Culture change is important and necessary within the healthcare system. How can a polyvagal informed perspective facilitate this process?
It is well recognized that significant changes to the healthcare system are needed in order to improve current conditions for all stakeholders, including patients and healthcare professionals. These changes include the culture, structure, and organization of the system. There has been frequent discussion implicating the system itself in the ever increasing prevalence of healthcare professional burnout. From my perspective, incorporating a polyvagal informed lens, this paradigm is incomplete and a previous article has further explained the rationale for this opinion. A polyvagal informed understanding of the nature and biology of burnout provides insights and explanations that are not otherwise frequently discussed. In my opinion, it is imperative that these concepts be included within the understanding of the nature of burnout and the strategies to address it.
Irrespective of the degree to which the system and associated culture is the cause of the current problems within the system, there is no question it is in need of substantial change. A key aspect in working towards changing culture is an understanding of what specifically we are trying to achieve, particularly identifying the defining features of the desired culture. Typically, this refers to a new culture in which all stakeholders are able to pursue their best, be their authentic selves, and support one another. Often, this is termed a culture of safety. Using polyvagal theory principles and terminology, this refers to the provision of sufficient safety to the nervous system of individuals allowing for ventral vagal activation, thereby allowing those involved to be in a preferred biological state to be at their best. From a polyvagal informed perspective, this requires individuals to be able to sufficiently self-regulate and, perhaps more importantly, co-regulate each other.
Continuing the polyvagal informed understanding of this dynamic reveals that in order to most effectively co-regulate others, we must first be sufficiently self-regulated. This requires adequate ventral vagal activation, providing our nervous system sufficient safety and connection which then allows for the spontaneous emergence and expression of cues of safety to other individuals. Conversely, if one were not in a state of sufficient safety and attempted to co-regulate others by trying to express cues of safety, this would be predicted to not have the desired effect because the lack of authenticity within the projected cues in this situation would be neurocepted by others as a cue of uncertainty or risk.
Keeping these concepts emerging from Polyvagal Theory in mind, lets return to the discussion regarding culture change. As has been described, the culture we are seeking to evolve towards within the healthcare system is one in which there is sufficient, if not optimal, safety for the nervous systems of those engaged within the system. As previously discussed, this dynamic requires self-regulation amongst those within the system as well as sufficient co-regulation between individuals. It must be emphasized that effective co-regulation is fundamentally dependent upon adequate self-regulation. Given this requirement, from my perspective (and I welcome discussion on this point) it then follows that the starting point for culture change would be development of self-regulation amongst individuals within the organization. This would be based upon individuals developing polyvagal informed skills and strategies to develop the ability to manage and shift their biological states towards safety and connection under the high demands of the healthcare system. After this has been accomplished, it then becomes possible for these individuals to effectively co-regulate others within the system, thereby eventually creating the desired culture of safety.
In order to more fully understand the importance of initiating culture change at the individual level, it can be helpful to consider the predicted impact of attempts to mandate or require change in the culture from the administrative/regulative level downwards to the remainder of the organization. If such a direction of attempted change was based upon those individuals embodying the principles discussed above, then it would reflect a starting point at the individual level. If, however, such changes were directed, mandated, or regulated from the administrative level, the effects may be quite different.
When changes are regulated, mandated, required or otherwise enforced this process can easily be neurocepted as cues of uncertainty, risk, or threat. This is analogous to the individual attempt to co-regulate others when not in a state of nervous system safety. The lack of authenticity can be received as a cue of threat or risk. In addition, the evaluative nature inherent within a mandated approach may provide unintended cues of threat and risk which would serve to further shift people away from a biological state of safety. The combination of these factors would not only remove the desired culture of safety, but may, in fact, inadvertently develop a culture of risk and threat.
When the desired culture change originates at the individual level through polyvagal informed strategies to develop and promote safety for the nervous system, there becomes an embodiment of these principles within those individuals. Not only will these individuals develop the ability to self-regulate and be at their best, but they will authentically co-regulate those around them, thereby increasing the number of individuals who are in a state of safety and allowing a greater number of individuals to be at their best. Ultimately culture change then emerges naturally when a critical mass number of people embody these principles. It is likely that the critical mass number of individuals would have to include a number of those in leadership and administrative positions in order to allow for sustainable change.
The polyvagal informed Practices of the Healthcare Athlete promote health, wellbeing, and sustainable high performance at the individual level. As can be seen from the above discussion, this paradigm also leads to culture change within the organization when a critical mass number of individuals embody these skills and strategies. In this way, this perspective is able to scale throughout an organization and positively impact all stakeholders within the healthcare system.
Allison, M. The Play Zone: A Neurophysiological Approach to our Highest Performance. https://theplayzone.com.
Dana, D. Anchored: How to Befriend Your Nervous System Using Polyvagal Theory. Boulder, Colorado: Sounds True, 2021.
Porges, SW. Polyvagal Safety: Attachment, Communication, Self-Regulation. New York: W.W. Norton & Company; 2021.
Porges, SW. The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, Self-Regulation. New York: W.W. Norton & Company; 2011.