Marie Manthey’s Nursing Salon

A recent dialog among Creative Health Care Management (CHCM) consultants resulted in an internal communication I have decided to share with the blog.  As always, your comments are welcome.  (Also…how do you like the new look?)

This communication about Relationship-Based Care started with a question from Mary Koloroutis via email within our company.   

From Mary to all Consultants: 

An issue that continues to surface in the RBC Leader Practicum and in some interactions I have with nurse managers and unit practice council members is that as much as they would like to implement a primary nursing model of nursing practice, that the acuity, staffing realities (ratios and schedules), and the geography of the unit, create huge barriers to their getting there.   How are client managers addressing this?

Jayne Felgen, president of CHCM, sent this reply: 

From Jayne Felgen to Mary, copied to all consultants: 

It IS the HEART of  RBC…accepting a responsibility relationship for the patient’s care throughout their stay on that unit is the ultimate expression of professional practice.

I’m naming it and claiming it! So, the work of the Unit Practice Council is to review current scheduling and assignment practices (Work Complexity Assessment) looking especially for fragmentation reduction opportunities…to make it more likely that the nurse who agrees to perform the admission activities might also chose to be the primary nurse.

So, like an attending physician retains responsibility despite multiple consultants, or her/his day off, so do nurses create an infrastructure in which they claim responsibility for 1-2 patients among their typical assignment. Once those responsibilities are “owned”, the nurses communicate in more deliberate ways, proactively, more precisely…not unlike a parent leaving explicit instructions for the sister who’s caring for the kids while parents have a get-away. When they return, they resume care. While they’re gone, they’ve anticipated every possible need.

Having said that, 100% compliance with this may be impossible, but, we urge them to shoot for it because it’s the right thing to do. And, using Appreciative Inquiry (AI) principles, learn why it worked when it worked, and then do more of that.

Until we accept this responsibility at this level, we’ll continue to ignore the crazy schedules (1 day on, one off, 8-10-12 hour shifts reporting on/off to each other, robbing Peter-to-pay-Paul floating practices, being married to geography rather than relationship, and other craziness that produces high variability and low professional reward/satisfaction in our systems.

I am abundantly clear that we must step up and claim our practice…not by tasks or shifts, but one relationship at a time…nurses, therapists, social workers, pharmacists, etc. It’s the professional v. technical dialog again.

I had a most thrilling experience today … 

Some of you may remember that I dedicated my book, The Practice of Primary Nursing to a nurse named Florence Marie Fischer. Sometimes when I speak, I tell my own story about how I became a nurse… and I always mention Florence Marie Fisher. I became ill at the age of 5 and was hospitalized for a month at St. Joseph’s Hospital in Chicago. It was a traumatic experience in a couple of ways. First of all, my parents didn’t know how to prepare me, since they had never been hospitalized themselves. So they just said I was going to a large building. They left me there and visited occasionally. However, when one or the other came, a very painful procedure was done involving an intramuscular injection of their blood (horribly painful), so I felt not only abandoned but also frightened and confused by the pain associated with their visit.

Florence Marie Fisher is the name of a nurse who cared for me. She would sit by my bedside and color in my coloring book. For some reason, that translated to me to mean she ‘cared for me’. I decided right then that I wanted my life to be about that kind of caring, and from then on, I knew I would be a nurse. As a kid I often got doctor/nurse kits for Christmas, and I always threw away the doctor stuff. Only being a nurse was of any interest to me.

Forty years later I wrote the book on Primary Nursing. When I finished, the publisher asked me who I wanted to dedicate it to, and after a few minutes of thought I said Florence Marie Fisher. Although we had never communicated in any way after I left the hospital, I never forgot her name. And so the book was dedicated to her.

The publisher thought it would be really cool to find her, so they contacted the Illinois State Board of Nursing, whose records indicated she had moved to Indiana and that her last name was Ambrose. They then wrote to the Indiana Board to locate her, but there was no response to their request, and the search had come to an end.

It was earlier just today, when my search resumed. I was going through my papers in preparation for turning them over to the University of Minnesota Library Archives. I found copies of the publisher’s letters to the state boards and got to thinking about a way to search for Florence Marie Fischer that wasn’t available almost thirty years ago… the Internet.

Now for the thrilling part. I didn’t find her, but I found her son… and I just finished talking to him. As I was explaining my connection to his mother, I got choked up several times just realizing I was actually talking to Florence Marie Fisher’s son! He was just as thrilled to hear from me, as he had no idea of his mother’s impact on me. Out of nowhere he gets this call about the influence his mom had on me. She died in 1989, so I guess I was just meant to find him now…. not back in 1979 when I was writing my book.

He knew nothing of me, my work, or his mother’s connection to that work. It is a straight line for me. And as I told him about my work, the book dedicated to his Mom… the impact on nursing and patient care this work has had… he got just as choked up as I was.

The connection we had was extraordinary. I never thought I would find her, and I guess technically I didn’t, but talking to her son felt very close. And being able to tell her son about the tremendous impact she had on me was one of the high points of my life!

I am sending him one of the few remaining first edition hard copies of The Practice of Primary Nursing and the second edition, which is also dedicated to Florence Marie Fischer.

John Nelson, Beth Beaty and I are planning to create a special section of our webpage for Primary Nursing. Interest has ebbed and flowed over the years, and seems to be building again as frustration with FRED (Frantically Running Every Day) continues to negatively impact nursing values and unit morale. We are envisioning an opportunity for people to share problems and solutions as well as a resource for articles and research. Let me know if you have any advice for our construction of this new site.

I know if I said this in a speech before an audience of nurses, many would get angry, and some would probably walk out. And yet, it is a statement I believe to be true. Not all nurses. Not in all work situations. Not all the time.

But over my many years in the profession, I have seen the restraints that handicap our role expansion and have envisioned the contribution nurses could make to the health care of society if those restraints were removed. The realities I call restraints are both internal and external. Some are imposed by regulations designed to protect the job security of others, as well as the job security of nurses. Some are in place because of historical precedents not yet dissolved….precedents like inadequate education, cost constraints, physician-nurses role delineations disputes, and the sexual discrimination still somewhat prevalent in today’s society. Some of these are so big, and are kept in place by such powerful forces, they seem insurmountable.

Others are restraints of our own making. These include a pervasive reluctance/fear to accept responsibility for ourselves, our practice and our interpersonal relationships. They include a ‘within the profession’ reluctance to assert the right of control over nursing practice by virtue or our license. They include a willingness to work in environments that are dysfunctional….without either fixing the problem or leaving the work setting. They include an incredible tolerance for ‘within the profession’ disputes about solvable problems like entry level educational standards and proper utilization of support staff (including Lens). Enormous amounts of energy is dissipated at the highest levels of professional development on issues that require strategic and tactical decision making among various interest groups within the profession. Decisive action in these areas, (while probably not agreed to universally) would still have the power to restore energy to more productive uses.

What do I envision? For openers…the lack of continuity at the system level patients suffer from could be solved by developing procedures for call-backs to patients homes. Not all patients, not all the time….but always a decision of a responsible nurse whether to do so or not. I can envision a role for RN’s that includes time for ‘looking at the big picture’ and exercising real coordination/cooperation among specialties in highly complex situations. This can be done by providing appropriate technical support staff. I can envision nurses partnering with physicians (or other primary providers) collaborating in decision making, along with empowering patients to participate/own health care decisions. I can envision nurses creating support structures for non-nurse care providers that both educates them in the techniques of patient care and also supports them emotionally

I am a partner in a company that has software for healthy people to track their own health care data…..and set goals under the guidance of an advanced practice nurse. The employees enrolled in our program have significantly fewer major health problems, and cost their employer much less for health care.

We are so bogged down in task performance…so diminished by our sense of self-worth…and so willing to abdicate responsibility for what we are licensed to do…we haven’t taken the time to lift our eyes…envision a new future…and learn how to play together to create a world here nurses are having a major impact on the health of society and are manifesting health lives ourselves!

Recently a graduate student in nursing asked if she could interview me for an assignment on Leadership. As I answered her questions …”when did you first know you were a leader?”, “where did you learn how to be a leader?” “what is the most important thing you learned?” … I was led into some

Recently a graduate student in nursing asked if she could interview me for an assignment on Leadership.   As I answered her questions …”when did you first know you were a leader?”, “where did you learn how to be a leader?” “what is the most important thing you learned?” … I was led into some insightful reflections about change I’d like to share with you. I hope the readers will share their own insights as we ‘blog-on’ together.

First of all, when Primary Nursing was originally implemented, I knew nothing about change.   If I had, Primary Nursing might not have started when it did.  We were trying to do something else, called Unit Management.   A few roadblocks along the way led us to change directions dramatically, with the result that the staff of real unit actually implemented the delivery system before we knew they were changing delivery systems. They didn’t know it either…none of us understood the profound change the staff was creating as they moved from traditional team nursing into what we eventually called Primary Nursing.

I didn’t know about PERT charts and force field analysis….or about how to deal with resistance, or any of the theories commonly taught as part of the change process. Therefore, we didn’t have steps outlined, with time tables, goals, benchmarks, etc…. and were thus free to support the staff throughout this period of change.  All we had to guide us was common sense.

Which leads to the first learning. Decentralized Decision-Making is the core of Primary Nursing.   As I came to understand how this organizing principle works, I eventually constructed the following equation:   Change:Empowerment = Empowerment:Change.  This equation is founded on the truth that the people who know the most about the work being done are the people doing the work. Therefore, their knowledge needs to be used in deciding how to improve the work.

What role does that leave Leaders?   And how can Leaders get people to agree on how to improve their own work?

The second learning has to do with the use of visioning and inspiration as leadership tools.  One of the most important roles of a leader is to be able to paint a picture of a foreseeable future that is more desirable than the present, in language that inspires others to follow.  A ‘good’ leader will base this vision on values that are positive universal human values.

And the third learning has to do with infrastructure. A good change project (one that is successful) will incorporate a structural design that provides clear roles/expectations for appropriate decision-making at the various levels of authority. The design of the structure must be carefully thought-out……be based on the current role responsibilities throughout the department/institution with decision-making carefully allocated to the appropriate authority levels.

Those of you who have read Relationship Based Care: A Model for Transforming Practice will recognize in the above paragraph two of the four elements of Jayne Felgen’s theory of change…..Inspiration, Infrastructure, Education and Evidence.   Our extended experience with operational change will hopefully extend educational realms.