?

[16:12] And if a new nurse walked in today,

[16:14] what would they learn about how you really do things?

[16:19] Well, what do you guys think?

[16:21] Am I right on?

[16:22] Am I far off?

[16:25] Shoot me an email@the conversingnursepodcast@gmail.com go to my website theconversingnursepodcast.com and leave me a voice message.

[16:34] Or reach out on Instagram @theconversingnursepodcast and let me know your thoughts and thank you for listening.