It may be hard to believe, but there’s an unnerving psychological parallel between Doomsday cults and ineffective health care operational environments. Doomsday cults have been around for centuries, and the cult members faithfully follow the leader—and a delusional agenda—preparing for the end of the world. But the end never happens. Failure.
In the 1950s the famous psychologist, Leon Festinger, studied a Doomsday cult called The Seekers. This cult believed a flood was coming that would destroy Earth. They trusted that superior beings from the planet Clarion would come to Earth in flying saucers to save them. The Seekers abandoned their families, jobs, and college and sold all their worldly belongings. On Dec. 21, 1954, they gathered in Chicago for Doomsday. Never happened. Failure.

What Made Them Follow?

Festinger went undercover to analyze how the cult members formed their thought constructs and to explore how the leader influenced their attitudes and behaviors. The study delved into what motivates someone to irrationally follow a leader with a hidden personal agenda. He concluded that these cult members experienced cognitive dissonance.

According to Festinger, people hold many cognitions, or perceptions, about the world and themselves. “When [these] cognitions clash, discrepancy is evoked, resulting in a state of tension known as cognitive dissonance,” he says. But because the experience of dissonance is unpleasant, “we are motivated to reduce or eliminate it, and achieve consonance,” or agreement, he says.

The cult members might believe leaving a family is objectionable, but they reverse their objection by convincing themselves that sparing their own lives is less objectionable.

How Businesses Follow Same Arc

In everyday business, take employees who are instructed to complete a work task they know is incongruent with company policy. They know it’s wrong, but they convince themselves to do it because losing their jobs is more objectionable.

Confusion, conflict, and tension are the coercive persuasions ineffective executives use to create cognitive dissonance in the conscious minds of employees. Without a doubt, ineffectual executives in leadership positions can be the modern-day prophets of operational Doomsday.

Consider a flagship continuing care retirement community (CCRC) with several hundred residents, independent living, assisted living, dementia care, and skilled nursing care. The CCRC has multiple business units, intense oversight by federal and state regulators, a complex medical and clinical nursing focus, and wide-open liability exposure that comes with caring for the frail elderly.

The campus has a successful track record of regulatory compliance, minimal complaint history with the local health department, a negligible history of legal action, and many effective, long-term employees. It just so happens that it needs a new executive director (ED).

In this scenario, the C-Suite—chief executive officer (CEO), chief operating officer (COO), and vice president (VP)—has one primary responsibility: to hire an experienced and effective ED.

But make an assumption that, somewhere, a hidden personal agenda interfered with the hiring decision. For some unknown reason, the C-Suite opted to hire a person without sufficient prior experience as an ED or nursing center administrator.

Even before the ED arrives at the campus, the management staff are in a state of cognitive dissonance trying to reconcile that their C-Suite didn’t hire an adequately prepared mentor and leader.

Inevitable Downward Spiral

Even a well-intentioned administrator-in-training program will only serve as a cursory training guide for the new ED. Consequently, the bulk of responsibility for teaching the new ED will be relegated to subordinate staff. As this scenario progresses, so does cognitive dissonance:
  • The amount of foundational learning for an inexperienced ED is enormous. Add the learning arc for fundamentals of long term care, clinical nursing care, state licensing requirements, and federal regulatory compliance and the knowledge capture becomes overwhelming and stressful.
Cognitive dissonance: As the training staff observe the ED’s inability to swiftly and adequately absorb and synthesize the knowledge capture, they simultaneously struggle with the conscious thought that they could be portrayed as ineffectual—and responsible for the ED’s declining performance.
  • As the ED progressively fails to master long term care subject matter, his or her pathologies surface and become more visible to staff; the ED reacts defensively and projects mistakes onto staff.
Cognitive dissonance: Training staff become conflicted about how to alter their instruction to fit the ED’s deteriorating frustration tolerance.
  • The ED resorts to self-preservation by circumventing staff training efforts and might revert to decision making from past operational experience, which is incongruent. Training staff become uneasy, even panicked; their new role is correcting and covering for their boss!
Cognitive dissonance: Staff become painfully conscious that their relationship with their boss is becoming confrontational and counterproductive.
  • Regardless of the support staffs’ genuine efforts to help the new ED, they are, unfortunately, perceived by the ED as undermining, even being obstructionist.
Cognitive dissonance: Staff fear losing their jobs!

As the work environment and facility leadership become more disorganized and less stable, long-term, diligent employees are now disciplined and written up under the guise of poor performance; some employees are even terminated.

Cognitive dissonance: Staff come to work every day feeling off-balance, abandoned by the C-Suite, and demoralized.

Consequently, the operational environment degrades until it is untenable. The internal pressure on the ED elicits an abrupt resignation. New employees brought in by the ED to replace terminated employees exit rapidly. The operation spirals downward and heads toward a proverbial operational Doomsday.

Ironically, it’s not the fault of the inexperienced ED; fault is exclusively on the C-Suite. Why did they ever hire someone so inexperienced? And why didn’t someone recognize the degree of mismanagement and subsequent chaos?

What They Should Have Done

What’s the psychological cure for cognitive dissonance and elimination of operational Doomsday? It’s simple. First and foremost, screen all job candidates carefully in an attempt to keep personal agendas out of the workplace. Every member of the hiring panel should be honest enough to admit why a candidate is or is not perfect for the job.

Conduct substantive interviews for all leadership—including C-Suite—positions. Stop asking questions about how someone “feels.” No one is paid to bring their feelings into the workplace. Don’t ask candidates for their position on social issues.

Stop trying to feel a candidate’s (or a panel member’s) “vibe.” In fact, if after an interview someone on the panel says he or she “got a good vibe” from a candidate, then you know the problem is on the panel. Analyze a candidate’s critical thinking and systemic strategies for long term care operational management.

The Right Questions To Ask

Ask candidates scenario-analysis questions. For example, ask how the candidate would systematically and methodically resolve either a current, or prospective, problem/challenge in a real-world facility.

Our organization has experienced a 6 percent decline in occupancy over the past three years. As CEO, describe your systematic strategy to operationally reverse this decline.

The organization has shown an inverse negative trend in our annual customer and employee satisfaction surveys. As the CEO, describe your methodology to discover the reason and reverse these negative trends.

As the COO, your position is tasked to develop and promulgate policy. Please describe your knowledge of the new Centers for Medicare & Medicaid Services rule for emergency preparedness and highlight the new components.

Our facilities have demonstrated a 22 percent increase in licensing and regulatory infractions over the past quarter. As VP, describe your systematic process to resolve infractions and improve compliance.

One of our continuing care retirement communities has demonstrated a 12 percent increase in complaints to the Department of Health in the past quarter. As the ED, describe your systematic process to reverse this negative trend.

Ask the director of nursing (DON) to describe your systematic process to reduce skin breakdown and maintain skin integrity.

A recent audit revealed a medication error rate of 15 percent in the past quarter. Ask the DON to describe the company’s systematic process to correct the error rate and maintain a medication management program in compliance with regulatory standards.

The above questions will reveal either the presence, or absence, of a candidate’s core competency to “operationally map” effective strategies to promote change.

Hiring effective leaders is an affirmative obligation of every long term care organization. The primary job of the C-Suite is to procure and provide their employees with experienced leaders capable of effectively mentoring their operational environments to eliminate conflict, confusion, and tension that precipitate cognitive dissonance.

Undoing the damage done with an organization that is doomed by cognitive dissonance is not an easy task; there is no quick fix. Hiring panels will need an entirely new perspective on what their job is, as well as what the job of the candidate is.
Jaime Todd, MBA, LNHA, is a health care reorganization/turnaround executive specializing in acute care, behavioral and mental health, primary care, and long term care. Todd is a widely published author of leadership, licensing/regulatory compliance, risk management, and health care operational management articles. He can be reached at