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Salon Update – Wednesday, July 19 – Draft July 21, 2017

Posted by mariemanthey in Leadership, Nursing Salons.
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The salon recently at my home was one of the best… which is what we always seem to say as we are checking out.

I’m often asked the ideal size of a salon, and I’ve come to the conclusion that something between 10 and 15 is just about right.

Having said that, I have had wonderful conversations with just 2 or 3, and I’ve facilitatated mass salons simultaneously for about 180 people seated at round tables at the TX nurses assn. delegates meeting. The excitement, enthusiasm and utter joy experienced during the checkout of all the groups was absolutely magnificient.

So, size for a salon is a moving target and should never be a determining factor on whether to hold one or not. If a group is very large – say 30 or more – it is entirely possible to have them divided in to two salons that meet simultaneously.

A further word about Wednesday night’s salon: it was truly inter-disciplinary, as so many are now. There were occupational therapists, a social worker, a physician, and the rest were nurses from such far-ranging occupations as a forensic-health medical examining nurse, a faculty member, a nurse executive, and staff nurses from different places working in different specialties. Truly eclectic yet the conversation was totally congruent in values and in the experiences of being a health care practitioner.

A Core Value: Humanization of Patients July 20, 2017

Posted by mariemanthey in Manthey Life Mosaic, Professional Practice, Values.
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Many many years ago I was being pressesd to articulate my deepest passion about Nursing.   Specifically,  what did I believe is the fundamental core value of the nursing profession?     After thinking about it deeply, I came up with a deep believe that  our most important role is to facilitate the humanization of patient care,…. which required that we first humanize the experience, practice and focus of nurses.   Nurses cannot humanize patient care unless they are empowered in their role and in practice.  Humanization of health care for patients  means  engagement of patients and their families in decisions about treatment choices, as well as end of life choices.    This ultimate exercise of free will is the pathway to fulfillment as a human….and the restriction of free will is dehumanizing.

I see this goal  becoming closer to reality in many situations, thanks to nursing’s incredible advances, as well as to advances in technology and  many other societal advances.   However,  I think much work is still needed to promote nursing’s role as patient advocates for their greater involvement in decisions.  The culture change we seek is to humanize patient care.   Nurses must support patients ability to accept responsibility for themselves, and to exercise their own  free will about their treatment and their lives, knowledgeable about the options that are available to them.

Empowered nurses are needed to empower their patients.

Whether the setting is an ICU unit, a Neo-Natal unit, or even hospice. Empowered nurses can make sure the patients and their families have all the necessary information to make their own life decisions – about end of life, or about courses of treatment – and that they are empowered to do so.

The change is coming.   Let’s make sure the nursing profession is ready to fully engage in the humanization of health care. The public is more ready than the health care system.

Leadership, by the book: the Army Manual book July 10, 2017

Posted by mariemanthey in Leadership, Professional Practice, Values.
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Re: 
U.S. Army's Army Field Manual 6_22 on Leader Development
i.t.o. psychological & psychiatric criteria for leadership.

This content is written by Prudence L. Gourguechon, widely known national expert on psychoanalysis for the fields of business, law, politics and marketing.

“Despite the thousands of articles and books written on leadership, primarily in the business arena, I have found only one source where the capacities necessary for strategic leadership are clearly and comprehensively laid out: the U.S. Army’s “Field Manual 6-22 Leader Development.”

“The Army’s field manual on leadership is an extraordinarily sophisticated document, founded in sound psychological research and psychiatric theory, as well as military practice. It articulates the core faculties that officers, including commanders, need in order to fulfill their jobs. From the manual’s 135 dense pages, I have distilled five crucial qualities:

Trust

“According to the Army, trust is fundamental to the functioning of a team or alliance in any setting: “Leaders shape the ethical climate of their organization while developing the trust and relationships that enable proper leadership.” A leader who is deficient in the capacity for trust makes little effort to support others, may be isolated and aloof, may be apathetic about discrimination, allows distrustful behaviors to persist among team members, makes unrealistic promises and focuses on self-promotion.

Discipline and self-control

“The manual requires that a leader demonstrate control over his behavior and align his behavior with core Army values: “Loyalty, duty, respect, selfless service, honor, integrity, and personal courage.” The disciplined leader does not have emotional outbursts or act impulsively, and he maintains composure in stressful or adverse situations. Without discipline and self-control, a leader may not be able to resist temptation, to stay focused despite distractions, to avoid impulsive action or to think before jumping to a conclusion. The leader who fails to demonstrate discipline reacts “viscerally or angrily when receiving bad news or conflicting information,” and he “allows personal emotions to drive decisions or guide responses to emotionally charged situations.”

“In psychiatry, we talk about “filters” — neurologic braking systems that enable us to appropriately inhibit our speech and actions even when disturbing thoughts or powerful emotions are present. Discipline and self-control require that an individual has a robust working filter, so that he doesn’t say or do everything that comes to mind.

Judgment and critical thinking

“These are complex, high-level mental functions that include the abilities to discriminate, assess, plan, decide, anticipate, prioritize and compare. A leader with the capacity for critical thinking “seeks to obtain the most thorough and accurate understanding possible,” the manual says, and he anticipates “first, second and third consequences of multiple courses of action.” A leader deficient in judgment and strategic thinking demonstrates rigid and inflexible thinking.

Self-awareness

“Self-awareness requires the capacity to reflect and an interest in doing so. “Self-aware leaders know themselves, including their traits, feelings, and behaviors,” the manual says. “They employ self-understanding and recognize their effect on others.” When a leader lacks self-awareness, the manual notes, he “unfairly blames subordinates when failures are experienced” and “rejects or lacks interest in feedback.”

Empathy

“Perhaps surprisingly, the field manual repeatedly stresses the importance of empathy as an essential attribute for Army leadership. A good leader “demonstrates an understanding of another person’s point of view” and “identifies with others’ feelings and emotions.” The manual’s description of inadequacy in this area: “Shows a lack of concern for others’ emotional distress” and “displays an inability to take another’s perspective.””

===========================

From an intraprofessional leadership perspective, this is a universal summary of essential leadership skills from a valid source.   Going back to Florence Nightingale, great leaders when matched to this set of criteria have great capacity to be powerful leaders who truly make a difference. Hospital origins were deeply linked to the military mindset of regimentation, discipline, following the chain of command, and maintaining discipline. Sometimes in ways that de-humanized patient care.

This value-based list of leadership skills represents an exciting awareness important values that can greatly improve performance and promote better engagement.

My own learning during the early development of Primary Nursing included an invaluable gift from ‘military literature’.    I don’t remember the exact document or book, but I know the conceptual paradigm of Responsibility Authority and Accountability came directly from a description of  a military ‘chain of command’ writing.   We were not using words like that in nursing during PN’s early development.

Every sector has a contribution to make to the collective well-being!

=================

References:

http://www.latimes.com/opinion/op-ed/la-oe-gourguechon-25th-amendment-leadership-mental-capacities-checklist-20170616-story.html

Role of Nurse Manager: Needs Support to be Supportive June 13, 2017

Posted by mariemanthey in Creative Health Care Management, Leadership, Professional Practice, Uncategorized.
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I’m reminded frequently about how strongly a leader’s influence drives the quality of work done…on nursing units and in every workplace.  The clarity of role definitions in the workplace – and in particular how the role of the leader is defined – is essential to effective leadership.

Leadership is often confused with limitless power.  Unclear scopes of responsibility for leaders and others creates confusion, unsatisfactory outcomes and personal stress among workers which in most cases results in bad outcomes.   This seemingly simple element is often the culprit of toxic work environments.

Leaders Empower Staff – that is the name of a basic curriculum component of CHCM’s work, and it’s also a phrase which sums up  much of our leadership philosophy and seminar focus.

We believe that the people who do the work should be empowered to make  decisions about the work, and good leaders actively support that by intentionally putting that power in the hands of their staff.

There are many specific skills and practices that need to be in place for the leader to do that and to support that structure. One of our accompanying basic beliefs is this: nobody walks in to a leadership role with everything already in place to be successful. Each new leader will have some parts of the skills set, and they’ll need to gain the rest on the job.

Each time a new leader is hired, there needs to be a systemic process of determining what they need to be successful in that role, and to provide the training, support, skills development, mentoring, etc.. necessary in order for them to grow in to that role.

Otherwise, insecure, ill-prepared leaders may assume that empowered staff are a threat to their authority and therefore to their success.   These leaders …at all levels in a hierarchy…..will hold on to power  to feel secure. Staff then are hindered from contributing at their highest level, restrained from using their actual knowledge and skill, and devalued within the workplace.  Morale is negatively affected.

Staff  need to be developed professionally so that they are confident and comfortable using their legitimate power.  Within their scope of responsibility, they need to learn how to identify operational problems, to generate solutions, to implement the solutions.  This level of employee engagement is a dream scene for most executives.

Both staff and leadership need to accept the fact that as humans, they’ll make mistakes, and that those mistakes are to be treated as opportunities for growth, not punishment. Integral to that is for leadership to actually react that way to mistakes!

Leaders do constantly need to bring their best selves to the job, to actively create for themselves a goal behavior pattern based on best leadership practices, and do their best to live up to those goals.

Accountability is crucial.

In some workplaces – within healthcare and outside of it – the accountability of leaders is sometimes problematic.  It is easy for leaders to obfuscate personnel problems, particularly if they don’t know how to or don’t want to deal with them..   The obfuscation may show up as being able to provide assurance to those they report to that staff are fine, operations are fine, progress towards goals is happening, the ship is tip-top. They may not  share sufficient detail about problem employees, hence  obfuscating their own responsibility to act, resulting in avoiding personal accountability as  leaders.   A great deal of the angst, stress and toxicity in workplaces today is due to inadequately prepared  leaders who are not held accountable for learning the basic skills necessary to create a culture of safety and empowerment.

Our values, principles and practices of Creative Health Care Management focus on changing workplace  cultures so that all members of the team (starting with the leader) have the support they need to produce efficient and effective productivity. The clear allocation of responsibility coupled with the delegation of commensurate authority and accountability are the key components to leadership and management success in every workplace.

The Nurse Managers who gain these leadership skills are the MOST essential element to creating a relationship-based environment that is healing for both the staff who work there and the patients who receive care there.

Personally… Being Mortal by Atul Gawande June 11, 2017

Posted by mariemanthey in Inspiration, Manthey Life Mosaic, Professional Practice.
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I lost a close friend recently, after a long struggle with some chronic medical conditions.

It’s a sad period, but one comfort is that his last days went as well as they possibly could. I’m reminded of this book: Being Mortal, written by practicing surgeon Atul Gawande.

In the book Atul explores what it means to ensure that the positive meanings of one’s life extend through the final phases of that life, clinically and in all other ways. Atul has completely defeated the normative medical profession’s reluctance to address that period after medicine stops being applicable. He explores what continues to be important for the person themself and their family.

I found it extremely moving and useful – not just for that period but for everyday. Highly recommend!

Additional Resources:

NY Times Book Review

Frontline: PBS Special

Pennsylvania Library Book Discussion Notes

The Guardian Book Review

The Choice of Every Nurse Every Day…an excerpt of my introduction to this new book….. June 24, 2013

Posted by mariemanthey in Creative Health Care Management, History, Inspiration, Professional Practice, Values.
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Advancing-Professional-Nursing-Practice-Book

A painting is not created by a free floating hand making marks with oils on canvas. The hand belongs to an artist connecting with his or her mind, body, and spirit, not only to the process of creating a painting, but to those who will one day see the painting. The hands of the artist are not where the skill lies. Without the whole person showing up in the creation of the painting, there is no art; there is just painting.

The art of nursing can be thought of in much the same way. The nurse can show up as little more than a pair of hands doing tasks, but this is not nursing; this is just doing tasks.

The art of nursing (as is perhaps true of any art) is about connection. In the art of nursing, the nurse connects to the patient, and the nurse also connects to the profession of nursing. Advancing Professional Nursing Practice is about the art of both of those connections. It is a book in which the ANA standards are named and explained, connecting nurses to the practice and performance standards of their profession. It is also a book about Relationship-Based Care, which is a care delivery model that connects nurses to patients and families by removing barriers to the nurse-patient/family relationship and improving relationships throughout the organization.

I’m always happy for nurses who get to work in cultures that support healthy relationships throughout the organization, and I share the distress of those who work in environments that seem to be fueled by chaos and competition. It is the choice of the nurse, however, whether to show up in either environment as a whole person, fully invested in the care of patients and families; or simply as a technically competent task doer.

In 1966, the way I viewed nursing was changed forever by an article I read in the American Journal of Nursing. It was written by Sister Madeleine Clemence, and it was called “Existentialism: A Philosophy of Commitment.” The way I saw it, this learned nun, a woman far ahead of her time, was challenging me, a young nurse leader, to show up as a whole person in my work. Her article challenged me to change my own practice and to mentor others to do the same:

“Commitment can mean many things: a promise to keep, a sense of dedication that transcends all other considerations, an unswerving allegiance to a given point of view. In existentialism, commitment means even more: a willingness to live fully one’s own life, to make that life meaningful through acceptance of, rather than detachment from, all that it may hold of both joy and sorrow.”[1]

It was no accident that Sister Madeleine was talking about “acceptance of, rather than detachment from, all that life may hold” in the context of the nurse’s work. As a nurse herself, she could see that the work of the nurse is secular for all, but sacred for only those who commit themselves to making it so. As we go about the work of nursing, are we solving problems or are we entering into the mystery of what it means to be with a person who is suffering, vulnerable, and afraid? She quotes philosopher Gabriel Marcel, writing, “A mystery is a reality in which I find myself involved…whereas a problem is [merely] in front of me.”

It raises a provocative question for nurses: Am I involved with my patients, or are they merely in front of me?

Over a century-and-a-half ago, Florence Nightingale helped to make nursing an art through bringing compassion into her own practice and then writing about it so that others might see that when the basic relational needs of the patient are tended to, there is a healing that takes place whether cure is possible or not. She famously encouraged the soldiers of the Crimean War to write to their loved ones. She understood the simple human truth that connection is healing—connection with loved ones (be they near or far), connection with one’s own thoughts and feelings, connection with the realities of one’s current situation.

The compassionate focus on connection that Florence Nightingale brought to nursing is still there, but it has gotten lost in the shuffle over and over; throughout history every time there was a major change in the world of health care. Here is some historical background:

Prior to the Great Depression, private duty nursing was the main avenue of employment for the nation’s RNs. As the Depression eliminated this avenue for many, RNs returned to their home hospitals as temporary workers, often on a volunteer basis, sometimes working for their room and board. As such, they found themselves working in a highly regimented, task-based, time-focused system of care that was designed to control practice and teach student nurses. This eventually became the main avenue for employment of RNs and remained so until fairly recently.  This move from more autonomy for RNs to less autonomy is a pattern that has repeated itself throughout modern history.

After WWII, the proliferation of new hospital beds coupled with the baby boom (which greatly reduced the nursing workforce), resulted in team nursing, a delivery system designed to maximally utilize technical expertise and assistive support staff under the direction and supervision of an RN. Again, the focus was on assigning and supervising the performance of tasks, since the only person educated to provide a therapeutic relationship was nearly always consumed with supervision and the performance of tasks requiring a higher skill level than that of her staff.

The system upheaval that characterized the last 30 years of the twentieth century, which was driven by finance, technology, and regulation, resulted in most health care organizations dealing with higher patient acuity coupled with severe cost cutting, which again resulted in a focus on managing the tasks of care rather than managing therapeutic relationships. The resulting dehumanization within the care system drove a spiral of regulations and system constraints that further complicated (and continue to complicate) an already intensely complex adaptive system.

The age we live in is no different. As we deal with the myriad changes of health care reform, we’re seeing, once again, a return to task-based practice. This time, however, it feels different to me in various ways. I’m heartened by the numbers of organizations that are embracing Relationship-Based Care. The publication of See Me as a Person is another example – it addresses the need for nurses and other caregivers to be “in it” with their patients rather than merely ministering to their bodies. As the next major societal shift in health care advances, whatever it is, the profession of nursing must continue to define itself. Society trusts us to do so, and our covenant requires it.

Nurses must ask themselves some important questions: What exactly is it that must always be present in order for nursing to really be nursing? What is the actual core of nursing? What strengthens that core? And what must be present in order for that core to even exist? In short, what is the nursing imperative?

I would ask you to mount your own inquiry, and come up with your own answers. Here are mine:

The nursing imperative is a two sided coin. On one side there is the imperative to be clinically competent in both technical skills and clinical judgment. The other side is the willingness to step into being with the human being for whom the nurse is caring. In health care, people experience vulnerability at every level of their being: mental, emotional, physical, and spiritual. The privilege of nursing is having the knowledge and skill, the position and relationship, to interact with a vulnerable human being in a way that alleviates pain and increases mental, emotional, physical, and spiritual comfort. This is the privilege of nursing—the being with a vulnerable human being. If this privilege is ignored or overlooked, nursing isn’t happening. No matter what is happening in a care environment, authentic human connection with the vulnerable human beings in our care can and must happen. That, to my mind, is the nursing imperative.

It’s clear that half of the nursing imperative is that we have a mastery of the technical aspects of nursing, but the other half of the nursing imperative—and it truly is no less than half—is staying present to the vulnerability of others. This book seeks to address the dual nature of the nurse’s work, both the instrumental and relational. If you are a nurse (or about to become one), I’d ask you to keep this dual nature in mind as you read this book.

Marie Manthey, MNA, FRCN, FAAN, PhD (hon.)

March 8, 2013


[1] Clemence, M. (1966). Existentialism: A philosophy of commitment. American Journal of Nursing, 66(3), 500-5.

Is Polite “Doing For” Really Enough? January 17, 2009

Posted by mariemanthey in Professional Practice.
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One of the consultants at Creative Healthcare Management recently sent me this description, written while her daughter was receiving care at a major medical center in the Midwest. My question to readers is this: if you see yourself in this description, what can you do to “be with” rather than just “do for” your patients?  Or does anyone want to explain why “doing for” is really enough? Responses are welcome.

“Care has been fine, but not extraordinary.  They  received Magnet designation in 2007 and have a great deal of pride.  Everyone asks each time they leave the room if there is anything else we need — and they have clearly received customer service training (AIDET).  The manager just visited our room and was gracious and emphasizing that we let them know if there is anything they can do.  The trouble is, they are doing … But there is no “curiosity”, no whole picture perspective — when asked the nurses rarely know the plan — I rarely see a therapeutic process; the nurse comes in to give meds, check if there is anything needed.  So very nice, polite — but detached.  I found myself charting my perspective using the boundary diagram from my article in the field guide on boundaries for the therapeutic relationship. Underinvolvement is the main descriptor I would use.

We have had some lovely exceptions. The pharmacist, who we know from the transplant team, spent 20 minutes with us yesterday making sure that we had all questions answered and providing some background information. A physician sat at eye level and began by asking Alicia about her and what this means in her life right now.  She was able to talk about school, and it went on from there.  He was extremely encouraging — reminding us that it has always been the case that my daughter would outlive the life of her kidney, and that we will take each challenge as it comes.  We do not have the biopsy results yet, but if it is early rejection we are dealing with, that can be treated and the kidney can continue to serve her.

I try to stay clear and unemotional about the lack of professional consciousness I see in so many nurses.  I feel so sad, because when they only focus on the things they are doing, they lose sight of the human being and the power of their care and they lose the amazing satisfaction that would come from a connection.  I am clear that it would take no more time to connect and involve the patient than to come in and out doing for the patient.  I believe the nurses on this unit like their work, and that transplant nursing would be extraordinarily satisfying.  So, the nursing care is fine.  The question is, is that enough?  I have nothing I would complain about, and I believe most patients would say the care was very good because the staff is responsive.  My daughter asked why so many people (nurse,  physician, nurse practitioner) give her the same information as though she is hearing it for the first time.  Not one nurse has asked Alicia about herself or what this hospitalization means to her — what she might be worrying about — what is most important to her.  This morning as I walked for my coffee I noticed no one looked up anywhere through the hallways to the cafe, so I began initiating and spoke to people even when they were looking at the ground.  I got responses in return and I am teaching my daughter how to be the initiator of relationships so that she can be seen and receive what she needs.  I have also had to work with her to monitor her responses (she got rather hysterical when experiencing pain and not feeling heard by the nurse — who I understand called her a whiner– I was out of the room at the time) — I followed up with the nurse and worked to help her feel safe and less defensive, we came up with an approach to Alicia’s pain and by the end of the day it was managed.  I had to intervene though, because I could see that the nurse was irritated with her and I want Alicia to learn how to care for relationships so she does not get written off.  She will need to be an expert as she will be needing care all of her life. “

“Make Them Stop Fighting” May 16, 2008

Posted by mariemanthey in Academia, Nursing Salons, Professional Practice, Values.
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At last night’s (May 15) Salon, a Clinical Nurse Specialist told of an incident he was involved in yesterday, when another staff member asked him to “make them stop fighting”. The “them” was a Nurse Practitioner and a Medical Resident. The “fight” was a role conflict that surfaced during a patient discharge. You can guess. The resident said the practitioner was practicing medicine and the practitioner said the resident … well, you can fill in the blanks. This “fight” delayed the patient’s discharge by 5 hours!

This was one of the many experiences the 20+ guests brought to last night’s discussion. And this particular incident led us into an interesting and informative discussion of role conflicts: what they mean, how to deal with them, and how to avoid them.

Two of the guests had graduated just the day before our gathering and are interested in how to enter the work world in a healthy way. One guest was a nurse leader from Kenya, Africa, whose issues mirror ours in so many ways, even when the systems and the cultures are so different. She spoke of the problem of nurses not being confident and many people talked about ways to acquire inner strength as a nurse.

A topic brought up almost every month is the issue of “entry level” into practice. A related topic was the new roles being created in new education programs. ADs,BSNs, MN, CNS, CNL, DNP, Phd. Last night we eliminated some people’s confusion. Others learned about new developments. The discussion ultimately focused on the many complexities we face, and how we, as a profession, stay united in purpose and integrated in message as we continue to evolve.

As always, the contribution of individuals reflected the uncertainty and pain of change — but also the hope and belief that, whatever our preparation, our relationships with patients, with ourselves and each other is the key to honoring our covenant with society.

***

I encourage everyone reading this to, first of all, add your 2 cents worth to the discussion. I love to read your comments and will respond. Secondly, join me in a campaign to replicate these Salons. I am convinced that nurses desperately need a safe place to talk about the issues we face in daily practice, as well as the complexities of providing appropriate care in the broken health care system.

I will help anyone interested in getting one started. I have a new written description that summarizes my experience hosting one for seven years. The healing that occurs when these deep connections are made about important experiences is truly profound. And it is very easy to have a salon. Just ask and I will tell you how easily it can be done.

The wonderful thing about these gatherings is that there is no agenda, no minutes and no action steps! No carry-over from one to another. Each one is a total event in itself. We just come together in a safe environment, agree to professional confidentiality and use the Socrates Cafe format to handle the discussion. The result is hope and healing.

My goal now is to have websites throughout the US where a nurse can go to see the Salons scheduled in his/her city/town for the month! Nurses can then pick the one to go to based on their own schedule and the events location.

Several of us have started talking about how to do this. Frankly, we don’t have a road-map, but then,we didn’t have a road-map for Primary Nursing back in the late sixties. Look how that idea spread from one unit at the U of M to a world-wide movement!

I know this one can too.