Concluding Insights

As a nurse for more than 30 years, I have spent the great majority of that time in a leadership position. I have learned many leadership lessons during this time, yet there is always more to know. Just as the world is continually changing, leadership methods must also adapt. Methods that worked well when I was a new nurse may now be obsolete as technology continues to advance and drive much of the day-to-day operations in our institution.

The past several weeks have been a great opportunity to think about what I know and what I have experienced over the years. It has also been a time of reflection, providing a context for some of those experiences and allowing me to see them with a different perspective. I have learned some new things, thought about some old things in a new way, and found areas that I am interested in learning about in more depth. Not a bad outcome! I will summarize some of my observations and insights here.

Systems Thinking

I have always appreciated the collaborative style of leadership in my unit. Our organization gives nurses many opportunities to contribute, reflected by the recent achievement of Magnet status for the fourth time! Over the past few weeks, I have learned these relational leadership methods are essential in the complex systems we face today. Technology forges ahead in all aspects of the workplace, and leaders cannot possibly be the sole source of knowledge. Strength comes from a team of employees working together, with each contributing his or her particular knowledge.

As hospitals and other healthcare institutions grow, they become increasingly complex with many departments, initiatives and priorities. Add in the ever-growing use of technology, specialization and an increasingly diverse workforce, and the need for leadership that can adapt quickly and smoothly is undeniable. Uhl-Bien (2012) explains the most effective approach to leading in complex systems is to respond with complex solutions. Rather than having one leader at the top who hands down the vision and organizes people to support it, the organization should establish leaders who gather information and ideas from employees throughout the organization, and utilize the talents of those employees to implement solutions in a more horizontal fashion. Understanding the difference between this new relational leadership style and the more traditional hierarchy will definitely have an impact on my approach as I more consistently apply the components of horizontal leadership.

One significant aspect of systems thinking is the idea that a small change can have a ripple effect that results in much larger impacts to the organization. An example from my own institution started with a simple product change. The manufacturer abruptly discontinued the brand of adhesive tape, which many departments had used for years. It would seem simple enough to switch to a new brand of tape, but the tape was used differently throughout the organization. Because patients moved frequently between units (i.e. med-surg to OR to ICU), using a variety of products was not a good solution. The nursery had concerns about tape allergies for their neonatal patients with sensitive skin. The med-surg RNs were adamant the new tape must be waterproof to prevent coming loose if it became wet from secretions or IV fluids. The ICU and OR were concerned with the adhesive properties and whether the new tape was sticky enough to hold the endotracheal tube securely in place. Each type of tape offered for consideration met some criteria, but not all. Before long, the entire organization was talking (and at times, arguing) about tape. It was somewhat unbelievable that so much commotion was occurring over such a minor product. Such are the ripple effects that can occur in a complex system.

An understanding of the inter-relatedness of everything should affect the way we operate. Decisions must be made with awareness of the potential, far-reaching impact. All stakeholders must be involved, and this especially includes the direct caregivers. The selection of team members for any project should be broad and inclusive, adjusting as needed as things progress. Nurses, doctors, therapists and anyone else providing patient care are in the best position to judge the effect of a process change. While they may not be the ones who make the final decision, the input they give should be carefully considered.

Self Reflection

The use of the blog format for learning lends itself to self-reflection. It has encouraged me to find examples from my own experiences and think about how they relate to the topics each week. Some experiences from years ago suddenly have a new meaning. I have found self–reflection to be valuable in several ways.

Understanding Motivation

Simon Sinek talked about learning our “why”. I have always known my personal motivation was to help others, but reflection helped me to delineate the idea even further. I specifically enjoy helping others grow and find their confidence, mentoring new employees into achieving a strong nursing career. Both of my current roles position me well to do this work, and defining it clearly will help shape my own goals and learning. Sinek also says caring for those you lead will inspire them to work towards the vision you set out for them. As I support people and help them see their capabilities, we build a trusting relationship, and as they feel more competent, they become more engaged. This knowledge lets me feel comfortable supporting nurses as I do, because it ultimately furthers the goals of the organization. Win and win!

Appreciating Differences

The personality test was fun (INTJ here!), and it pointed out areas of both strength and weakness. All personality types have both. It is good to know your own, but it is also important to understand others. Sometimes people may respond in a way that I find less desirable, but a moment of reflection may point to a personality factor at play. Understanding these variations helps me be more understanding and less irritated than I might have in the past.

As a Girl Scout leader, when one of the girls would fall and scrape her knee, I was not likely to run and give her a hug (which is exactly what my co-leader would do), but rather I would examine the injury and assess the need for first aid. The other leader may have thought I was heartless, while I usually thought she was too dramatic. In reality, she had strong empathy skills, and I have a very practical nature. Both commodities were necessary, and our girls benefited from the combined personalities of the two of us! Taking these types of differences into consideration when dealing with others will help me be slower to assume negative motivations.

I also gave considerable thought to the idea of conflict as the basis for innovation. I have seen much conflict over the years, and I have seen teams successfully resolve differences. The idea of conflict as desirable to inspire creativity is intriguing. Jeremy Gutsche says most innovation is the result of a simple idea that builds on many other ideas that came before it.

A leader in my organization told of a group that worked for several months on a project with no progress. A personality test given to the team demonstrated that all of the members were the same type. With this new information, several more people were added to the team, specifically selected for their different personality types. The team suddenly began making progress and soon successfully completed the project. If everyone thinks the same way, it is hard to come up with new and innovative ideas. A little conflict can make all the difference.

Learning from Errors

While the idea of learning from mistakes seems obvious, thinking and reading about this concept gave me some new insight. One idea I read was that the learning is not from the mistake, but from the reflection on it afterwards. A small but significant point! When I make an error, I often think about what happened and what I will do differently next time. I have coached nurses this way at times, but it has not been a routine practice to help them reflect. Sometimes it happens, other times it does not.

One less experienced nurse was admitting a trauma patient for the first time. After arriving from the ER, he was quickly given blood products and sent to the OR. It all happened very quickly, and it did not go smoothly. Once he was gone, the nurse and I talked about the experience and discussed what could have made it less chaotic. She had several ideas and I was able to make some suggestions as well. The few minutes we took to reflect helped us both learn from the experience. We would be better prepared the next time. After learning more about the benefits of self-reflection, I will definitely make this a routine part of my work with our nurses.

Reviewing a process and what could improve is beneficial for other aspects of work, not just errors. Reflecting after a presentation can make the next one more engaging, more concise, or more clear. Thinking about the results of a meeting could result in changing the agenda, adding additional people to the team, or starting a list of discussion points for the next meeting.

Our unit has debriefings after a significant event occurs. Although these happen inconsistently, I see them more and more frequently. The entire team takes a few minutes to review the event. The staff appreciates the chance to ask questions, hear positive feedback, and receive constructive suggestions in a non-threatening venue. These are great opportunities to learn and improve, and they also build team rapport.

In my own role as a QI coordinator, I think making a point of reflecting on each project on a regular basis would be beneficial. Reviewing what a group is working on, what follow-up needs to be done, whether the right people are included and what else they might need from me are all things to think about. I do this intermittently, but not routinely. Clearly, regular reflection is worthwhile!

Leaders Set the Tone

Porter – O’Grady and Malloch conclude that leadership is not a personality type or a specific set of traits, but it involves learned skills and can be accomplished by all personality types. The skill set, emotional competency, and vision of the leader determine the ability and success of the team. This concept is one I have seen in action, but I had not heard it explicitly stated before. Ken Blanchard expresses it simply (and humorously)!

As a CN, I know my attitude will influence everyone’s mood as we start the day. If I walk into shift report and announce we are short two nurses, the care assistants both called in, we have several surgery patients scheduled to come, and there are no patients transferring out, it sets everyone up for a bad day. Why would I want to do that to the nurses at the beginning of a 12-hour shift? Even if all of that were true, it would be so much better to say something like, “It is going to be a busy day, but we have a plan. Call me if you need help!”

Simon Sinek describes a leader’s role as caring for those she leads. I love this definition! If a leader can give the team what they need to succeed, the possibilities are limited only by the creativity of the team. I appreciated seeing this idea spelled out. All of these ideas are concepts we have explored:

• Hire (or select) a great team - embrace diversity, don’t be afraid of conflict. Choose people who know the content. Pick a few people who may resist the change. They can help fix the problems they will undoubtedly be pointing out!
• Give the direction or goal – The Elephant and the Rider example explains this idea in detail. The big take-away is to keep things simple and clear, and remove barriers. I took notes!
• Use emotional competency - meet the team where they are and model EQ behaviors. People are ALWAYS watching. If you have a positive attitude and model the changes, others will follow.
• Be vulnerable – admit what you don’t know, and be willing to learn from others. Though it seems counterintuitive, vulnerability builds trust, and trust is necessary for good leadership.

Colin Powell talks about the idea of trust and caring for your team in this short, but powerful video:

Keep Learning

As I reflect on the idea of complex systems and responding to change, I remember Jeremy Gutsche’s discussion of innovation. He likened people who prefer the status quo to farmers, and compared innovators to hunters. The idea of constantly looking for change may seem daunting, but especially as a QI coordinator, I know there are always things to improve. Moreover, if I am honest with myself, I am more engaged when I am working on a new project than when things seem to be on auto-pilot. This particular talk has encouraged me to strive for a hunter mindset.

I have loved watching all of the leadership videos and reading about the experiences of others in their leadership journeys. I have saved much of the content for future reference after our class has ended. Every new thing I learn is one more thing in my toolbox. Old tools can be repurposed to solve new problems, so nothing is ever wasted. Our roles as leaders is ongoing, but our leadership must be open to adapting to the constantly changing environment. We must learn continuously so that we, too, may be repurposed as needed.

P.S. ONE MORE THING: It is never too soon to start learning these skills. As a pediatric nurse, I leave you with a few thoughts from some young leaders…

References

4-H iGrow Video Resources (Director). (2014). The elephant and the rider [Video file]. Retrieved from https://www.youtube.com/watch?v=-XYxudAQk5w

Forum Corps (Director). (1990). Kids on leadership [Video file]. Retrieved from https://www.youtube.com/watch?v=UQfrcOX5tW4

Heath, C., & Heath, D. (2011). Switch: How to change things when change Is hard. S.l.: Random House US.

Porter-O'Grady, T., & Malloch, K. (2015). Quantum leadership: Building better partnerships for sustainable health (4th ed.). Burlington, MA: Jones & Bartlett Learning.

Raffo, D. (2012). Blogging as a reflective tool for leadership development: An exploratory study of a leadership practicum grounded in the relational leadership model. Delta Pi Epsilon Journal, LIV(2).

TED (Director). (2009). Simon Sinek: How great leaders inspire action [Video file]. Retrieved from http://www.ted.com/talks/simon_sinek_how_great_leaders_inspire_action?language=en

The Ken Blanchard Companies (Director). (2011). Ken Blanchard - It's always the leader[Video file]. Retrieved from https://www.youtube.com/watch?v=dS0cpKj1bLY

Trendhunter (Director). (2017). Disruptive innovation keynote speaker Jeremy Gutsche on trends & change [Video file]. Retrieved from https://www.youtube.com/watch?v=J7B9xvzawmY

Uhl-Bien, M. (2012). Complexity leadership in healthcare organizations [PowerPoint]. Retrieved from Http://c.ymcdn.com/sites/www.plexusinstitute.org/resource/resmgr/files/complexity_leadership_plexus.pdf.

YouTube (Director). (2011). The essence of leadership [Video file]. Retrieved from https://www.youtube.com/watch?v=ocSw1m30UBI

Healthy Organizations

Dealing with Setbacks

Often life experiences teach us new things about ourselves. We find new perspectives and strengths we may previously not have been aware we possessed. It was hard for me to listen to Ann Voskamp’s reflections on broken lives. As I have said before, I prefer to solve problems rather than dwell on them, and her reflections, while useful, seemed unnecessarily emotional to me. (Sorry, I call them as I see them!) Perhaps more to the point, I related her thoughts to my own experiences, and I usually spend less time thinking about how I feel, and more time deciding my next steps. Regardless of the approach, however, I do agree with the idea that disappointments or failures can help us grow.

Back when I was in junior high, several of my friends became part of a clique, and I suddenly found myself alone on the outside. At first, I was upset and angry, but before long, I decided I was not going to spend all my time wishing I were in their group. If they were no longer going to be my friends, I would make new friends. I joined the cross-country team and auditioned for the school play, and soon I had many new friends with a variety of interests. From this experience, I learned to think for myself, and I gained the ability to act independently. It boosted my confidence, and it helped me to see I was not a victim of circumstances. Similar situations have occurred over the years, and they have taught me I am not helpless, and I can have a say in what comes next. While I cannot necessarily change a situation, I can certainly choose my response. This crucial lesson has served me well for many years.

Acceptance is not submission; it is acknowledgement of the facts of a situation. Then deciding what you're going to do about it.”    ― Kathleen Casey Theisen

Anger Management

The Anger Profile Survey was another difficult exercise for me (this was a rough week!).  My results indicate I am a “stuffer”, suppressing or hiding angry feelings. It is true in the sense that I do not openly express angry feelings in the moment. It is also somewhat inaccurate, however, because I do express anger in a safe and appropriate environment. For example, if a patient’s parent is being unreasonable and difficult, or a nurse is not receptive to my comments, I try to maintain a calm demeanor and neutral tone, regardless of my feelings. Expressing anger will not help the situation, and it may make things worse. Once I am in the charge nurse office, or at home with my family, I will most likely vent. We have a saying, “what is said in the CN office, stays in the CN office!” If I need to follow up with the family or the nurse, I will do it with emotions in check and the same neutral tone in order to keep communication open. In my mind, this is necessary anger management. I can’t think of very many situations in which openly expressing anger towards another person will help resolve an issue.

Emotionally Competent Leadership

What's My EQ?

The 18 behaviors of emotionally intelligent people was an interesting article, and I needed to reflect on it for a while. The terminology itself makes me cringe a bit, because, as I have said before, I would rather problem-solve than deal with tears or other emotions. The ability to be detached and think rationally in the midst of a crisis has served me well over the years in my role as an ICU nurse. I tend to think rationally about emotions as well. I realize a new nurse is not asking for help because she is embarrassed, nervous, overwhelmed or shy, and I adjust my approach. I understand parents are difficult at times, because they are angry, feel powerless, are frustrated, or feel stressed. Once I determine what is going on, I decide on my next step. I can be supportive, empathetic, encouraging, reassuring, etc… as needed, but I tend to be more analytical about the situation than emotional. This manner of handling emotions is apparently consistent with the INTJ personality. Remaining calm and detached is a means of protecting my own emotions according to the description of this personality type, and I am sure that is exactly right when I consider my particular work setting.

5 traits from the list which I identify with most are as follows:

Know my strengths and weaknesses
Good judge of character
I tend to analyze things, so these two tend to be true most of the time.

Do not seek perfection
Appreciate what I have
Working in the ICU has taught me there are no guarantees in this world. Everyone is dealing with something, and challenges are part of life. I am thankful for the life I have, and I know most of the problems or issues I encounter are not the end of the world.

A favorite quote, which I have shared often:

Disconnect

This one is easy for me as an INTJ. I definitely recharge internally, and I always find that time one way or another. Cooking relaxes me, running is great for thinking and reflecting, and I keep trying to get started with meditation, although that one is quite challenging. I may find quiet time, but it is not as easy to totally quiet the mind!

Additionally, these are areas in which I continue to need work:

Curious about people – As an INTJ, I find I must be intentional about building relationships. I can do it, but if I don’t think about it, it is easy for me to exist in my own little world much of the time.

Embrace change – I wouldn’t say I am resistant to change, however, I am resistant to change that is not an improvement. There is a difference. It is easy to have “knee-jerk” reactions to events, or to jump on board with the latest trend, but these actions are not always best in the end. It is difficult, at times, to be supportive of decisions, which seem suboptimal, even if they may be the most appropriate given the situation and resources at hand.

Don’t hold grudges – It is easy to be upset with someone who creates barriers or seems uncooperative. I continue to work on keeping a neutral tone (my kids will tell you this is one of my favorite suggestions!) when talking with difficult people. I try to give people the benefit of the doubt, but I do so knowing the history and with some wariness.

Get enough sleep – This will improve in about four weeks!

Hiring EQ Nurses

EQ, or emotional intelligence, refers to one’s ability to be aware of and manage their own emotions and to adapt them in order to interact with others effectively. A nurse leader in our organization once said, “I can teach you the technical skills; I can’t teach you the attitude.” I have seen this wisdom play out many times over the years. Employees who are unable to work well as a team have many difficulties which are hard to resolve.

In our interviews, we ask many questions and pay close attention to the relationship skills the applicants discuss such as working on a team, teaching others, handling conflict or being accountable. I remember one applicant who talked about a resident physician who “didn’t know what he was doing” and how she had to “set him straight”. While it is not unusual for a resident to need some education or coaching from a seasoned nurse, the approach she used (as well as the tone), told us a great deal about her EQ.

It is difficult to change something if you don’t know what it is or why it needs to change. Too often, people with lower EQ are unable to see how they may be contributing to a problem. It is logical, then, for organizations to look for candidates who will not require additional resources to help them become team players and be effective in their role.

Lessons Learned

Henry Cloud’s article “Ten Things Successful People Never Do Again…” listed several things that are essentially lessons learned from experience. They are life lessons, which can apply to both work and personal situations. Overall, the theme is to be true to yourself and to take a pause and reflect before everything. It is true that taking time to consider a situation usually results in better choices made.

I would also add:

1. Successful people do not dwell on mistakes – it is good to reflect, but then it is important to move on, lesson in hand.

2. Successful people do not judge people quickly – everyone has an off day. If we judge someone based on one not-so-great encounter, we may miss many outstanding qualities that didn’t happen to show up that one time.

Using EQ with Millenials

The Simon Sinek talk, Millenials in the Workplace, particularly resonated with me. Many of our younger nurses demonstrate the qualities he described, whether or not they officially belong to the millennial category. While energetic and tech savvy, they often struggle with interpersonal communication and building relationships.

As a mother of two young adults who are the same ages as many of these nurses, I find myself coaching them in a similar fashion. At one point, someone told me they had found me intimidating when they first started working in our unit, which was rather devastating to me, since I always tried to go out of my way to be friendly to everyone. I realized, however, that I needed to do more to demonstrate that I was approachable. I not only offered to help newer nurses with tasks, but I began telling them stories about similar situations in the past, showing them an easier way to do something, or teaching them a new skill with no judgement - “It took me three or four times to get that right – you’ll get it!”.

Once I changed my approach, I noticed these same nurses were calling me when they needed help, or seeking my input when they weren’t sure what to do. I also make a lot of effort to sit with people at lunch who are off by themselves or who I know are relatively new, and I engage them in conversation. It’s kind of fun to see the phone get laid aside as they realize someone is interested in talking to them. These are a few things we can do to create the environment of trust and cooperation Sinek discussed. I am always open to new ideas as well!

What's Your Story?

The Ladder of Inference discussed by Trevor Maber reminded me of a speaker I heard several years ago. He divided us into small groups and gave us the following scenario: a coworker has started coming back from lunch 20-30 minutes late every time you work with her. He gave us two minutes to come up with as many reasons as possible why the person was doing so. GO!

No problem:

• Lost track of time

• Started a walking program

• Calling home to check on a sick child

• GI issues

• Watching a new soap opera

• Lazy

• Looking for a new job

• Calling their mechanic

• Leaving the building to buy a healthier lunch

• Fatigue

• Pumping breast milk during break

• Taking a smoke break

• Etc...

When he called us back together, among all the groups we had over 25 possible reasons the person was taking extra time at lunch. Which was the right answer? He told us: It could be ANY of them, or others we hadn’t thought of yet. The truth was (and usually is) we didn’t know.

What we tend to do most of the time is pick one story from the list – she’s not keeping track of the time.

Based on the story we choose, we have a feeling – angry, annoyed, disrespected.

Based on how we feel, we act - snub the person, make snide remarks, have an angry confrontation.

We base our reaction on the story we told ourselves, but it may be the wrong story.

What if we found out the person’s mother was in hospice care, and she was calling to talk with her each day during her lunch hour? Our reaction would most definitely be different. We would have different feelings about this story (sorrow, sympathy, compassion), and we would act differently in response to them (ask about her mom, offer additional breaks, listen).

In addition, if we had been treating this person poorly, because we told ourselves the wrong story, we might be embarrassed and feel bad about our behavior. We would also realize we had added to her stress level at the worst possible time. It is critical to “know the story” before we react.

This is one narrative I have shared many times over the years. It has influenced me greatly, and to this day, I always try to give people the benefit of the doubt. Things are often not as they seem, and we should be slow to judge.

Leadership Development

Porter O’Grady and Malloch (2015) state “Leadership occurs in the space between individuals working together. It is an emergent property of their relationships, and not the management or direction of work by individuals placed in superior positions.” (p. 393). This philosophy is evident in our workplace. We have many nurses who are leaders in a variety of ways, regardless of whether or not there is an accompanying title. Nurses feel free to make suggestions, to advocate, to ask for clarification and to participate in the work of the unit. As the QI coordinator, I often see teams come together and provide leadership to the rest of the unit for improvement of patient care. These opportunities are the things that engage nurses and help them grow in their knowledge and skills. I believe my role, and the role of our unit director, is to create and support the opportunities.

Some of the quantum leader traits I will continue to work on include:

• Compassion - As an INTJ, I know my tendency is to be somewhat detached, and this quality serves a purpose. It is necessary, however, to find the correct balance, and this is something I continue to grapple with.

• Resilience - Dealing with disappointments and failures requires resilience, and this quality is key to helping a nurse or team bounce back. This topic is definitely one I need to learn more about.

• Passion through balance - Finally, finding my focus in a time of information overload can be challenging. Understanding how to prioritize and zero in on a few key elements of work and allow passion to exist in those venues is essential to be effective and to find the purpose driving the work.

These three things should keep me occupied for some time!

In summary, Simon Sinek suggests that the role of a leader is to care for those you lead. He states people who feel safe will respond with trust and cooperation, and this environment leads to a team willing to work towards the vision the leader has set forth. Sinek calls this phenomenon “servant leadership”, and it requires leaders to have a high EQ. We have been commissioned!

References

16 personalities. (n.d.). Architect personality and emotions. Retrieved from https://www.16personalities.com/intj-personality-and-emotionshttps://www.google.com/webhp?hl=en&sa=X&ved=0ahUKEwjhqO3lkpPTAhWT0YMKHZITA8MQPAgD

Bradberry, T. (2015). Are you emotionally intelligent? Here's how to know for sure. Retrieved from http://www.inc.com/travis-bradberry/are-you-emotionally-intelligent-here-s-how-to-know-for-sure.html

Cloud, H. (2014). 10 Things Successful People Never Do Again. Retrieved from http://www.success.com/article/10-things-successful-people-never-do-again

Cole, S. (2014). Why emotional intelligence is more important to hiring than you think. Retrieved from https://www.fastcompany.com/3029306/why-you-should-make-emotional-intelligence-the-cornerstone-of-your-hiring-strategy

Forleo, M. (Director). (2016). How to be a great leader: Inspiring others to do remarkable things [Video file]. Retrieved from https://www.youtube.com/watch?v=NzBqJNh8z2U

Porter-O'Grady, T., & Malloch, K. (2015). Quantum leadership: Building better partnerships for sustainable health (4th ed.). Burlington, MA: Jones & Bartlett Learning.

TED-Ed (Director). (2012). Rethinking thinking - Trevor Maber [Video file]. Retrieved from https://www.youtube.com/watch?v=KJLqOclPqis

YouTube (Director). (2016). Simon Sinek - Millennials in the workplace [Video file]. Retrieved from https://www.youtube.com/watch?v=5MC2X-LRbkE

Errors as Opportunities

Learning from mistakes

As a nurse for many years, I have learned it is best to take the extra time to check and double check things. I have seen many errors over the years, because I, or someone else, was in a rush, and a pause to clarify or check details was omitted. It is easy to assume the intent of an order is understood, even if it seems odd or incorrect. It is easy to miss a discrepancy in dosing, because time is not taken to look it up. Our organization has a “high reliability” campaign in place, and every employee is required to attend error prevention training. The tools learned there are becoming part of the regular vocabulary in emails, presentations and even face-to-face discussions: team member checking, clarifying questions, ARCC, STAR and several others. These tools go hand in hand with the leadership style of the Information age, because they create horizontal relationships and encourage everyone to ask questions, make suggestions, and voice safety concerns, regardless of their “rank” in the organization. It does not happen overnight, but changes are apparent!

Responding to conflict and errors

Our medical director is a leader who handles conflicts and errors well. He is slow to judge, gathers information, and likes to take the “30,000 foot view” when considering situations. He is not reactive, but instead he gives thoughtful consideration and asks for input from others before making decisions. When a reportable event occurred a while ago, his response was to talk with those involved, review the chart, and maintain a calm demeanor. He also demonstrated great concern for the staff involved and their well-being, speaking to all in a supportive manner and avoiding blame. This approach is a stark contrast to another leader I worked with in my early years as a nurse. This leader’s approach was more hierarchical and controlling. Her tone was condescending, and she had a negative attitude towards the staff. She was more likely to place blame on people, thus, most nurses were not forthcoming when an error was made. Ultimately, the situation put patient safety at risk, because potential system problems could not be identified and remedied when people were afraid to report errors.

As a CN, I strive to connect with everyone I work with. Sometimes I worry about the time used chatting with nurses, especially if it is non-work related, but it is ultimately time well spent. I know people more personally and have a sense of who they are. I find a nurse is more likely to hear me and trust what I have to say, when they know me. I can relay safety information as a helpful tip or something nurses needs to know rather than an edict they must follow, and they are not only receptive, but they perceive the interaction as supportive and helpful rather than commanding. I am always open to suggestions or ideas for improving safety, and I try to share them with others as well.

Insights from Atul Gawande

Many of the ideas Gawande discussed in his TEDx talk go right along with the high reliability work my organization is doing. Standardizing certain elements of care to ensure all critical steps are completed, taking time to think about the task at hand, and respecting the role and value of each team member’s contribution are examples of such work. I appreciated the idea of a “pause” before proceeding. In a time when technology has increased the pace of work and distractions are plentiful, taking a few moments to focus on the task at hand is essential. Providing safe care is critical to improving the quality of care, and ultimately increases the value as well.

As a non-profit organization, cost effective care is important, although perhaps for different reasons than a for-profit organization might give. In order to stay in business and offer care to all, regardless of ability to pay, the institution must closely manage the budget. The difficulty is determining what will result in cost effective care. For example, it might be more expensive to use a particular dressing on a central line, but if it does a better job of protecting the site and preventing a costly blood stream infection, the money is well spent. For these reasons, patient outcomes should also be measured, and strategies used to improve unacceptable rates. Ultimately, this approach can result in decreased costs as well as improved patient care.

Patient satisfaction should also be measured. While it can seem superfluous at times, how the patient feels about the care received holds a great deal of influence and cannot be dismissed. “Patient satisfaction affects clinical outcomes, patient retention, and medical malpractice claims. It affects the timely, efficient, and patient-centered delivery of quality health care. Patient satisfaction is thus a proxy but a very effective indicator to measure the success of doctors and hospitals (Prakash, 2010, p. 151).

Porter-O’Grady and Malloch (2015) discuss the need to eliminate things that do not contribute to good outcomes. As a QI coordinator, I wholeheartedly ascribe to the idea of efficiency and making the workload lighter in order to focus on the essentials. If a service or task is not adding value to the care of the patient, it deserves closer scrutiny and possible elimination. The value a service or task adds to the patient experience and outcome is worth measuring in order to decide which things stay and what is eliminated.

Addressing Interruptions

As technology continues to advance, there are more ways than ever to find ourselves distracted. Social media, cell phones, and email are always present and demanding our attention, but as a nurse, there is a multitude of additional interruptions to our focus. Alarms, patient needs, coworkers with questions, and new orders are a few, and the list goes on indefinitely. This problem is particularly worrisome, because a study cited by the Patient Safety Network suggests there is a 12.7% increase in the risk for a medication error with each interruption while the med is being prepared and administered.

There are many ways to tackle the issue of interruptions, and multiple aspects of care to consider. Our organization has begun looking at the issue of alarm fatigue, and changes are occurring in the default settings of our monitors. In our unit, a project is being considered to determine whether the noise level is an issue. As a CN, I find it difficult to get through lunch without multiple phone calls, and the number of interruptions as I gather report information at the end of the shift continues to grow. I try to model not interrupting if I arrive at a patient room for report and see the nurse in the midst of a complex tubing change. I move on to the next room and return to that nurse later. I have also coached nurses how to address families who are talkative, or have many requests, in order to decrease interruptions. For example, “I need to get these medications ready and give them to Billy, so I will talk with you more when I am done” or “I need to check on my other patient, so I will be out of the room for a while. I will be back at 2:00, and we can give Sarah her bath then.” As a QI coordinator, this topic would be a good one to address, as the problem is huge, and the impact directly affects patient outcomes. This idea is definitely something I need to consider.

Handling Mistakes in a Just Culture 

As a nurse in the workforce for over 30 years, I know all too well how easy it is to make an error. I also know the guilt and stress produced by errors. Rarely do errors occur due to maliciousness or neglect, but rather they usually seem to be the result of a memory lapse, inattention, misunderstanding or some other understandable, yet unfortunate, situation. I try to have a very supportive response when an error is made, because I know most nurses are devastated when something happens.

I am thankful the organization for which I work believes strongly in a just culture. There is concern for the patient, determination to investigate and avoid similar events in the future, and support for the person who made the error. Of course there may be consequences if risky or negligent behavior is involved, but overall, there is not a rush to judgement or blame, and the entire situation is approached as a system issue as the analysis begins.

The state of Missouri has recommendations related to patient safety; however, there is no requirement for mandatory reporting. As a high reliability organization, all employees are encouraged to report safety issues of any type through an internal reporting system, including “near miss” events in which no harm reached the patient. Positive feedback is given for such reporting including “great catch” awards, which are reported in the employee newsletter. While the increase in reporting requires an increase in follow-up activity, the outcome is such that problems are identified and addressed. This focus on safety and preventing errors is definitely a step in the right direction.

References

Beyea, S. (2014). Interruptions and distractions in health care: Improved safety with mindfulness. Retrieved from https://psnet.ahrq.gov/perspectives/perspective/152/interruptions-and-distractions-in-health-care-improved-safety-with-mindfulness

Boynton, B. (Director). (2012). Interruption awareness: A nursing minute for patient safety[Video file]. Retrieved from https://www.youtube.com/watch?v=PGK9_CkhRNw&t=311s

Extension Healthcare. (2016). Clinical Interruptions. Retrieved from http://www.extensionhealthcare.com/industry-challenges/alarm-management/clinical-interruptions/

MISSOURI –Public and Private PolicyMedical Errors and Patient Safety. (n.d.). Retrieved from http://qups.org/med_errors.php?c=individual_state&s=26&t=all

Porter-O'Grady, T., & Malloch, K. (2015). Quantum leadership: Building better partnerships for sustainable health (4th ed.). Burlington, MA: Jones & Bartlett Learning.

Prakash, B. (2010). Patient satisfaction. Journal of Cutaneous and Aesthetic Surgery, 3(3), 151-155. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3047732/

TEDx Talks (Director). (2012). Atul Gawande: How do we heal medicine? [Video file]. Retrieved from https://www.ted.com/talks/atul_gawande_how_do_we_heal_medicine

Understanding Preferences and Personalities

PERSONALITIES

After taking the test on the 16 Personalities website, results indicate my personality type is INTJ. Some of the traits of this particular personality include calm, rational, reserved, and independent. It is interesting to note these descriptors are similar to those I mentioned last week when discussing how others describe me. While I think the overall description is accurate, I know I work to overcome some of the tendencies, because the situation at hand requires it. For example, it is more my style to address the issue at hand than it is to deal with the emotions of the situation. My coworkers and family can vouch for the fact that I do not have a lot of time for tears and drama, but instead I prefer to fix the problem. Working in an ICU can require that kind of objectivity at times. There are other times, however, when a sympathetic ear and a compassionate touch are needed, and I try not to ignore those situations, even though I am much less comfortable dealing with them.

Another mom and I were co-leaders of a Girl Scout troop for several years, and we were as different as two moms could be. I looked up the opposite of INTJ, which would be ESFP, and it described her quite well! She was very social, creative, nurturing, and supportive, and she had all kinds of fun ideas for our group of girls. She did not always appreciate my organized nature or request for more specific details. During one memorable discussion, she asked me in a perturbed tone, “Do you always have to be so practical?” I suppose laughing was not the supportive response…

In the big scheme of things, however, I think the two of us working together as leaders was a good situation for the troop. My ideas were not nearly as creative as hers were, yet she did not have the organizational skills to follow through with her plans. Instead, my co-leader came up with excellent suggestions, and I planned a way to make them happen. While we sometimes would be annoyed with each other, we both appreciated that the other helped fill in the areas in which we were lacking. Together we were a great team!

INTROVERTS and EXTROVERTS

Susan Cain’s TED talk about introverts and extroverts describes the differences between the two groups and suggests the world needs both. As a life-long introvert, I can identify with the need for alone time to regroup and recharge my energy. I think both personality types have much to offer, and the challenge for me is to help direct the energy of the extroverted team members or attend to the introverts need for solitude in a constructive manner.

As a CN, I will sometimes task an extrovert with a project or something that can channel their initiative, such as taking a new piece of equipment around the unit and making sure everyone is familiar with how it works. As a QI director, I try to match skills and personalities to the needs of the projects we are working on. Extroverts can be a great help when it comes to generating buy-in from the rest of the staff. On the other hand, introverts are easier for me to work with, because I can relate to them.  I know the quiet nurse or CA may have an untapped well of capabilities, and I am definitely going to tap into it to help them grow and to benefit our unit simultaneously.

I am more likely to suggest a QI project that allows a nurse to choose her level of participation, meaning she can do as much or as little as she desires. For example, she might agree to join a committee and attend a few meetings, then gradually begin to offer ideas or take on some of the work that needs to be completed. This approach is less threatening, and often people begin to contribute more as time goes on and they feel more comfortable. On the other hand, a more extroverted person might offer to be the project lead!  I think of extrovert or introvert as a guide to help me determine some of the abilities of the person and perhaps a way to fine-tune my approach to working with them. Both personalities have needed qualities!

CONFLICT RESOLUTION

Differences in personality can affect every aspect of life including the manner in which we deal with conflict. Some people may avoid it at all costs, while others seemingly create it wherever they go. Conflict can create negative emotions, and people handle it differently.  While one person may sulk or even leave the room, another may have outbursts or speak negatively with others about the situation. As a common element in most relationships, however, it is important to find healthy and productive means of dealing with conflict. As an INTJ, conflict is particularly uncomfortable, because it means I must engage with people who are exuding all kinds of energy, and it is exhausting!  On the other hand, if I have a planned response to potential clashes and controversies, my INTJ personality is better able to handle it.

Jeff Muir defines conflict as the expression of an unmet need, and he lists three steps for dealing with it:
1. Determine if the need can or cannot be met
2. If it can be met – resolve
    If it cannot be met – negotiate a resolution
3. Conflict management if unable to resolve

Dana Casperson suggests two steps to use in negotiating a conflict:
1. Don’t hear the attack
2. Develop curiosity

I agree with these recommendations, and I have seen them work. A patient advocate gave a talk to our CN group several years ago.  She said her standard way to approach an upset family is to introduce herself, pull up a chair, sit down and say, “How can I help?” In doing so, she does not “hear the attack”, because she is entering into the conversation with no preconceived ideas about the issues.  She is also is developing curiosity to truly hear what need is being unmet. I think this approach is also acceptable to many personality types because it allows for whatever kind of response the person wants to give. By offering to help, the stage is set for negotiation and resolution from the beginning. I don’t remember anything else from her talk, but that one tip has served me well many times.

INNOVATION

Jeremy Gutsche compares innovators to hunters, and he likens everyone else to farmers.  A farmer, happy with the crop from one year, will repeat the steps to obtain a similar result the next time. He describes the farmer mindset as complacent, repetitive and protective. A different approach, which has the potential to return different and better results, is that of the hunter.  A hunter is insatiable or never satisfied with the status quo.  The hunter is also curious and willing to undo the current process in order to develop a better one. While the hunter is not always successful, the constant search has a higher likelihood of discovering something completely new.

This topic really resonated with me, as I have found myself restless at times with our current projects.  While most things need ongoing measurement and oversight, it is easy to get complacent and spend the time on routine tasks. A recent conference I attended sparked some new ideas for using cell phones to streamline some processes in our unit, but implementation would require big changes to the usual organizational stance on such technology. An interesting idea to investigate!  I appreciated the task list given at the end of the talk, which included exploring curiosity, thinking about relationships in a new way, and not giving up.  I do know from experience that sometimes you have to bring up an idea multiple times with many different people before someone finally starts to really listen and think about your proposal.  This talk has inspired me to think more like a hunter!

SYSTEMS THINKING

Systems thinking is an approach to problem solving that requires looking at the entire system, as well as the manner in which the individual system components are related and have an impact on each other. This type of thinking is necessary in a large organization such as a hospital, where, too often, work is done in each department with little thought of how it affects those in other areas. When a problem occurs, it is necessary to consider the “big picture” in order to avoid solving one issue while creating other problems. Systems thinking can also help identify relationships and forces throughout the organization that may not have been known or understood prior to the investigation.

One example of a systems approach to problem solving is the Donabedian Model, which has three components: structure, process, and outcome. Examining elements of each component ensures a thorough investigation of an issue before starting the problem-solving process.  By looking at all organizational factors and relationships, it is much more likely that the necessary information is available to enable a satisfactory solution.

An example could be an ongoing problem with surgical site infections. The high infection rate is an outcome measure, but the cause of the problem, or the best type of intervention, may not be obvious. A systems thinking approach would consider what process and structural elements contributed to the outcome. Structural information gathered could include such things as the number of surgeries done each day, the number of OR rooms, the staffing, the credentials of the surgeons, the supplies and equipment used in the OR, and so on. The processes considered could include how the patient is prepped for OR, how instruments are sanitized, the manner in which OR staff prep before entering the surgical suite, and the process for administering prophylactic antibiotics.

Gathering all of this information gives the team an overall view of how the entire system fits together. Armed with the big picture, it is possible to hone in on issues that may not have been apparent during the initial discussion and consider a wider variety of interventions. It is worth noting that personalities and interpersonal conflicts can be pertinent to systems thinking, because both are elements which can define a culture and have an impact on processes.

FINAL THOUGHTS

O’Grady and Malloch discuss the evolution of our culture from the Industrial Age to the Technological or Information Age in their book, Quantum Leadership. We are in the midst of this change, as organizations are comprised of a multigenerational workforce with employees at all stages of transition. In my own institution, I work with some nurses who are completely befuddled by “cutting and pasting” in a Word document, and others who can trouble shoot a computer, cell phone, or any other piece of technology with little apparent effort. The setting is ripe for conflicts and personality clashes if not handled correctly, but some of the webcast speakers suggest these events should be embraced as a means of resolving issues and achieving growth. Furthermore, letting anger and resentment go unresolved can create team dysfunction.

The authors also suggest an effective leader will consider differences as part of their systems thinking, using their findings to develop a means of aligning the individual strengths and values of the staff with the goals of the organization. In other words, the leader should figure out the best way to present information in order to help employees understand the need for change and to gain their buy-in. Part of motivating change, however, includes allowing people to help create the change.

Those most affected by a change must be part of the change process to ensure the solutions chosen are reasonable and sustainable in the “real world”. Often those most affected are the direct caregivers such as nurses, therapists and CAs. Asking for their input when making decisions is clearly a new way of thinking for many leaders, but one which is certainly needed.

Change can be a challenge for so many reasons. Involving all stakeholders in the decision-making from the beginning offers the best chance of achieving employee investment in changes that reflect and meet organizational goals. In order to accomplish this task, an effective leader is willing to give up some of the control and allow others to be involved in problem-solving. This type of leadership is based on equity, team building, and relationships rather than a hierarchy in which the manager is in control. This type of leadership also creates accountability and ownership, both of which are of great value to the organization. While it is not easy to sit back and let others take the reins, the results can be well worth the temporary discomfort.

References

Breakthrough Marketing (Director). (2013). Conflict resolution [Video file]. Retrieved from https://www.youtube.com/watch?v=KY5TWVz5ZDU

Dawn, I. (2013). Introverts - Extroverts [Web log post]. Retrieved from https://uminntilt.com/2013/03/05/introverts-extroverts-change-takes-courage/

INTJ Personality: An Overview. (2016). Retrieved from http://www.personality-central.com/INTJ-personality.html

Porter-O'Grady, T., & Malloch, K. (2015). Quantum leadership: Building better partnerships for sustainable health. Burlington, MA: Jones & Bartlett Learning.

Shi, L., & Singh, D. A. (2015). Delivering health care in America: A systems approach (6th ed.). Burlington, MA: Jones and Bartlett Learning.

TEDx Talks (Director). (2015). Conflict is a place of possibility [Video file]. Retrieved from
https://www.youtube.com/watch?v=WfQeH3092Sc

TEDx Talks (Director). (2012). The power of introverts [Video file]. Retrieved from https://www.youtube.com/watch?v=c0KYU2j0TM4

Trendhunter (Director). (2015). Better and faster [Video file]. Retrieved from https://www.youtube.com/watch?v=VFshvhzcCVw