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RAA Part III – Achieving Full Experience of Will Power June 15, 2017

Posted by mariemanthey in Creative Health Care Management, Manthey Life Mosaic.
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This is part III of an initial series of articles about RAA. Here are links to the previous parts:

RAA Part I

RAA Part II

 

After 10 years of experience applying these ideas to professional roles and organizational structures, I began thinking about them in relation to my own life.

By this time one thing I knew for sure was that when nurses accepted responsibility for the Primary Nursing (PN) role, they experienced empowerment and manifested less victim behavior than before…..and much less than those who’s did not accept responsibility.

I also knew for sure that accepting responsibility was an experiential activity……not an intellectual activity.   You can’t just think you are responsible….you have to experience it, to literally place yourself in the position of being responsible, in order to have full access to legitimate authority.

In PN, this only seemed to occur when the nurse established a responsibility relationship with the patient.   The explicit establishment of that relationship was necessary in order for the nurse to experience responsibility acceptance. The closed door of power (personal or other) only opens when an individual experientially recognizes their responsibility.

So, my epiphany moment occurred when I asked myself the question of whether or not I had accepted responsibility for my life.

I immediately remembered with resentment areas of my life where I felt victimized.   My ex-husband, a former boss….etc.   With great clarity I knew that if I had truly accepted responsibility for all aspects of my life, I would not feel victimized by past events. As this thought process evolved, I recognized that accepting responsibility for one’s own life involves the three major components of behavior: thinking, feeling and acting.

So, accepting responsibility for my thinking meant I had to develop new thought processes.  Often, my thinking fell into automatic pathways developed over the passage of life.   These pathways needed to be examined and in many cases changed, as they led directly to victim thinking.

The new thinking required the development of new neuron pathways, and then also lots of deliberate practice until consciousness of choice became my automatic thought process in response to situations and events in my life. This involved learning to make space in my reactions to events and people for the experience of choice.

Likewise, accepting responsibility for my feelings meant I had to learn some skills for handling feelings in an appropriate way which also often involved changing the way I think.   The connection between thinking and feeling began to be more manageable. Further, accepting responsibility for my actions helped me recognize the connection between thinking and acting and how action can positively influence thinking and feeling.

This overall development required me to develop new ways of being in my life, and the results have been increased positive energy, increased choices, and increased well-being.

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

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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.

Discipline without Punishment (Poll!) May 30, 2017

Posted by mariemanthey in Creative Health Care Management, Leadership, Professional Practice.
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A crucial component of the Responsibility/Authority/Accountability paradigm is accountability, which means looking at results and determining what lessons can be learned, what needed behavior changes can be identified, what course corrections can be made.

Sometimes there is a need for the manager to address a staff nurse’s behavior directly, and the best way to do that is via positive discipline, which never includes punishment.   The derivation of the word punishment is penalty, while the deviation of the word discipline is learning.   We need a shift to discipline and away from punishment.

Punishment for mistake making and behavior problems is punitive when it incudes the intention of making the person feel shame or guilt.   Guilt as a behavior modification tool seems to be coming back in to popularity again, and that is truly mind-boggling.   And it is punitive.

I’d like to hear about your experience! Please join the conversation by participating in these two polls, and/or commenting.

 

Readers, please share examples of experiences when punishment (suspension, shame or guilt) was the goal; in contrast to times when discipline (learning) was the goal.

Absence of RAA – Problems Universal May 16, 2017

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..Disparity in the balance between responsibility, authority and accountability at the personal, departmental and administrative levels of operations creates dysfunctional organizations and troubled human relationships.

Case Study Working Kitchen.docx

Case Study_Small Organization.docx

Nursing_More Work Than Time

Absence of RAA in the workplace leads to many problems and struggles that make it much harder to get the work done. Not only that, but the people involved are required to spend additional energy and internal resources just to continue on, all the while contributing much less to their groups’ effectiveness than would otherwise be the case.

Today we’re looking at some non-nursing examples, because RAA has universal applicability, and it can be easier to identify things when they are at a distance from one’s own situation.

At the top of this posting, you’ll see links to the case studies we’re referring to in this post. One describes a dysfunctional restaurant situation, the other a problematic instance in a small organization.

In both cases – symptoms are unhappy workers, managers on the defensive and not leading positively, and stressful work experiences.

The main issue is lack of clarity about the scope of responsibility.   When individuals don’t have clarity about the scope of their responsibility vis-a-vis mangers, etc., the workplace becomes dysfunctional.    Conversely, when the scope of responsibility allocation is clear, but commensurate authority is not delegated, the stressful workplace becomes dysfunctional.   And finally, when responsibility has been clearly allocated, but is not fully accepted by the individual, the workplace is stressful and becomes dysfunctional.   Responsibility Authority and Accountability need to be sequential and commensurate.   Any disparity or imbalance creates a stressful and dysfunctional workplace culture. When workers are given responsibility without authority and accountability, they are prevented from doing their useful best.

When managers are given authority but never held accountable, they do not have the opportunity to learn and grow.

Managers and staff perceive each other through their own filters, clouded by their own life experiences and expectations, and impacted by organizational and external forces outside the control of either of them.

Often people feel their situation is hopeless, and they just check out.

In these difficult times, it’s important for each of us to bring our best self forward in pursuit of our goals.  Success in one’s work life often results in the perception that one’s life is successful….and it is!    RAA and related concepts are useful in that process.

Acceptance of allocated responsibility is an important strategy because it results in actually experiencing the reality that we always have choices. We have small choices and a few big choices available to us pretty much continually, if we are honest.

The act of simply making a choice is powerful, even when the choice itself is small.

Like staff nurses who have more work to do than time available, everyone in the workplace needs to honestly assess to the best of their abilities and skills what most needs to be done, and then Own Those Choices. Letting go and trusting people to interact with us as needed in a healthy way about our choices (and their choices) frees up a wonderful amount of energy.

We can model the behavior we want to experience. We can manage our feelings from within the situation, look at it objectively, and assess the likelihood of it becoming something we  consider tolerable/optimal.

We can decide to stay in situations that we don’t like because of reasons that are valid – making even that choice is itself an improvement, and opens up other choices.

The suffering martyr/victim posture is limiting and destructive, and is never necessary or useful. By taking care of ourselves more, we’re also acting in the best interests of those around us (in the long term certainly).

We’d love to hear your stories of your struggles, journeys, lessons and useful insights!

 

 

RAA Series May 2017 Part II of III May 10, 2017

Posted by mariemanthey in Creative Health Care Management, Professional Practice.
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By Marie Manthey

When the design of nursing service delivery and function allocation is organized with integrity and balance between Responsibility, Authority and Accountability (RAA), the hospital workplace culture is efficient, quality of care is high and organizational trust is in place. That dynamic is similarly true in all other workplace environments.

Working theories and ideas and practices from general industry have been put to use in our work over the years creating Primary Nursing, Relationship-Based Care and leadership practices, now we will also be expressing these ideas in terms of nursing as well as other workplaces.

In using these concepts to design the organization of work, four questions need to be answered. They are:

Who has decision-making authority, and for what time frame?

Is work allocation basically by task/skill levels or whole function assignment?

How is communication handled?

How is the whole function managed?

These four elements ultimately govern how most work is assigned and performed.   The way they are defined has a profound impact on the experience of the workers and the quality of the work.   I was astonished during the formative years of Primary Nursing to see major changes in both performance level and personal growth of individuals when the organization of work changed! That’s all that changed: not the patients, not the doctors, not the staffing, not the hospital systems.   With the same staffing levels, the same level of knowledge and skill of the workers, the same amount of tenure and experience, the quality of work dramatically improved, the culture of the unit did a 180 change and all involved, patients, nursing staff, physicians and others commented on the extraordinary difference they experienced.

For me personally over many years, I have observed whole nursing staffs move from a state of dependency-framed entitlement-voiced victim thinkers, to a group of professionals able to assume their legitimate role as full participants in the collaborative management of patient care.   In order for that collaboration to be real, registered nurses need to be in the role of Primary Nurse where they fully experience the professional autonomy that their license affords them.

Implications for Teamwork

Throughout my years of experience with these concepts, one issue has become crystal clear:   The morale of the work group has a profound impact on the quality of the work.   Furthermore, I fully realize that morale is the result of the interpersonal relationships of the work group, the way the staff treats each other in the face of these every day realities of hospital work. Strong team work and healthy staff relationships create positive morale. These and other attributes of Relationship-Based Care are essential to optimal patient care delivery.

Healthy interpersonal relations require three behaviors.   These are:

Open communication

Functional trust and

Mutual respect

Interestingly, it seems that liking/loving your team mates is not at all essential to healthy team work.   In fact, it matters little, if at all.   What is absolutely vital however is for each member of a healthy work group to accept responsibility for managing relationships using these behaviors.

Open Communication

Of the three, the most challenging is open communication.   It has been my experience, that difficult conversations are often avoided.   In highly stressful situations, this is even truer.   I have found that more often than not, the culprit is inadequate communication skills.   Most of us simply don’t know how to say hard things tactfully.   And the effort to learn that skill is often at the lowest point of a busy person’s priority list.

It is incumbent on everyone to find ways to deal directly with one another about difficult issues tactfully, and for others to learn how to not accept one workers complaint about another, unless it is to help the complainer figure out how to deal directly with the issue.

Functional Trust

In the sense used here, trust means trusting one another to do the work assigned in the right way.   This impacts interpersonal relations in many ways, as well as the effective utilization of the resource of support workers.

It is the person who mistrusts that has the biggest impact on team functioning and therefore it is incumbent on that person to identify and openly communicate to the mistrusted person what they need to do to regain trust.

Mutual Respect

This element is also absolutely key to healthy team work, and requires moving beyond role valuation when that valuation creates dysfunction.

It is vital that each member of the team be recognized as having equal potential for improving or destroying morale, and for contributing to their teams effectiveness.

Are these elements in place where you work now? What has your experience been, currently or at prior work places?

Questions or Comments? Join the conversation!

Part III of this particular mini-series on RAA is coming soon!

RAA Content Series – Part I May 2, 2017

Posted by mariemanthey in History, Leadership, Manthey Life Mosaic, Professional Practice.
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Part I

 

A useful framework for improving the workplace and other areas of life is RAA. RAA stands for Responsibility, Authority and Accountability. Those words convey multitudes of meanings.   Their use in this paper is based on definitions found in dictionaries, and applied in this article to:

Organizing complex functions,

Clarifying interpersonal relationship issues and

Achieving the full experience of will power.

To introduce this concept, I’ll share the story of its origins, and how this concept came to become the framework I hold up to every aspect of life.

It started when a group of nurses on a single hospital unit began to change the way they were taking care of their patients.   It was the late sixties and unrest was a societal norm.   I connect the underlying causes motivating the protesters and the changes initiated by these nurses.     These days, with different kinds of disruptions underway, the relevance of these concepts is higher than ever.

Paul Goodman wrote about decentralization, the Equal Rights Amendment was nearly passed, ‘power to the people’ was a popular slogan.   As I was trying to understand the principles behind the changes the nurses were making, I was led to literature about Responsibility, Authority and Accountability.   Interestingly enough, some of that literature was about the use of these concepts in military organization, and in the law.   Ultimately, I opted for a simple definition based on dictionary terminology.   My definition is as follows:

Responsibility – The clear allocation and acceptance of response-ability so everyone knows who is doing what (who is managing the process of each specific functionality being accomplished).

Authority – The right to act – to make decisions and direct behavior of others – in the area for which one has been allocated and accepted responsibility.   There are two levels of authority: Authority to recommend and authority to act.   Clarification of which level applies in each specific situations is functionally useful.

Accountability – The retrospective review of the decisions made or actions taken to determine if they were appropriate.   In the case of the decision-making having been non-optimal, corrective action can be taken for the purpose of improving functionality. That corrective action must never be punitive.

 

ORGANIZING COMPLEX FUNCTIONS

I spent the next 10 years pragmatically applying these concepts to both a delivery system for nursing care and to the complex bureaucratic institution known as a hospital.   These were not theoretical applications of concepts or armchair speculations, but rather actual reorganizations involving changing roles, relationships and responsibilities of real people working in real hospitals.   During that period of pragmatic and intense organizational application, I learned many things.   Among them:

  1. How changing work organization impacts on personal development, as well roles, relationships, work quality and energy levels of workers.
  2. How disparity in the balance between responsibility, authority and accountability at the personal, departmental and administrative levels of operations creates dysfunctional organizations and troubled human relationships.
  3. How personal maturity and responsibility acceptance are totally intertwined
  4. The defined difference between a profession, an occupation and a vocation.

IMPLICATIONS FOR ORGANIZATIONS

Lack of clarity and disparity of balance regarding among these concepts results in dysfunctional organizations and negative interpersonal relations.   These conditions in turn, produce low morale, inefficiency and low quality work.

First of all, the issue of clarity.   The scope of responsibility involved in each and every role, needs to be clear to both the person in the role and to those who interact with that role.   Role confusion regarding scope of responsibility creates incredible job stress and interpersonal tensions.   Whenever responsibility has not been clearly allocated, there is a power vacuum resulting in power struggles.   These power struggles can fall anywhere on the spectrum from having individuals assume authority way beyond their legitimate scope and …conversely,  things not being done because everyone assumes the other person will do it.   Role clarity with specific attention to scope of responsibility is essential to effective functioning.

Clarity of authority levels is also crucial.     The delegation of authority should ideally be exactly commensurate to the scope of responsibility.   An effective decentralized organizational structure will reflect careful attention to matching responsibility to authority.   In some situations, individuals may be unwilling to accept responsibility and will therefore be reluctant to use the authority they have been delegated.   These individuals will manifest continued dependencies and often fall into victim thinking. On the other hand, some individuals refuse (or are unable) to see the limits of their responsibility scope, and insist on exercising authority over functions that fall outside their scope of responsibility.   These situations result in an abuse of power.

When these elements are not in alignment, individuals affected by that have an opportunity to provide correction.   For example:

Imagine a situation where your boss asks you to take over a new function.   Maybe run a new clinic in a nearby town, in addition to your current clinic responsibilities. He/she says “You are responsible for getting this up and running and ‘in the black’ within a year.   Do a good job!”     You may say, will I be choosing the site we will rent?   And the answer is “NO …the site is already decided.”   You may then ask, will I be hiring the staff for this clinic?   And the answer is NO…. the type of staff (and consequent costs) will be controlled by Budget Control Office.   You may ask, will I have a marketing budget to announce this new service. And the answer is NO…that is under the control of the marketing department. And you say, will I have anything to say about location, equipment to be purchased, staff to be hired, services to be given and amount clients will be charged, to which every answer is “NO – someone else has that responsibility.” You are only responsible for bringing it into profitability within one calendar year. In this scenario, a wise employee would say, ‘Boss…. I am willing to coordinate the opening of this clinic and to do everything in my power to assure financial success, but I cannot take responsibility for that since I have no decision-making authority.’

.. to be continued

From the Heart – Writings in Process, an inside peek April 23, 2017

Posted by mariemanthey in Creative Health Care Management, Professional Practice.
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For this first ‘From the Heart’ note, I wanted to let you know what I’m working on next from my writing queue. Almost my whole career, there has been a constant backlog of things I wanted to write. Now, after all these years, it’s as intense as ever!

So there are two immediate things I’m working on: One on RAA, and the other on coping with workplace stress.

RAA – many of you know stands for Responsibility, Authority and Accountability. There are so many aspects to these concepts and their implementation – I could write a book about it all! Hey.. first things first though, we’re planning on putting out a series of articles in this space. We’d like to incorporate your comments, stories and questions as well! So anything you’d like to share, please feel free!

And then in the more immediate future, in the next week or two I’m planning to post some thoughts about the endless struggle to respond optimally to workplace stress. This is another struggle this is as present as ever these days. How is it going for you? Do you have any particular strategies that you’ve found special success with over the years? Is it an even higher mountain to climb lately? How is it going?

When you write, if there are aspects of your comments that you don’t want posted and/or if you want your name withheld or anything like that, just let us know.

Looking forward to hearing from you!

 

MM/cs

Nurse Manager vs. Head Nurse January 4, 2011

Posted by mariemanthey in Leadership.
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I’ve been thinking about the title change and its significance. I was active in promoting the change to NM and now wonder about it. In particular, are Nurse Managers still in charge of nursing? Or are they in charge of management? What do you think?   When the title was Head Nurse was the role clearer?  Your  comments, please.

…About naming and claiming the RN Role September 25, 2007

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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.

Nurses Have an Amazing Capacity To Do More! March 24, 2006

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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 are 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 that patients suffer from could be solved by developing procedures for call-backs to patients homes. Not all patients, not all the time, but it a responsible nurse can decide whether to do so or not. I can envision a role for RNs 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 that we haven’t taken the time to lift our eyes, envision a new future and 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 healthy lives ourselves!