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Leading for Change December 16, 2005

Posted by manthey in Creative Health Care Management, Inspiration, Leadership, Manthey Life Mosaic.
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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.

Strategic Problem Solving at the Staff Nurse Level December 13, 2005

Posted by manthey in History, Leadership, Professional Practice.
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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 the surgeons changed their minds 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 take 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.