Changing the way we do things: a qualitative exploration of culture change in clinical care and education before and during the COVID-19 pandemic in an academic health center

Abstract

Purpose

This study investigated the necessity of culture change in clinical care and medical education within a US academic hospital before and during the COVID-19 pandemic. It explored how the syndemics of COVID-19, racism, and the mental health crisis magnified the urgency of culture change in healthcare and aimed to understand the impact of these syndemics on healthcare and educational culture.

Method

An 11-item survey with 8 open-ended questions was distributed to healthcare teams and trainees at a large academic medical center before (Dec 2019 to March 2020) and during the pandemic (Feb 2021 to April 2021). The survey examined need for culture change, where it has worked well, and factors contributing to successful culture change. Responses were analyzed and themes were generated by qualitative analysis.

Results

The study revealed a strong focus on person-centered care before the pandemic with an emphasis on interdisciplinary care, communication, and safety. Within the pandemic, the focus shifted to COVID-19 safety, increased staffing and support, addressing health disparities and racism in healthcare, and use of telemedicine. As the pandemic evolved, burnout and mental health concerns became more prominent raising questions about the sustainability of culture changes..

Conclusion

The study highlighted cultural shifts within healthcare and medical education magnified by syndemics. There is a growing emphasis on anti-racism, respect, and psychological safety. It emphasized the importance of understanding cultural shifts within institutions to drive effective culture change. Future research should explore different healthcare settings and post-pandemic culture changes. This study provided valuable insight into the landscape of culture change, clinical care, and education, especially in response to COVID-19 pandemic challenges.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44250-025-00241-7.

Introduction

The need for culture change in medicine has long been nationally recognized in the United States (US) [1–3]. During the syndemics of COVID, racism, and the mental health crisis, the urgent need for culture change within the US health system was magnified [4, 5]. In the context of health care and medical education, the term syndemic describes the interaction of multiple interconnected health conditions that synergistically worsen each other’s effects. We propose that the interplay between COVID-19, systemic racism, and the mental health crisis exemplifies a syndemic. Each of these factors not only exacerbates the others, but also magnifies their combined impact on patients, healthcare workers, and trainees, underscoring the need for an integrated approach to address these overlapping crises. Each of these pandemics further exposes ongoing systemic inequities and the failure of our current systems to adequately address the needs of society’s most vulnerable populations [6]. The syndemics further highlight how the current systems fail to support the healthcare workforce and uphold their core values of effective communication and compassionate, person-centered care. The COVID pandemic led to extended work hours and, initial unsafe work environments with inadequate protective equipment, lack of a vaccine, and uncertain treatments, adversely affecting an already morally distressed healthcare workforce [7, 8]. Clinical demands for both faculty and trainees surged as faculty struggled to teach in a constantly shifting educational environment [9].

Approaching culture change in medicine and medical education requires examining the existing culture within the healthcare system and the educational environment of future healthcare professionals. While there is a shift to improve curricular content and methodology in undergraduate and graduate medical education by addressing structural racism, inequities, and mental health [10–12]; less has been done to examine and address the systems and structures that maintain workplace toxicity, racism, and inequities within inpatient hospital settings and educational environments [13, 14]. Appreciation of the impact of COVID on groups working within clinical care and education serves as an opportunity for value clarification and as a catalyst for positive change. Within the present study, we conducted a survey-based qualitative exploration to better understand the need for and approaches to culture change in clinical and educational settings in a large academic health center before and during the COVID pandemic with the purpose of examining the syndemics’ effects on clinical care and educational culture.

Method

Data collection

An 11-item survey instrument (see Supplementary file 1) with 8 open-ended questions about culture change in health care and education was distributed to healthcare teams and trainees in the inpatient setting at a large academic medical center. Respondents were recruited through direct emails or via email distribution lists associated with an institutional leader. Groups included internal medicine and anesthesiology residents, fellows, and attending physicians; medical, physician assistant, nursing, and pharmacy students; nursing staff, pharmacists, chaplains, physical and occupational therapists, nutritionists, social workers, case managers, hospital administrators, and faculty wellness officers. Informed consent was obtained from all individual participants included in the study.

Data were collected using Qualtrics, an online survey tool [15]. In order to ensure that everyone operationalized key terms in a similar way, the survey provided definitions as part of the instructions and participants were also able to use their own definition of culture. Hospital culture was defined as attitudes, behaviors, beliefs, expectations or practices in the hospital/organization, and culture change was defined as a perceivable shift or difference from previous attitudes, behaviors, beliefs, expectations, or practices. For both surveys, participants completed basic demographic questions before responding to open-ended prompts about where culture change is needed in the delivery of patient care and education, why culture change is needed, where culture change has worked well in hospital and training environments, and what contributes to successful culture change. At the end of each survey, participants had an opportunity to share additional thoughts on the topic of culture change.

The pre-COVID survey was distributed from 12/2019 to 3/2020. It was closed in early March 2020, because of the start of the COVID-19 pandemic in the United States. The within-pandemic survey was distributed from February 2021 to April 2021. The within-pandemic survey instructions were updated to ask participants to reflect on culture change after the “start of the COVID-19 Pandemic.” Two reminder emails were sent to all groups during each of the study periods. The study was reviewed and exempted by the Oregon Health & Science University Institutional Review Board and in accordance with the Helsinki Declaration. All responses were anonymous.

Data analysis

Respondents who completed only the demographic portion of the survey were excluded from analysis. All respondents who responded to one or more prompts were included in the final sample. Survey responses were analyzed using the 6-step Braun and Clarke method of thematic analysis [16]. Data familiarization and code generation were completed individually by three coders who reached consensus on codes and code definitions. A final code book was used by all coders. All items were independently coded by two coders. The final adjudication of relevant codes was performed through discussion and reconciliation with a third coder.

Results

Respondent characteristics

There were 89 respondents to the pre-COVID survey. The majority of respondents were physicians, including faculty, fellows, and residents; followed by medical students. Respondents represented multiple levels of training from nursing and medical students to nurse practitioners, physical and occupational therapists, and attending physicians. Representatives from across healthcare teams completed the survey including care/case managers, chaplains, hospital administrators, psychologists, and social workers. For a breakdown of respondents to the pre-COVID survey by gender, please see Table 1.

Table 1.

Pre-COVID—study participants by patient care role, gender

	Man	Woman	Transgender/non-binary	Genderfluid	Did not specify	Total
Care/case management	1	2	0	0	0	3
Chaplain/spiritual support	1	0	0	0	0	1
Dietician/nutrition services	0	1	0	0	0	1
Hospital administration	0	1	0	0	0	1
Medical student	6	10	2	0	0	18
Resident	3	3	0	0	0	6
Fellows/faculty	8	13	0	0	2	23
Nursing student	1	7	1	0	1	10
Nurse/nurse practitioner	0	3	0	0	0	3
Physician assistant	0	3	0	0	0	3
Physical/occupational therapy	2	8	0	0	0	10
Psychologist	0	1	0	0	0	1
Quality improvement role	0	1	0	0	0	1
Social work	1	7	0	0	0	8
Total	23	60	3	0	3	89

There were 69 respondents to the within-pandemic survey. Nursing and physicians responded in similar numbers (n = 16 and n = 17 respectively). A few new members of the healthcare team completed the within-pandemic survey including physician assistant students, pharmacy students, pharmacists, and medical school administrators. For a breakdown of respondents to the within-pandemic survey by gender, please see Table 2.

Table 2.

Within COVID—study participants by patient care role, gender

	Man	Woman	Transgender/non-binary	Genderfluid	Did not specify	Total
Care/case management	1	0	0	0	0	1
Medical student	2	5	0	0	0	7
Resident	3	6	0	0	0	9
Fellows/faculty	2	5	0	0	1	8
Medical school administrator	0	1	0	0	0	1
Nursing student	1	1	0	0	0	2
Nurse/nurse practitioner	2	13	0	1	0	16
Physician assistant student	1	3	0	0	0	4
Physician assistant	1	4	0	0	0	5
Physical/occupational therapy	0	7	0	0	0	7
Pharmacist	1	1	0	0	0	2
Pharmacy student	0	1	0	0	0	1
Psychologist	0	1	0	0	0	1
Social work	0	4	1	0	0	5
Total	14	52	1	1	1	69

Thematic analysis

Before the pandemic

In the pre-COVID survey, prompts were used to explore where culture change is needed in the delivery of patient care, culture change within the learning environment, why culture change is needed, where culture change has worked well in hospital and training environments, what contributes to successful culture change, actions related to effective culture change, and additional thoughts. Tables with additional responses for each code are available as Table 3.

Table 3.

Pre-COVID: themes, and illustrative quotes from participants—questions on patient care delivery, education, where culture change is needed and working well, examples of successful teams working in culture change, and additional thoughts

Emergent themes	Representative quotation(s)
Care delivery
System of care: safety, cost consciousness	holding people accountable to their behavior (e.g. addressing sexual harassment, microaggressions), improve staffing ratios, pay employees better	[The institution] garnered a record operating profit of $175 million on record operating revenues of $3.2 billion, according to the unaudited financial results.""and our patients leave our hospital with crippling debt… Stop making patients pay criminal amounts for basic health care	More thoughtful ordering of diagnostic tests, i.e. CTA chest, which is way overordered in the ED and has something like a > 95% negative rate for PE
JEDI: diversity in the workforce, special populations, intersectionality	Hiring more employees than needed to just barely cover shifts. When we are spread thin, we do not get to spend enough time talking to patients to really understand their home life, eating habits, financial challenges, etc	More minority physicians in the emergency room, Increased recruitment of LGBTQ and minority faculty	More in person translators
Patient centered care: patient care environment: communication, teamwork, efficiency, patient-centered care, silos	Patient’s understanding of their conditions/illnesses, patient interruption (how we wake them up multiple times in the morning for rounds)	Increased recognition that a patient’s care “team” includes many players (CM, SW, RN, MD, RT, CNA, etc.) and effective care means effective coordination of all these people	Respectfully accepting professional clinical decisions from a different service than your own, if your patient has multiple teams, all teams need to meet at the bedside regularly (together) to eliminate diverging advice and confusion
Respect/value *unique theme	Room for compassion in the day is at least as important as clinical volume, respect for all. We are all on the same team. Don’t bash other services or patients, Provider satisfaction is as important as patient satisfaction	Understanding and respecting the role of master’s level clinicians in social work	Treat chaplains with equal respect to other professionals in the hospital, especially in offering their services to all patients/families and doing adequate staffing
Education
Systems of care: cost consciousness, professional development	Teach teachers how to teach, give incentives for teaching and remove people from teaching responsibilities if they repeatedly have bad reviews	Funded time for education (the 15% knock off of RVU referent to community/benchmarks is not real)	More support for education program management to ensure ‘top of license’ work within the education realm as well, equal consideration of the time/money required for innovative education (educational RVU?) by leadership
JEDI: intersectionality, diversity	(Intersectionality) more emphasis on the patient as a whole and their illness experience, rather than solely on biological aspects of health; we deal with so many patients whose primary concern or health issues stem from social determinants of health and these need to be better addressed	Awareness of how gender biases impact evaluation, including when it maybe happens against gender nonconforming men/women/or LGBTIQ folks generally (maybe less of a problem in IM in my opinion, but might be more prevalent in other core rotations in my opinion)	Diversity in student experience (students with families, for example)
Patient care environment: communication, teamwork, efficiency	Communication between inpatient and outpatient providers leads to inaccuracies in the inpatient team's plans and charting and frustrations on their part when they realize their inaccuracies. Yet no one ever reaches out to the PCP who could answer questions quickly	Detach stigma from persons with chronic pain; don’t assume (in ED especially) that they are looking for opioids, detach stigma from persons with addiction, teach people not to ever say “the patient failed (X treatment).” It is disrespectful to the patient: it respects the treatment that doesn’t work more than it respects the patient. If it’s an adherence issue, just say “The patient found (X treatment) hard to adhere to, so it was not effective”	More emphasis on the patient as a whole and their illness experience, rather than solely on biological aspects of health; we deal with so many patients whose primary concern or health issues stem from social determinants of health and these need to be better addressed, better communication with patients about their disease process, management, course, etc.; especially at discharge. This should be the responsibility of all care team members including physicians, nurses, social work, etc
Learning environment: valuing learners/learning, safety, curricula content, interprofessional	Less reliance on subjective measures, especially with respect to clinical knowledge, awareness of whether extraversion/introversion is being misused as a proxy for clinical knowledge/ability (again, less prevalent in IM in my opinion, more for other areas of medicine generally)	Balance learning over service (ex. no time to teach on work rounds)	More autonomy for students, less pure shadowing
Need for culture change
Systems of care: professional development, cost consciousness, safety/wellness	Faculty need experiences paid for by the university on work time to grow as educators given most don’t have a prior background in teaching. Residents need a formal wellness/leadership curriculum to give them tools to succeed in their careers as attendings that is sponsored by GME. And finally, gender bias is real and impacts which learners get opportunities, that needs to be changed and made more transparent	In the limited capacity with which I’ve experienced being part of team that’s worked on implementing somewhat radical program to improve patient care (in a VERY patient-centric way), it’s been hard to grapple with how much rigidity there can be when the matter of logistics comes into play. It has felt like for every one person we encounter who champions our idea, there are 5 who want to shoot it down from a ‘this sounds like it’s more trouble than it’s worth’ perspective. Ultimately, it leaves me feeling like our institution has culture change in mind in theory, but in practice, isn’t always ready to put in the work	Awareness of how gender biases impact evaluation, including when it maybe happens against gender nonconforming men/women/or LGBTIQQ folks generally (maybe less of a problem in IM in my opinion, but might be more prevalent in other core rotations in my opinion)
JEDI: diversity, intersectionality	Awareness of how gender biases impact evaluation, including when it maybe happens against gender nonconforming men/women/or LGBTIQQ folks generally (maybe less of a problem in IM in my opinion, but might be more prevalent in other core rotations in my opinion)
Patient care environment: teamwork, communication, collaboration	For years I’ve heard providers, including many I have high respect for, speak about patients “failing” a medication or a treatment. I always want to say, “Wow, that treatment must be so disappointing in that patient.” I have brought this up with many colleagues and most agree with me, but we still do it. Patients do not fail treatments	Consider restructuring rounds to better facilitate patient flow	Patients do not understand roles of everyone who stops in
Learning environment: valuing learners/learning, curricula content/focus	Balance learning over service (ex. no time to teach on work rounds)	We need to embrace a learner-centered culture where learners set goals and take responsibility for meeting those goals	Include students in a meaningful way, Get rid of subjective grading policies
Where culture change is working
Systems of care: professional development, safety/wellness	Efforts to develop delegation order protocols. Finally (15+ years. of trying), team-based case manager trials
JEDI: diversity, intersectionality, special populations	Attitude toward IVDU population from blaming/punitive to a more harm-reduction approach. Attitudes of MDs at [this institution] are very different from other hospitals I’ve worked at. I also feel like nursing buy-in of harm reduction attitudes has really increased over the last 3 years, so it now feels like we’re all on the same team when taking care of this challenging patient population	Transition of hospital medicine program to ensure adequate backup coverage among all CHS and MTS faculty. Racial Bias training	Adding pronouns to ID badges, printing correct name/gender expression on patient IDs
Patient care environment: teamwork, communication, efficiency, interprofessional, patient-centered care, silos	Iinstitution has a great culture that values collaboration and not rushing. It is founded upon true academic interest and patient needs. I never felt like I was an afterthought as a student there	When a young person who knows how to listen to the fears of his/her peers also wins the trust of an old (usually white male) leader, culture changes	The HELP program, initiated for delirium prevention, has shown that increased mobility using volunteers and other means reduces hospital falls and improves post discharge outcomes. The geriatrics team has increased attention to goals of care and helped other teams recognize and understand their value the medical school SNAP program has engaged early students in patient-centered systems learning that could be expanded to interprofessional students and more venues
Learning environment: valuing learners/learning, education	Change for the first 2 years of medical school and how grades are not the focus. As in, A-F grades. I think this really takes some of the pressure off and makes it more about learning and understanding rather than regurgitating info	At an away rotation, I saw one division had replaced their chair, and other faculty stepped up to change the culture from competitive to collaborative, bringing in younger faculty was an excellent way to better include students in patient care, because they were recently residents and could remember their time and ability at the student level
Ideal/ways to improve model programs	At an away rotation, I saw one division had replaced their chair, and other faculty stepped up to change the culture from competitive to collaborative, bringing in younger faculty was an excellent way to better include students in patient care, because they were recently residents and could remember their time and ability at the student level
Successful teams culture change
Approach	Some institutions have attendings cover the service while residents attend grand rounds/presentations so that residents don’t have to chart and be distracted	If we were running late, attendings would take it on themselves to circle back and fill in the gaps we might have created by taking an extra minute to teach/learn, or to interact with a patient	Because all members wanted to contribute to the change—especially the administration, and it was enforced! Bringing on younger faculty often imbues the program with more motivation
Cohesion	When multiple disciplines get together to problem solve, additional problems tend to get identified and resolved faster than staying in our own silos. I was on a team to reduce inappropriate ordering of therapy services and we had RN and MD involvement. It helped identify areas of improvement for education to staff	Multidisciplinary rounding. Educational rotation with other disciplines	Team based clinical teams who have adequate time (bandwidth) to move beyond “survival mode” to teach or connect with peers’ trainees and faculty who reach out to offer 1:1 support or refer to peer support program when colleagues are struggling
Motivation/purpose	Schwartz Rounds Interprofessional collaborations Creating space for creative solutions to addressing complex issues like acute and chronic pain, poly substance abuse, and complex mental health factors When management and directors’ step back, read cultural nuances, listen to feedback and offer solutions to create practical changes	Transparency. Very clear, short rationale for what needs to change and why. Emphasis on a slow deliberate process	Commitment from leadership, clear goals and objectives, buy in from staff, understanding of why these changes improve patient care
Resources	One of the assistant deans is a literal saint. I am not even remotely exaggerating. When I was going through a hard time, she reached out to me, and many other students, and always made herself available. One occasion, she even offered to call me while she was on vacation with her family. That is dedication. That is commitment. That is compassion. Give her a raise, a promotion, a medal, something. She is, without question, one of the most remarkable human beings I have ever encountered. Whatever ideas she has for implementing cultural change, you should listen to her	The gender equity center and confidential advocate program were successful largely due to actual FUNDING and great support from the Title IX office, as well as outstanding student leaders
Leadership	The gender equity center and confidential advocate program were successful largely due to actual FUNDING and great support from the Title IX office, as well as outstanding student leaders
Reinforcement	Class consistently held. I believe RNs are all aware of the class, so pts is more likely to attend	Because all members wanted to contribute to the change—especially the administration, and it was enforced! Bringing on younger faculty often imbues the program with more motivation
Observed effective practices in culture change	Repeated, direct communication and re-education both of medical teams and of multidisciplinary teams has slowly changed culture over time. Their practices are rooted in compassion, and in listening to the patient perspective, and relentlessly advocating for this	Really believing in the work, champions from multiple disciplines, dedication to the mission/vision of the program and having unified mission/vision	Constant presence requires more sensitivity to the language we are using. Also, peers provide a great model and constant feedback for us on how to communicate with these patients
Additional thoughts	Meeting with students at the beginning to assess their experience of the rotation and to get to know them better set the tone for a rotation where I felt valued. An end of rotation meeting felt final and was a great way to bookend my time	The anesthesiology department has made it a priority. They have practiced what they preach and once you start telling people they belong more will follow!	Openly talked about our moral distress of a case and what we can do about it

Care delivery

When asked where culture change is needed in care delivery, respondents commented consistently and broadly on the theme of person-centered care. Respondents noted a need for more focus and attention to the “whole person,” with quality of care emphasized over quantity of care, and increased patient safety and autonomy. Examples respondents included were introductions of names and roles, increased face-to-face time with patients focusing on education and communication, limiting repetitive exams, fewer disruptions to promote rest and sleep, and implementing consistent schedules for care activities such as rounding and physical therapy to help patients establish a rhythm and ensure they are awake for critical conversations with their team. Another area of focus was language, including limiting medical jargon, using more in-person interpreters, and incorporating linguistic and culturally sensitive care. One respondent called for “assume positive intent” for team members who fail to respond rapidly as well as patients with substance use disorders. Several respondents identified the importance of incorporating social work, chaplain services and palliative care services as part of patient care teams. A theme that frequently arose in discussions of person-centered care was intersectionality and considering the multiple identities that patients and providers have. Respondents commented on the need for an increased understanding of the social and emotional circumstances patients are facing, maintaining respect and sensitivity for patients who have experienced trauma, educating staff on trauma-informed care, and addressing social determinants of health. People also discussed being aware of bias and stigma associated with identities or diagnoses. The next most common theme was communication. Respondents commented on the need for more face-to-face communication, improvements to paging culture and interprofessional communication, and better communication with outpatient providers. Several highlighted how improved communication is important for trust and respect within teams. Teamwork was identified as a major theme and included understanding roles and scope of practice, respecting all of the team members, and recognizing the breadth of the patient care team. Efficiency and safety were the next most common themes. Comments on efficiency focused on the burden of administrative work, the desire to work at the top of their license for all team members, and the redundancy in the system. Comments related to safety consistently addressed the need for more staff coverage.

Learning environment

Responses to the prompt on where culture change is needed in the learning environment included the need for bedside teaching, unpacking “the hidden curriculum,” education on preventive care, trauma-informed care, interdisciplinary care, nutrition, and social determinants of health, and how to collaborate within a team. Respondents expressed a desire for training on how to mitigate microaggressions and called for the eradication of gender and racial bias in education and for racial, ethnic, and gender diversity in education and leadership. Students shared the need to feel useful, seen, and valued in the work environment. A call for more funding for educational time and CME for faculty, support of trainee and faculty scholarship, uninterrupted learning time for residents, and less clinical demands to create more teaching time from faculty were also highlighted.

Culture change is needed

Respondents were asked to provide examples of why they felt culture change is needed in care delivery and education. Several students commented on witnessing other students put down or mistreated and called for a safer learning environment. In discussing the need for culture change in the delivery of care, one respondent wrote, “I have witnessed moral injury lead to a breakdown in quality patient care and broken trust amongst departments.” Numerous respondents also highlighted the need for culture change related to how people approach patients with mental health and substance use disorders and limited resources.

Where culture change has worked well

When prompted to comment on where culture change has worked well in the hospital or educational environment, respondents highlighted the increased focus on new educational leaders, education, and training on novel patient care approaches, particularly those that support underserved and marginalized populations and the increased hiring of staff from under-represented backgrounds. One respondent wrote, “When multiple disciplines get together to problem solve, additional problems tend to get identified and resolved faster than staying in our own silos.”

Reasons that culture change was successful

When reflecting on reasons that culture change was successful, respondents consistently commented on the importance of shared motivation and experiences. One respondent wrote, “Because all members wanted to contribute to the change—especially the administration, and it was enforced! Bringing on younger faculty often imbues the program with more motivation.” Others reflected on the role of leadership support, funding, and constant feedback in successfully accomplishing culture change.

Actions related to effective culture change

Asked to describe actions related to effective culture change several respondents commented on the importance of leadership support “to ensure mass participation among [the] workforce.” Several people commented on the role of diligent follow-up and communication and the role of the mission in effective culture change. One respondent, reflecting on culture change in education, described how “a faculty member attended a conference on racial and cultural bias in the health system, brought notes back from this conference, and was vulnerable with other staff regarding her learning…THIS is an effective way to educate.” Finally, several individuals shared examples describing projects that led to desired outcomes and how that drove their effectiveness.

Additional thoughts

When asked to share additional thoughts, respondents commented on diverse aspects of culture change. One respondent wrote, “If you want culture change, it’s important to remember the people who are at the center of the work. They have to be involved in every step of the process—designing, implementing, education, and ongoing reinforcement. You can’t force change from the outside in. It needs to be driven by those using it.” Another respondent stated, “I’ve never seen it done. There needs to be more of an attitude of loving kindness. It radiates from within, and I think that no amount of external policies could change the way people feel about one another or the way people treat one another. Good luck I guess.”

The Justice Equity Diversity and Inclusion (JEDI) framework was consistently demonstrated in the Pre-COVID data within care delivery, education, need for culture change, and where culture change is working. Statements coded as reflecting the JEDI framework highlighted the need to hire more under-represented physicians in the emergency room, and the need for increased recruitment of LGBTQ+ and under-represented faculty for clinical care and educational settings.

Within pandemic

The same prompts were used for the within-pandemic survey exploring delivery of patient care, culture change within the learning environment, why culture change is needed, where culture change has worked well in hospital and training environments, what contributes to successful culture change, actions related to effective culture change, and additional thoughts. Respondents were told to reflect on culture change “after the start of the COVID-19 pandemic.” Themes related to virtual meetings, telemedicine, and online learning emerged across all prompts. Similarly, there was a focus on COVID-19 safety, communication, resources, and policies and procedures. Respondents also commented on ways in which respect and values changed during the COVID-19 pandemic. Tables with additional responses for each code are available as Table 4.

Table 4.

Within COVID pandemic—themes and illustrative quotes from participants—questions on patient care delivery, education, where culture change is needed and working well, examples of successful teams working in culture change, and additional thoughts

Emergent themes	Representative quotation(s)
Care delivery
Workplace safety	Anonymous reporting culture is toxic and carceral; structural changes to support safe, face-to-face, real-time feedback and/or conflict mediation promotes trust instead of undermining it
Diversity: special populations, intersectionality	Challenge how white supremacy is perpetuated in the hospital by systems and structures designed to protect and support white American English-speakers, for example,... knowing politeness customs, knowing how to navigate Pacific Northwest passive aggressiveness, etc. gives white workers a huge advantage over workers of color
Patient care environment: communication, teamwork, efficiency, patient-centered care	Finding intentional ways to replace/center face-to-face interaction or be transparent about its marked absence, i.e., acknowledge how dehumanizing virtual sitters can be	Lack of patient education: We do not educate patients about what we know and find out or what we are thinking, especially on the inpatient side, Shared decision making: we continue to provide paternalistic care in which we do not allow patients to make decisions, assuming they want us to make decisions for them	MORE FOCUS ON COMMUNICATING WITH FAMILY!—Ideally, more liberal visitation policies, but barring that more resources and services to effectively communicate with family members
Respect/value	Respectful appreciation of diverse perspectives	Actively demonstrate a culture of learning, teaching each other tasks
COVID-related	Better addressing the additional psychological impact, the pandemic has had on patients and their current care	Provide healthcare providers with more time off and time away from the hospital—caring for COVID patients is an entirely different level of exhausting”
Virtual	Family/society connection while hospitalized-invest in technology to connect people while hospitalized—e.g. more tablets/phones, etc
Education
Cost consciousness	Better staffing to allow for more time for on-the-clock education. Currently no time to properly take education modules
Intersectionality, diversity	There have been general e-mails, but it feels the education on the unit level is not consistent or readily available regarding racial and LGBTQI + issues	Change education rooted in eugenics and white supremacy (e.g. BMI, separate labs for Black/African American patients)	Training for supervisors on strengths-based leadership, addressing unconscious bias and racism
Patient care environment: communication, teamwork, interprofessional, patient-centered care	There is less real time, at the bedside, interdisciplinary education opportunities because of social distancing in the hospital	Handouts for patients available easily in ANY language, Increased language interpretive services and cultural interpretive services	Newer staff have not received the training that used to be mandatory annually (and they want it)
Learning environment: valuing learners/learning, interprofessional	Finding good ways to safely teach physical exam skills, not forgetting about students who are excluded from group workspaces, not confusing directness with aggression—offer direct feedback and communication clearly and upfront so students aren’t left guessing (or at worst, completely paranoid) re: expectations and performance	Dedicated education time has declined it seems from an increase in acuity of patient care activities	Recognition of the emotional toll on learners to have fewer social connections, outlets, changes in training, changes in career opportunities/jobs
COVID-related	Newer staff have not received the training that used to be mandatory annually (and they want it)	Including family members via virtual or in person education while safely distancing, keeping families updated virtually who cannot visit to assess and educate them on the situation of the patient
Virtual	Education accessibility varies. If it could all be recorded, even if it is a live session, it would be beneficial to those who are unable to attend or would like to be able to watch it a little bit at a time, whether for personal reasons or due to learning style	Virtual seminars are mixed in quality of teaching, engagement by participants, learners still really need real-time, hands-on training, specific feedback, recognition of the emotional toll on learners to have fewer social connections, outlets, changes in training, changes in career opportunities/jobs
Need for culture change
JEDI: diversity, intersectionality	Despite openly progressive policies, there is a culture of distaste and some contempt at times for patients coming from difficult living situations	Because of our white supremacist society, systems have been built to not trust people, especially poor people, to know what they need to spend their money on. We give out money only in certain situations and only if they meet our criteria. This is classist and paternalistic. People know what their needs are better than ours. People are struggling to pay their rent or buy food. Health is happening in their lived environment, and we need to support them by helping them having enough financial security to have emotional/physical/spiritual capacity to focus on their health	Multiple staff and patients/families have expressed concerns around the [institutions] commitment to white supremacy, rather than a radical approach to anti-racism. The “efforts” [the institution] has made thus far (predominantly by white management) feel performative and superficial–and feels like gaslighting
Patient care environment: teamwork, communication, interprofessional	Robust contextual info is not obtained or accessible to care teams on a regular basis. I think i[it] would be a culture change to assess family strengths and challenges for all, equally—so that care plans are tailored, and resources linked up in meaningful ways for more people	As staff, we are working these designated hours where we can devote our time and attention to patient's healthcare needs. Patients are having to fit in their healthcare needs amongst all of the other stressful things going on in their life, yet we expect them to respond to our calls promptly and for them to be available when we are available. I work in an interdisciplinary team, and we have 2–3 people trying to connect with the patient/family within a week and it is not standard practice to try to coordinate that communication, so we minimize the time we are taking away from the patient
Learning environment: valuing learners/learning, curricula content/focus	I think we have set up a situation in which current trainees will “burn out” much faster in the coming years because of the unaddressed additional strain of covid care and lack of wellness support	The health care disparities that have been magnified by the pandemic are going to be entrenched for many years to come—we need to set up more robust social work and admin to support the complex care of discharge for these patients. Trainees need additional training in health care disparities	Students are “nonessential” which seems to be interpreted as an excuse for being able to forget about their learning needs It feels like students are not respected/their role isn’t recognized as important, it feels like no one wants to take responsibility for their role in teaching
COVID-related	If your entire staff is stressed out by productivity standards and management will not hire more personnel, this shows me that the organization doesn’t value employees and as a student it doesn’t seem like a good place to work	Because the administration was cranking out policies that were not implementable on the floor. No one supported us to implement these. For example, patients wearing masks. That policy was basically a joke on our floor	With suicide rates and substance abuse rates up with COVID, there seems to be a lack of resources available that we can use in-house or supply outpatient to address concerns as to why these issues present. Our patients may present for a myriad of issues, but if substance abuse impairs their ability to independently care for themselves effectively, we need to be treating the whole person, not just the immediate issue. SW in and of itself is not equipped to provide this role, and inpatient psych consults seem to be rarely used
Virtual	Staring at faces on a computer screen is not an adequate proxy for human interaction
Where culture change is working
Diversity	Now a days there is a big emphasis on addressing social determinants of health and embracing diversity
Teamwork	Many people have rolled up their sleeves and helped solve problems	Nurses have come together on our unit and regularly care for patients that are not their own to support nurses stuck in isolation rooms
Learning environment: valuing learners/learning, education	I have noted that some units have been proactive not just in providing education regarding discussions around racism in healthcare as well as LGBTQI + issues in healthcare, but also in sending reminders about said education and providing multiple opportunities to engage. While I still wish that these could be recorded and available for those of us who may be neurodivergent in ways that make sitting for long periods difficult, I do appreciate the attempts made to ensure it is available for multiple times and situations	Virtual didactics actually seem to be working quite well. While it is not ideal for the presenter, and there is less interactive learning, most didactics end up being minimally interactive, anyway (a topic for improvement another time). As a student, I feel that I have not missed out on much by doing didactics/grand rounds/learning conferences virtually	The virtual elective in Care Management which gives Medical Students an opportunity to see real SW and RN CMs doing Transitional Care and addressing SDOH in the community. There is also an opportunity for learning about the shortage of subsidized housing and intergenerational poverty and institutional racism as a few causes of houselessness
COVID-related	More awareness of need to be appreciative of each other’s efforts—“spreading good”, more transparent, regular communication from healthcare leadership, wellness regularly discussed-COVID19 Wellness Task Force, Schwartz Rounds well attended–signs of need for connection, support, promotion of individual psych support resources for all
Virtual	I feel that the educational programs have done an excellent job pivoting and rewriting some of their curricula to accommodate distance learning	Virtual programs have been helpful in getting knowledge and education out to family members, like using the iPad to include family members in care planning	More ability/flexibility to work from home. More understanding of needing to stay home when sick. Telehealth
Successful teams culture change
Motivation/purpose	The people on IM... respect humans. That’s it. They’re humanistic, empathetic, protective of people with decreased autonomy (including medical students who are trying to get good evaluations while super stressed!), and realistic about expectations	Shared group focus/appreciation of importance (well-being/burnout)
Teamwork	Our unit already had a culture of teamwork before the pandemic began but it has been elevated to another level during this time. On other units we float to, it often feels like every nurse for themselves. Some floors won’t even answer a call bell if it’s not their patient	I believe the cohesiveness of the group has been helpful, as well as the persistence of the units in ensuring this education is provided and made widely available	Start with respect for the team, these teams usually are more successful
Flexibility in the workplace	I hope that supervisors are recognizing that more flexibility in the workplace is better for staff's wellness. The culture change I have seen seems to only be from necessity. I greatly fear that once things are “back to normal” that the positive culture changes that have occurred will be stripped away from us
Virtual	I think it’s been successful because the clinic is fully invested in switching to virtual platforms and has been willing to help walk patients through troubleshooting, or switch to a different type of visit, to help facilitate	The virtual programs with the iPad have been successful I think because it not only included bedside staff but also the providers so that everyone knew it was an option and how to make it happen	I think telemedicine has been successful because we’ve had access to new tools (Epic Zoom), Webex, headsets, cameras, etc. and multiple folks working on it
Observed effective practices in culture change	Being proactive in addressing issues regarding culture, as well as promoting accountability with each other	Intentional moments to re-focus by teams	Communication—once daily Covid-19 communications have helped so much!
Additional thoughts	We are exhausted. I have received not one free pizza slice, not one thanks you letter from my management team, or any other manager or director since Covid began. Other hospitals have been phenomenal at recognizing and supporting staff burnout. In my unit at least (vascular access team), we have had no support or check-ins for our staff, and we've been on the frontlines of Covid care in the ICUs and ERs. Any recognition or appreciation of how we have put our lives on the line from our managers, directors, or hospital admin would have been wonderful. A year in now and I want to leave nursing completely. If I had been supported in any way during this last year by [the institution] it would be different	There was a lot more stress placed on nurses and a lot of support was taken away.... Social Workers/Case Managers and other professionals sometimes were entering rooms and put it on nurses to obtain info and arrange things they would normally arrange. It was expected that we would keep up with new policies WHILE maintaining vigilant adherence to isolation precautions. But there was no extra support. There was a lot of tone-deaf communication and not a lot of administration coming to assess needs. There were casually “check ins” and coffee brought by- but no pointed follow up on actual issues

Delivery of care

When discussing the delivery of care, numerous respondents highlighted the need for increased staffing and support. One respondent wrote, “With skilled nursing facility shutdowns and increasingly more barriers, the time spent doing non-medical care is increasing exponentially (already too high!).” Increased resources and empathy for patients presenting with mental health concerns were also noted by several respondents. Numerous respondents commented on health disparities and racism in healthcare, acknowledging how it affects everything from pain management to health outcomes. Improved interprofessional communication, including communication with outpatient providers by inpatient teams, was consistently highlighted by respondents. When efficiency in the patient care environment was discussed within the pandemic, it was often related to barriers to admission and discharge. Comments related to the new use of the virtual environment discussed both the benefits and drawbacks of telemedicine in patient care settings. Several respondents expressed a desire for better connections for patients with family, whether in-person or virtual. On the other hand, respondents expressed concerns about the enforcement of visitor policies and masking, and the ongoing risks healthcare professionals faced during the pandemic. Numerous respondents commented on burnout during the pandemic and how that affected interactions. One respondent wrote that within the pandemic it is “me-focused”, instead of “we”/team-focused. Respondents consistently expressed a desire for more support from leadership and coworkers. A need for consistency in communication and policy enforcement, including support for policy implementation by leadership, was a common theme. Respondents noted how their responsibilities expanded with new policies, but they were not supported in meeting the increased demands of their jobs.

Learning environment

Respondents commented on how the learning environment changed with the COVID-19 pandemic. Students discussed being separated from patient care teams and missing out on conversations related to patient care or even direct patient care. Respondents also commented on how increased patient care requirements, including increased acuity, due to the pandemic made it harder to provide time for teaching or completion of required continuing education. Several respondents requested protected time for learning, such as noon conferences, acknowledging how difficult it was to be attentive to the virtual session while providing patient care. They further highlighted how policies related to not eating in team rooms to prevent the spread of COVID-19, made it difficult to find time and places to eat during the day and socialize with team members. There was a desire for education at every level on racial and LGBTQ+ issues and addressing unconscious bias and racism. Respondents were mixed in their feelings about the virtual learning environment. While some highlighted the improved accessibility virtual sessions provide and the ability to tailor education to learning styles, others highlighted the variability in the quality of online learning and the tendency or expectation that people would multitask during online sessions.

Need for culture change

Responses to the prompt on the need for culture change focused on how the COVID-19 pandemic affected both patient care and the learning environment. A majority of respondents mentioned the constantly changing hospital policies around visitors and masking, discussing how difficult these policies were to implement, and how enforcing the policies increased burnout and exhaustion among hospital staff. Staff reported feeling unsupported in implementing constantly changing policies and struggling to identify where to find the most up-to-date COVID policies. Respondents also spoke about the need to address the syndemic associated with COVID-19. They discussed the need to educate trainees about health disparities, make culturally competent care a priority, and address needs and barriers related to substance use, mental health, and financial instability. The lack of resources to support the syndemic was mentioned by several respondents, as well as the feeling of stress and burnout.

Where culture change has worked well

When prompted to comment on where culture change has worked well in the hospital or educational environment, respondents highlighted the increased focus on diversity, social determinants of health, and anti-racism. Several respondents commented on the pivot to virtual learning environments and how that allowed people to stay engaged when they were rotating off-campus or staying home with a sick child. Teamwork was highlighted by several respondents as well as improved communication from leadership.

Reasons that culture change was successful

When reflecting on reasons that culture change was successful, some respondents described the importance of shared values and mission in driving culture change, while others felt that the observed culture change was out of necessity and may revert back to old patterns once things are “back to normal.” Teamwork was consistently highlighted as being important to successful culture change. Telemedicine was consistently named as an area of successful culture change due to the combined efforts of staff across numerous disciplines and settings.

Actions related to effective culture change

Asked to describe actions related to effective culture change that they observed, respondents most frequently listed communication. Respondents also described the importance of “[b]being proactive in addressing issues regarding culture, as well as promoting accountability with each other,” and “intentional moments of refocus by teams.”

Additional thoughts

Although the themes across the additional thoughts prompt were less closely aligned, the majority of respondents commented on the toll COVID-19 has taken on healthcare professionals. One respondent wrote: “The morale on the unit has been low due to constant understaffing, heavy patient acuity, high numbers of isolated patients, risks to our health and safety and on top of all we endure, watching the hospital we commit our lives to nickel and dime us for 7 months to avoid giving raises despite massive profits during a global recession. We feel disheartened and devalued!” One respondent, reflecting on culture change, wrote, “[It is] going to be hard. This was forced on us due to the pandemic. I don’t feel our culture will change or I will be well retired or have quit medicine by that time we wise up and fix the system inefficiencies.”

As in the pre-COVID analysis, the within pandemic data demonstrate the Justice Equity Diversity and Inclusion framework within care delivery, education, need for culture change and where culture change is working. The JEDI framework was supported by statements regarding bias against patients, the need for promotion of anti-racist practices, and the call for ongoing institutional commitment to equity and inclusion in education, patient care, and the overall work culture.

Discussion

The present study garnered perspectives on culture change in clinical care and education from members occupying diverse, multidisciplinary roles within an academic hospital before and within the COVID-19 pandemic. The study focused on areas in need of culture change in medicine and education, and what made culture change successful when it was implemented. The timing of the surveys, before and within the COVID-19 pandemic, provides insight into how the recent syndemics shifted what participants desired for change. Several studies have highlighted the need for culture change in healthcare and medical education [1–3, 17–19]. We found a similar desire for culture change among survey respondents in the present study and also uniquely demonstrated the shift and intensification of those desires within the pandemic.

Care delivery

Before the pandemic, the focus was on person-centered care. Respondents named specific examples to improve patient care such as interdisciplinary rounding, coordinated care, and clearer communication with patients and families. There was a desire to address social determinants of health, increase cultural sensitivity, address bias and stigma, and incorporate trauma-informed care. Communication and teamwork were also highlighted as being of critical importance. This included communication between members of the treatment team, communication with patients and family, and communication with outpatient providers. Safety was mentioned less frequently and when mentioned focused on the need for better staffing to improve patient care.

Within the pandemic, there was no longer a focus on specific ways to improve person-centered care. There were numerous calls for increased staffing, resources, and support for staff. Comments about burnout and moral injury were more common, a topic reflected in the literature on the effect of the pandemic on health professionals [20]. Health disparities were still mentioned, with increased calls for addressing racism in healthcare. The increased number of comments on anti-racism reflects the medical community’s more focused engagement with racism following the murder of George Floyd [10–14]. Interestingly, within the pandemic, there was a narrowing of the language around health disparities. Terms such as trauma-informed care, culturally sensitive care, social determinants of health, bias and stigma were used less frequently. Respondents were more likely to use the terms unconscious bias, disparities, and white supremacy; likely reflecting training initiatives at the institution around unconscious bias as well as an increased focus by the media on the health disparities associated with the COVID-19 pandemic [21]. Respondents also reflected on the use of telemedicine in healthcare. The use of telemedicine as part of routine care changed abruptly and significantly due to the COVID-19 pandemic and remained part of healthcare delivery [22]. Communication remained a key theme, but the focus shifted to communication with family and visitors and clear and consistent communication from leadership.

Education

Pre-pandemic students called for more training on a broad range of topics including unpacking the “hidden curriculum,” addressing microaggressions, preventative care, trauma-informed care, and social determinants of health. During the pandemic, there were specific calls for education on racism and LGBTQ+ topics, and other topics were mentioned less frequently. During the pandemic, learners were separated from patient care teams to comply with quotas for how many people could be in a team room. As a result, learners were left out of conversations related to patient care or even direct patient care. Studies suggest that medical students missed out on opportunities to learn core clinical skills such as suicide assessments during the pandemic [23]. Addressing the isolation experienced by learners and finding ways to meaningfully connect all members of the team will be important for student wellness as well as team cohesion and communication. Studies have shown that medical students reported increased stress and anxiety during the pandemic [24, 25].

COVID-specific themes

Pre-pandemic, patient mental health was a common theme, while within the pandemic comments mentioning mental health expanded to include healthcare workers. Respondents reflected on how caring for healthcare workers and ourselves is critical in order to care for our patients. This aligns with the growing conversations around healthcare worker burnout and the increasing number of healthcare workers leaving their jobs [20, 26, 27]. Interestingly, there was a narrowing of where culture change was working within the pandemic. Before the pandemic, respondents included examples of education, patient care, and systems of care. Within the pandemic, there was a loss of focus on education and patient care. Previously, respondents identified culture change associated with improvements in person-centered care; within the pandemic, the focus on patient care shifted to addressing safety, communication, and visitors. Pre-pandemic concerns mostly focused on systems of care and social disparities, but the difficulty of providing care during the pandemic led to a focus on sustaining work and high-quality patient care within the pandemic.

Several new themes emerged in the within-pandemic survey including a focus on healthcare worker safety and the incorporation of anti-racist education and healthcare practices. Respondents were cautious about how long these changes might last, expressing concerns about what happens when things go “back to normal.” Critically, respondents noted that culture change during the pandemic was out of necessity and that the gains may not be maintained in the long-term as the circumstances change.

Limitations and future directions

There are several limitations to the present study. First, culture is subjective and it is possible that the definition was not conceptualized similarly by our participants. The study was at a single academic medical center in the Pacific Northwest and may not represent the values of all academic medical institutions. The within-pandemic survey was administered in the earlier part of the pandemic before vaccines were available and when social distancing and visitor policies were being enforced within healthcare settings. There were fewer respondents, representing less diversity, in the within-pandemic survey compared to the pre-pandemic survey. The timing of the survey influenced the content of responses but captured a critical moment in time. Understanding thoughts on culture change during crisis operations may ultimately provide clearer insight into the needs and values of an institution. Future studies should explore other care and educational settings to assess for generalizability and the impact of COVID-19 on culture change.

Conclusion

This is the first study to characterize differences in culture change in medicine and education before and within the COVID-19 pandemic. Person-centered care remained central with a shift in focus related to maintaining patient safety during the pandemic. The focus on addressing health disparities and incorporating anti-racism, respect and psychological safety for all into healthcare and education increased as a result of the syndemics. Burnout and mental health were more commonly discussed within the pandemic than before. Understanding the desired cultural shifts within an institution and how those were influenced by the recent syndemics is critical for accomplishing culture change within healthcare and medical education. Future studies should explore other care and educational settings to assess for generalizability as well as post-pandemic culture change.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

Dr Marr, Dr Patel and Dr Harrison all wrote the main manuscript text and prepared or contributed to tables. All authors reviewed the manuscript for publication.

Funding

MCM is supported by R25MH135837.

Data availability

The data that support the findings of this study are available from the authors, however, to protect study participant privacy we are unable to share publicly.

Declarations

Ethics approval and consent to participate

The study was reviewed and exempted by the Oregon Health & Science University Institutional Review Board and in accordance with the Helsinki Declaration.

Competing interests

The authors declare no competing interests.