Healthcare organizations spend millions of dollars investigating adverse events, near misses, and patient harm. We review charts, analyze processes, and search for technical failures. Yet some of the greatest threats to patient safety are not found in an operating room, an ICU, or an electronic medical record. They are found in culture.
A study published in the Journal of Applied Psychology examined how leaders influence the behavior of those around them. The authors found that leaders who rely on dominance, control, and forceful authority unintentionally create environments where employees develop what researchers call a “zero-sum mindset”—the belief that one person’s success can only come at the expense of someone else’s. As this mindset grows, helping behaviors decline. Employees become less likely to share information, support colleagues, and work collaboratively toward common goals.
While this finding has important implications for every industry, its consequences in healthcare are uniquely alarming.
Healthcare is fundamentally a team sport. No surgeon operates alone. No nurse cares for patients in isolation. No physician, administrator, technician, therapist, or support staff member can deliver exceptional care independently. Modern healthcare depends on the seamless exchange of information, trust, expertise, and mutual support. When people stop helping one another, patients suffer.
What makes this particularly dangerous is that dominant cultures often masquerade as high-performance cultures. Decisions are made quickly. People appear aligned. Conflict seems minimal. Leaders are viewed as decisive. From the outside, everything may look efficient.
But efficiency should never be confused with excellence.
Underneath these cultures, people often learn that questioning authority carries risk. Speaking up becomes uncomfortable. Challenging assumptions feels dangerous. Over time, individuals begin to protect themselves rather than protect the mission. Information becomes guarded. Collaboration decreases. Compliance replaces commitment.
The tragedy is that these behaviors rarely emerge overnight. They trickle down from the top.
People learn far more from what leaders do than from what leaders say. Team members observe which behaviors are rewarded, which voices are heard, and which concerns are dismissed. They watch who gets promoted, who gets protected, and who gets silenced. Culture is not created by mission statements. Culture is created by repeated behaviors that leaders tolerate and reinforce every day.
This is where healthcare organizations must be particularly vigilant. The presence of “sacred cows”—long-standing practices, influential individuals, or unquestioned traditions—can create conditions where harmful behaviors become normalized. When people stop asking whether something is right because it has always been done that way, organizations become vulnerable. History is filled with examples of catastrophic failures that occurred not because people lacked expertise, but because they lacked psychological safety.
The operating room offers a powerful example. Every member of the team may recognize a potential problem, but if even one person feels unable to speak up, the entire system becomes less safe. A culture that discourages questions does not simply affect employee engagement; it directly affects patient outcomes.
Fortunately, the opposite is also true .Just as fear trickles down, so does courage. Just as silence spreads, so does openness. Just as dominant behaviors can shape a culture of self-preservation, supportive behaviors can create a culture of collective success.
When leaders ask questions instead of providing all the answers, curiosity spreads. When leaders admit mistakes, accountability spreads. When leaders help others succeed, collaboration spreads. When leaders create psychological safety, people become willing to raise concerns before they become disasters.
The lesson from this research is not that leaders should avoid being decisive. Healthcare requires decisive leadership. Lives often depend on it. The lesson is that influence rooted in control and self-interest carries unintended consequences that may undermine the very outcomes leaders seek to achieve.
Every organization should periodically ask itself a difficult question: What behaviors are spreading through our culture, and where did they originate?
If teamwork is declining, track it to its source. If people are afraid to speak up, track it to its source. If silos are growing, trust is eroding, or collaboration is disappearing, track it to its source. Because culture leaves clues.
The responsibility of leadership is not simply to achieve results. It is to create conditions where people can do their best work, challenge assumptions, and support one another in pursuit of a common mission. In healthcare, that mission is not profitability, prestige, or personal advancement.
It is patient care. Each of us has a choice. We can contribute to cultures that reward fear, competition, and self-preservation, or we can build cultures that reward trust, transparency, and collaboration. We can become part of the problem, or we can become part of the solution.
And when we encounter environments where harmful behaviors have become normalized, where psychological safety is absent, and where patient welfare is repeatedly compromised, we have another responsibility: to protect our teams, protect ourselves, and most importantly, protect our patients.
Because in healthcare, culture is never abstract. It ultimately reaches the patient.
Reference
Kakkar H, Sivanathan N. The Impact of Leader Dominance on Employees’ Zero-Sum Mindset and Helping Behavior. Journal of Applied Psychology. 2022;107(10):1706-1724. The study demonstrated across multiple experimental and field settings that dominant leadership increases employees’ zero-sum thinking and decreases helping behaviors, largely through changes in how employees perceive success and competition in the workplace.
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