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.

M. B., a nurse from Alberta emailed me with some comments about professionalism:

I highly value the principles of professionalism but find in some workplaces and amongst some nursing colleagues that this has varying connotations and meanings. I have put this question to various professionals in health care and some exclaim that it does not truly exist. The more I search I have come to realize that professionalism in an institution is largely dependent on leadership’s belief and value of professionalism.

The extent of the leadership’s belief is reflected in how professionalism is exercised and maintained in culture of that work environment. If this belief is low, then any kind of behavior is acceptable in that work environment. If it is high, then that the culture will be of mutual respect and high trust. This indeed would be the ideal workplace but I am afraid I have been exposed to both in my life time career, thus far. The first is “hell”, the second is “heaven”.

I was very confused about the meaning of “professionalism” for a long time as well. Then I was taught about the definition used by sociologists, particularly the professionals use of autonomous decision making. I think our lack of clarity about what decisions we can rightly make (despite the clarity of language in the license) leads to the ambiguity that exists at all levels

So, first of all, there is the matter of professional practice. And then the matter of professional behavior. I find it useful to concentrate on the first: professional practice. This is where, as my friend from Alberta notes, leadership is critical. If the CEO, COO, CNO, CFO — the top leaders of the hospital — do not accept the notion that nursing is a profession with decision-making authority, they will not trust nurses.

This lack of trust creates a workplace environment that is antithetical to the normal risk-taking of decision-making. This lack of trust in employees sets up structures and behaviors that result in negative interpersonal relations. Nevertheless, I have seen many examples of creative and courageous leaders (below the level of the “Os”) who have been able to create healthy unit or departmental level cultures in spite of a lack of support from the highest level.

I know these statements are a simplification of highly complex factors, but trust is one of the major reasons some hospitals are heaven for employees, while others are hell. Couldn’t agree more. Like many of us, M. B. is looking for ways to build up professional nursing:

I am looking for more tools, any works that are currently out there to share with others to move nursing in this direction.

Creative Health Care Management has some 3-day programs that can transform nurses and their practice. One is called Leading an Empowered Organization and is for unit and departmental leaders and managers.  The other two are Leadership at the Point of Care and Reigniting the Spirit of Caring, both for clinical care-givers. All three are set up so we can ‘train-the trainers’ and license the programs for use by associations, large systems, and individual hospitals

M. B. speaks for so many of us when she ends with:

I believe nursing is an honored and privileged profession/family to belong to.

Jean Harry, in reaction to my post of July 28th,  feels that the term “ratios” is troublesome:

You can make a ratio out of any two things, but it doesn’t give any hint to the complexities or potential affect on the outcomes. There must be a better way to describe how intertwined all of this is. People latch on to ratios because it’s concrete, but it minimizes the important stuff. Staff mix is another area of struggle. Not only in terms of RN/LPN, but mix of RN’s with differing educational preparation. In Vermont, the number of both LPN and ADN programs & graduates outnumber BSN. We are creating new issues on top of those we already have.

I agree that the “ratios” is misleading….and that the variety of entry points into practice is increasingly confusing. We need to analyze work complexity in terms of knowledge and skills needed for safe Nursing Interventions in a particular patient population that are sophisticated enough that also take into account the workplace relationships that impact utilization of support staff. I think that by going back to the basics over and over again (knowledge and skills coupled with effective interpersonal relations)….rather than trying to differentiate by broad credentialing, we will be able to see the forest for the trees.

For example, when an LPN works as a care pair or a care partner with the same RN over a period of time, his/her contribution to the RN’s workload changes substantially. Likewise, coupling a new AD or BSN with an experienced clinician rather than having them work straight nights significantly increases the speed with which they get on board.

Personally, I like the structural clarity that comes from licensure delineations to guide differentiation….. and this leads me to my current absolute conviction that the major difference between RNs (of all types of preparation) and LPNs (and other skilled technicians) lies in the decision-making role. RN’s are licensed to make decisions about the amount degree and kind of care patients will receive. Period. No one else has the license to do so. When we step up to the plate and incorporate that in job descriptions, work expectations, nursing education, etc….I think the role of support staff (and appropriate skill mix for any unit) consequently will be clarified. inally, nursing is a practice profession and RN’s need to be able to combine care-giving with care management in order to acquire the complex knowledge about their patient necessary for good decision making

Finally, I guess the diffusion of educational programs (now with the post-baccs, practice doctorates, etc) increases the challenges we will be facing in the coming years. I hope that by focusing on knowledge and skill requirements for patient care, within the structure of licensure healthy workplace cultures, we will have the guidance necessary to maximally utilize the knowledge, skill and talents of every member of the staff. I am optimistic that if we keep focusing on what is right for patient care, what is fundamentally sensible and legally appropriate; we will be able to minimize the confusion of the future challenges to resource utilization.

So, here we are: after a few months of talking planning and learning by trial and error, we are ready to get my blog up and out there for everyone to see. I go forward in this with very mixed feelings.

First of all I’m excited because I see this as a new way for nurses to come together, discuss important issues, gain strength and focus while recognizing and respecting differences. I believe this kind of discussion will clarify our understanding of complex issues and help us discover new truths.

That is the good news. The hesitation is because I’m not exactly sure what a blog is and exactly how it works. Friends of mine in the office of Creative Health Care Management are helping me with all that and assure me it is a good idea and entirely doable. So….here goes.

I’ve always believed that professional nursing occurs at the point of interaction between the RN and the patient whether that is the bedside in the hospital; the exam room in the office or clinic; or in the patient’s home. So to me, the staff nurse position is the one we need to focus on for development, enrichment and support.

I’ve enjoyed the big challenge of tackling and removing the barriers, both external and internal, which interfere with the nurse delivering the very, very highest level of competent compassionate care during those moments of interaction with the patient. This has involved changing the focus of management to leadership. That means the individual staff nurse’ must mature and develop enough to manage his or her self, relationships, and practice. It also means organizations have to change so they support creative problem solving of the staff nurse at the bedside. Obviously this has been ‘a tall order’. But Primary Nursing was a giant leap forward from which many lessons were learned that are still being operationalized today.

In all my 50 years in this field, I have never been so convinced that we have what it takes to move nursing into true mature professionhood. I have a profound sense of the changes in organizational dynamics that has occurred in my lifetime. Every time I speak with a group of nurses, I am amazed and energized by the incredible passion for patient care alive in nursing today.

A few years ago, I started a Nursing Salon. My intent was to bring nurses together to talk about the big issues of the day and to get in touch with the down-deep values of nursing. These Salon meetings always restored our hope.

Our cumulative wisdom is now so much more accessible due to the electronic revolution. Nurses from all around the world, in all settings and specialties can pool our experience and knowledge, thus increasing the intellectual capital available to all of us in the field. I hope this blog can play a role in energizing and informing the lives of those who visit.

Some days, I am deeply concerned about nursing: we are not helping in the way that we could be. The average RN does not get to make decisions about the kind, degree and amount of nursing care our patients get. That should be the first item on any staff nurse job description.

We need to claim our authority.

We need to stop using “assessment” and other mealy mouthed words that allow us to avoid talking about authority and responsibility.

My friend and colleague, Mary Koloroutis, is working on a field guide to Relationship-Based Care. She has been looking over some of my old writings and asking me questions, trying to clarify some fundamental concepts. As we talked, I realized it is important to review those fundamentals every so often.

So, here is what I shared with Mary about Articulated Expectations and Authority:

Authority has to do with power……the power or right to take specific actions. This is the concept so hard for nurses to accept, and yet it is the foundational element of a profession, which has the defining characteristic of autonomy as the core of its meaning. Autonomy….the right to make decisions based on an ‘identifiable body of knowledge acquired in a formal education program’…..is one of the main characteristics that differentiates a profession from an occupation or a vocation. In order to have autonomy, one needs to exercise authority. The three concepts —Responsibility, Authority and Accountability are three aspects of a single process…..decision making. Whether it is decentralized or centralized doesn’t really change the process. Whatever the allocation of responsibility, it is only right and just for the person who accepts that responsibility to have commensurate authority. Anything less than that is fundamentally unjust. I believe this is true throughout life. In relationships of all kinds…..especially that of parents of adult children.

And as nurses we remain unclear about our true responsibility, in that we accept responsibility for many functions over which we do not and should not have any authority…..and refuse to accept responsibility for that for which we are licensed. To me….this is the essential conundrum that needs to be resolved at this point in time, for now and the future.

It is not surprising that we are here….given the history of women’s oppression in the greater society…..but the challenge now is to grow out of ‘here’. I continue to believe that with the attention paid to autonomy in Magnet and the lack of reaction to it among our physician and administrative colleagues is proof positive that any failure to perform autonomously at the bedside is ours to own. My severe frustration is that everyone seems to agree with me, but no one has come forward to join me in making this growth step happen.

PS. Collaborative practice is not in opposition to autonomy…..au contraire….true collaboration cannot exist without prior autonomy.

For years, we’ve expanded or contracted their roles based on the supply of RNs (and the money to pay them). As a group, few have contributed as much, or been valued as little as these folks. In my opinion, there is no doubt that we need skilled technicians to act as assistants to RNs. Why? Logic dictates that with today’s acuity levels we need more skilled technicians than patient care aides. When RN energy is consumed with clinical activities, it is not available for the professional work of nursing. Making decisions about the amount degree and kind of nursing care a patient will receive, in the context of a therapeutic relationship with the patient.

This is what RNs are licensed to do. The license does not say RNs have to give 100% of the care tasks patients receive…but is does say we are the only care providers in the whole system with specific responsibility to make decisions about nursing care. And yet, this is the activity most often given up in order to perform tasks. This is the activity most often given up in order to ‘fix’ a system problem with dietary…or with lab…or with pharmacy…etc. etc.This is the activity most often given up in order to do almost anything else. Albeit some tasks require the high skill level of an RN. Others however are routine or of lower skill level. And yet, often regardless of staffing levels, the exercise of professional authority regarding the amount degree and kind of nursing care a particular patient will receive is on the lowest rung of any RNs work-priority rating.

The pressure to perform tasks and to ‘fix’ system problems is almost overwhelming. The pressure to accept professional responsibility for managing the care of a patient is totally underwhelming. No one asks about nursing decisions. Everyone asks if the tasks were performed and documented.  Job descriptions are even silent about decision-making!

You may ask “What does this have to do with LPNs?” My answer is “If I were a chief nurse today, I would hire well-trained LPNs to work in partnerships with experienced RNs!” When this is the arrangement, LPNs can safely contribute high-quality, highly -skilled bedside care to the maximum of their ability within the framework of effective delegation. RNs as senior partners can contribute to deliver bedside care, and have the time and energy to evaluate individual patients and decide on the amount and kind of nursing care they will receive. We have seen the benefits of well-designed and well-executed partnership systems. We have also seen that often logistical problems exist in terms of union rules, schedule preferences or employment practices. These are problems that need to be solved in order to create staffing paradigms that will benefit patients today and the profession tomorrow. As long as RNs are running around performing countless tasks in high-pressured environments, nursing will not develop as a profession.

What is Wrong with this Picture?

Several times a week, in hospitals all over, system or another breaks down…requiring a staff nurse to ‘fix’ the problem so a ‘patient won’t suffer’ from the breakdown. Maybe it’s pharmacy sending the wrong drug….or not sending it on time….or a late tray that never arrives for a hungry patient….or the transporter arriving without a wheelchair to take a patient for a test…..you know the situations.

Time after time, nurses stop what they are doing to ‘fix’ the problem. Eventually their frustration mounts to the point they tell their nurse manager that something needs to be done.

What would Nightingale do?

She would assess the pockets of power, align herself with strong allies, and convince people that a solution to the problem will be found. She had an extraordinary knack for letting some things go until they had to be fixed. I’m reminded of the story that when she arrived in Crimea the British Military Surgeons refused to let her enter the hospital. They did not want to deal with a ‘do-gooder’…and a lady at that. The fact that she arrived with a ship fully loaded with medical supplies, dressings, bedding, food, clothing, etc. gave her the leverage she needed. She responded to their refusal to let her enter the hospital by refusing to allow the ship to be unloaded. For some days it sat in the harbor with desperately needed medicine, equipment and supplies….until they changed their mind and invited her and her nurses to come work in the hospital. It seems clear to me that during those days the ship was in the harbor, there were patients who ’suffered’ because they didn’t have the food and medicine on the ship.

The lesson I take from this is that the strategy of letting a failing system fail might be better than the situation by situation ‘fixes’ nurses engage in, which takes them away from the patient.   Strategy is important. Over the next few weeks, I’ll share some examples of potential strategies I’ve either seen work….or would like to see someone try. Meanwhile, please share strategies you’ve used or heard of to get failing hospital systems to work better.