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Leading for Change December 16, 2005

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

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.


1. Heidi Orstad - May 9, 2015

I realize that I am reading this blog posting nearly 10 years after it’s posting, but I am compelled to respond as it still rings true!

In reading: “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.” I say this-Yes, Yes, Yes!

In the environments where I serve as a nurse leader, my team and I are (like most teams) in a constant state of process improvement and change. Some change is obligatory, some change is suggested by staff, some change is suggested by patients, and some change follows evidence based best practice.

No matter the change, I recognized early in my role as leader, that the most effective way to introduce change is to partner with staff champions (and to vary the staff champions!). For example, we were introducing an patient assessment tool. It was my role as leader to pull in our organization’s context (the details about the tool, the system, and the documentation expectations), but the staff champions helped us define when to introduce the tool into the RN work flow, the scripting, the questions their peers might have, and the questions patients might have. These champions trialed the tool first, came back with feedback, and created a workflow. They will introduce the workflow to their peers and serve as peer leaders.

I might add that. in my experience, not only is the process of honoring staff nurses as team change agents a respectful, leadership practice, it also fosters a team culture of inclusivity. Silos are “busted” and the relationship between the leader and staff is collegial and reciprocal. The staff RN’s recognize that the leader values them as colleagues and their input and opinion of equal value.

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