- Email: [email protected]
Revisioning, re-educating, regenerating, and recommitting nursing for the twenty-first century
Revisioning, Re-educating, Regenerating, and Recommitting Nursing for the Twenty-first Century Karren Kowalski, PhD, RN, FAAN Laurel Burton, ThD, FCOC M a u r e e n Rehwaldt, RN, MS, DNSc(c)
In a rapidly changing health care environment, nursing must continually transform itself. For this to occur, nursing leaders must be willing to commit to a vision of relationship-centered care that includes the behaviors of team building, participatory decision making, trustworthiness, positive self-esteem, low control needs, trust in self and others, and openness to explore new programs and gain new knowledge.
M
ax DePree described leadership as an art, ~and as in most forms of art, it is also committed work. This committed work of leadership is at the heart of this article. Faced with the task of leading their nursing staffs--and others--through the myriad of changes facing health care in the last years of the twentieth century, nurse leaders must build a new vision of the health care enterprise and nursing's role for the twenty-first century. Because nursing leadership is faced with the task of creating nursing services and education that will flourish in the twenty-first century, Leland Kaiser, the well-known health care futurist, has said, "We can create our future by choosing what we focus on. ''2 One vision for nursing leadership focuses on creating a healing place for staff as well as for patients and families. To create this type of healing environment, it is necessary to
Nurs Outlook 1997;45:220-3. Copyright © 1997 by Mosby-Year Book, Inc. 0029-6554197155.00 + 0 3511184214
220
Kowalski, Burton, and Rehwaldt
have constructive, productive, accountable, and humanistic relationships within the health care team. Such relationships and their impact on patient healing have been described by the Pew-Fetzer Task Force in a document entitled "Relationship-centered Care. ''3 In most facilities, numerous relationship conflicts exist. These conflicts may be between doctors and nurses, nurses and administration, nurses and other nurses, nurses and other health care providers, or nurses and patient families. A clear goal of relationship-centered care is to promote positive encounters and to diminish negative interactions among health care providers and recipients. Realization of this goal eliminates "grousing," gossiping, blaming, and making other team members wrong. Relationshipcentered care helps caregivers focus on their purpose for working in a given specialty or setting: providing quality care to patients. It creates a positive, supportive, and nurturing environment. Consequently, interactions between staff members and patients
and families in crisis look quite different, with staff members being less likely to react negatively to patients and families and to label them as "difficult" or "out of control." Staffmembers are also more likely to search for solutions to problems when relationship-centered care is used as a model. This enables patients and families to focus their energy on coping and healing and to leave the health care facility without additional psychological baggage such as anger or negative judgments about their treatment. To this end, all provider-patient interactions must be therapeutic. A goal such as this requires additional interpersonal skills and personal insight on the part of the staff. It requires the transformation of staff interactions.
A clear goal of relationshipcentered care is to promote positive encounters and to diminish negative interactions among health care providers and recipients. This transformative restructuring of staff relationships requires four phases: revisioning, reeducating, regenerating, and recommitting. The task of nursing leaders is to help nursing staff re-vision their relationship-centered roles vis&-vis the changes in health care; to reeducate staff members, giving them tools that are immediately accessible for use in achieving and fostering these new roles; to regenerate a sense of purpose, including elements of pro-
VOLUME 45 • NUMBER 5
NURSING OUTLOOK
ductivity, innovation, and "creating value"; and finally, to help staff members recommit themselves to the values of the profession. Three separate but related programs were offered to the staff members of one division in an academic medical center. Each program is related to one of the first three phases. The rccommitrncnt phasc is a continuing process.
REVISIONING The program for the revisioning phase, called "Navigating Change," explores one view of what is happening in health care and the vision of how staff members in one given specialty area can address these changes most effectively. N a v i g a t i n g Change is a 2-day program (lasting approximately 10 hours each day) that explores the dynamics of change, personal responsibility, and teamwork. This program is open to all staff members, from those in housekeeping to physicians. It concludes with an opportunity to "break through" personal and professional obstacles that stand in the way of successfully coping with change. Participants learn about effective personal and team strategies such as collaboration and goal setting through a variety of games and group exercises. Several experiential learning activities exemplify the business dimensions of health care and the importance of cooperation as opposed to intra-organizational competition. During the debriefing period after the games and exercises, participants explore personal learning and team learning. Each person is introduced to "The Rules of the Game" (Box 1). These basic agreements provide a structure for interpersonal relationships. Each employee also agrees to a "Commitment to the Team to Realize a Best Practices Culture" (Box 2). The four areas of best practices reflect the values of the institution and constitute demonstrations of these values. Staff evaluations of this program suggest that it is helpful in the revisioning phase: "We have more tolerance for diversity of opinions; there is less gossiping and less blaming; coworkers are more caring and friendlier." RE-EDUCATING Once staff members become familiar with the new vision through the Navigating Change program, the work of aligning behaviors with the vision begins. The "ArtNURSING OUTLOOK
1. 2. 3. 4. 5. 6.
7. 8. 9. 10. 11. 12. 13.
Be willing to support (name of hospital) game, purpose, rules, and goals. Speak supportively. Correct supportively. Acknowledge whatever is being communicated as true for the speaker at that moment. Complete your agreements. When a problem arises, first use the system for corrections. Then communicate the problem with alternative solutions to the person who can do something about the problem. Be effective and efficient. Optimize every event. Create more with less. Work smarter, not harder. Have the willingness to win and to allow others to win. Focus on what works. When in doubt, check out feelings. Agree to disagree until reaching consensus. Tell the truth from the point of personal responsibility.
works Core Course" is used because it provides a powerful framework that can be used by each staff member to view how this new vision relates to her or him personally and corporately. Furthermore, staff members can explore the actions that are needed to enable this vision to become a fuller reality. The Core Course lasts approximately 21/2 days (24 hours) and is based on a model that focuses on principles of acceptance, responsibility, trust, and the ability to take c o m m i t t e d a c t i o n (B. Adamski, personal communication, 1995). The course facilitators help re-educate participants about how their own sense of purpose and the needs of relationship-centered care can come together. Often staff members reframe current views of reality (i.e., alter perceptions and beliefs) so that they can imagine new possibilities, rather than remaining "stuck" or limited by fears and anxiety. Each participant has the opportunity to speak about her or his purpose, desired outcome, fears, obstacles, and so forth. A series of presentations and exercises inform and underscore the learning. An example of one part of the content is the "Spoken Frames of Action" (Box 3). It is theorized that people in general and people in health care specifically spend more time focusing on emotional themes (the right column in Box 3) rather than on potential solutions or paths to solutions (the left column in Box 3). People can get "stuck" in their opinions, positions, reasons, interpretations, perceptions, or judgments. The potential for relationship-centered care is greatly enhanced when people move from
SEPTEMBER/OCTOBER1997
being stuck to seeing new possibilities and from speaking about one's purpose rather than one's position, what one promises to do rather than one's reasons for what one has done, and one's requests of another rather than one's interpretation of the other's behavior. Focusing on the purpose for being in the work setting rather than taking "positions" or making judgements about others supports a different perspective. Making commitments to process and outcomes rather than believing that others are wrong because of their differing points of view constitutes a significant shift in behavior. One participant commented after the core course, "I am now more open to change and have more opportunities to grow and practice new skills."
REGENERATING Nursing, by definition and practice, has become a "generative" profession; that is, nurses seek to generate competence in their patients and themselves and create value and new learning through their work. Maintaining this generative focus can be difficult for nurses, especially during times of downsizing. Much of this focus is reclaimed through the revisioning and re-educating phases of our approach. It is the task of the regenerating phase, through the "Vision in Action" and "Leadership" programs, to consolidate these phases and foster them in day-to-day practice by providing monthly meetings among staff and administration. One or both of the monthly sessions are open to everyone who has completed Navigating Change and the Artworks Core Course. Kowalski, Burton, and Rehwaldt
221
As individuals, we make a difference. Those of us involved in the provision and delivery of health care commit ourselves to a team effort with our co-workers and with the institution to live out the values of the institution to create a "best practices" culture and community where people are expected and empowered to make a difference.
Excellence We continually improve the way we administer services to ensure the highest quality patient care, education, research, and community service. • I will work to anticipate the needs of those people I serve. • I will work continuously to search for ways to improve the services I provide. • I will work hard and make an extra effort to be sure the right job is done right. • I will take pride in my work. Compassion We treat all people in a caring way, with respect and dignity. • I will always act in a courteous way toward patients and co-workers. • I will recognize and use the contributions of people from diverse backgrounds. • I will show respect for the feelings and concerns of others. • I will honor the privacy and confidence of others. Social Responsibility Obligation to serve is appropriately linked and balanced with responsible stewardship of resources. • I will confront bias and intolerant behavior when I see it. • I will act in keeping with the mission and values of the institution. • I will find ways to personally contribute to the well-being of the greater community. • I will find ways, in my own work, to manage material resources responsibly. Faith in Self and Others We believe in each person's ability and willingness to work together to do what is right. • I will demonstrate a strong sense of ethics in my work. • I will develop and sustain cooperative relationships. • I will not blame others. • I will focus on solving problems, not making others wrong.
Possibilities Purpose Promises Requests Declarations Commitment
Opinions Position Reasons Interpretations Perceptions Judgments
The Vision in Action and Leadership programs provide the necessary coaching, open communication, and positive reinforcement needed to continue work on the promises made and shared during the Core Course. Usually a particular topic related to the information, methodology, or promises made during the Core Course is addressed. The discussion is lively and free-wheeling, as the professional (and sometimes personal) relationships of the participants become the topics or projects presented by group members 222
Kowalski, Burton, and Rehwaldt
for review and intense work. Both support and confrontation are part of this process, but the atmosphere is always respectful and focused on learning. One person who said she had difficulty being direct with a challenging co-worker promised to seek coaching to support her desire to be clear and direct with this coworker and then follow through and report back. She used the "Leadership" session as a way of gaining additional support for changing her behavior and also began to learn how to move the interactions between herself and her co-worker in a more positive direction for both of them. The Leadership program has the additional feature of being intentionally supported by a core group of unit directors who, along with staff members, have each chosen to work on a particular project. Participants use the monthly Leadership meetings to review progress, to provide feedback regarding the status of these projects, and to get new ideas for ways to approach ob-
stacles that block the project's success. Staff members report that these sessions offer a place to talk about what is and what isn't working as they seek to become more relationship focused. These interactions set the stage for constructive feedback via the coaching, teaching, and role-modeling that have been shown to be effective empowerment strategies. 4 As one person explained, "Each of us is a support for everyone else who has attended and a role model for those who have not." The Vision in Action and Leadership programs promote and foster the characteristics exemplified in learning organizations as described by Peter Senge. s Senge suggests that sharing a vision, challenging assumptions, and understanding the interrelationship of problems and causes is essential for building such an organization. It is during this regenerating phase that participants ask again and again, "What do we want to achieve ?" Answers to this question help to build a learning organization
VOLUME 45 • NUMBER 5
NURSING OUTLOOK
in which answers are lived rather than merely discussed.
RECOMMITTING The underlying philosophy of all of these programs is that all people have value and make contributions. To be successful in the future, people in health care must increasingly function as a team. To work closely together, team members must demonstrate mutual respect and support, remain accountable to each other, and promote ongoing innovation and creativity. Joel Barker said, "A leader is a person you will follow to a place you wouldn't go by yourself. ''6 The recommitment of nurses and nursing leadership to the success of the twenty-first century health care enterprise will mean leading staffmembers to a place they wouldn't go by themselves. The emphasis on p o s i t i v e reframing, m a k i n g choices, accountability, and innovation in the context of teams will be increasingly necessary for success. This recommitting process, while important for staff members, is especially important for nursing leadership. That is why unit leaders--each of whom has participated in all aspects of the program described h e r e - - h a v e regular meetings. In these meetings the various methodologies are reinforced through mutual problem solving, shared goal setting, and team learning. Individual coaching sessions are used. Persons choose to become coaches on the basis of interest and demonstrated skill. These nursing leaders are recognized and rewarded for "walking the talk" through such mechanisms as public recognition, written feedback on performance appraisals, and merit increases.
SOME INITIAL RESULTS In 1988 a biannual employee opinion survey was initiated to assess employee attitudes across the medical center. The survey was administered to a majority of employees. Early in 1995 the identified division participated in a "targeted survey" that focused on that operating unit alone. Although only slightly better than a 50% return rate was obtained, the results were interesting when compared with the all-employee survey of 1992 (which included this division as well). First, the employees' assessment of upper management's effectiveness increased from 29% to 61.5%, an increase of 112% over the 1992 survey (significant at p < 0.01 ). Second, staff members in this operating unit indicated that they
NURSING OUTLOOK
were well informed about the division, an increase from 49.2% to 68% (up 58.5% from 1992, significant at p < 0.05). Third, staff members believed that they were involved in job decisions, an increase from 44% to 59.3% (up 34.9%). W h e n the responses of persons in non-nursing job classes were reviewed no significant differences were found in ratings of the work e n v i r o n m e n t , perhaps because the staff f u n c t i o n s more as a team, not as separate, different, and competing groups. Many variables could have influenced attitudes: • In the spring of 1993, more than 800 full-time equivalent positions were cut throughout the entire institution • In the summer of 1993, new leadership for this specific area began work focusing on i m p l e m e n t a t i o n of the aforementioned programs • In 1994, a 5% reduction in work force across the institution occurred • In 1995, another 5% reduction occurred with the new budget year A number of open-ended questions included along with the targeted survey asked staffmembers to describe any changes in their work environment, a content analysis of these responses was done. Whereas 26% mentioned the visible changes ofdownsizing and cutbacks in staff, 29% described an improved relationship among physicians and nurses and between units. In addition, these respondents said that more teamwork and increased communication was taking place and that management was more effective. Ten percent described more visibility and role modeling by management. Because these data are only inferential, a rigorous study of this overall programmatic approach is currently under way. Such an improvement in positive responses from this division in 1 9 9 5 - - after the fourphase program was instituted--compared with the 1992 data is worth further investigation. Whereas these programs may not be the only ones that can help move an organization toward its vision, they have worked well to revision, re-educate, regenerate, and recommit the nursing and support staff in one operating unit. The success in implementing the overall program has been the result both of the efforts and support of administration and the response of managers and staff. The organization's values have been put into operation in a way that helps empower staff to change and
SEPTEMBER/OCTOBER1997
grow (see Box 2). A n added advantage is having people from administration facilitate many of the programs, which increases their visibility, availability, and approachability with staff, thus reinforcing commitment to a shared vision.
CONCLUSION In today's rapidly changing h e a l t h care e n v i r o n m e n t , nursing must c o n t i n u a l l y transform itself. For such t r a n s f o r m a t i o n to take place, we need nursing leaders who are willing to commit to a vision of r e l a t i o n s h i p - c e n t e r e d care t h a t includes the following behaviors: team building, participatory decision making, trustworthiness, positive self-esteem, low c o n t r o l needs, trust in self and others, and o p e n ness to explore new programs and gain new knowledge. 7' 8 •
REFERENCES 1. DePree M. Leadership is an art. New York: Doubleday; 1994. 2. Kaiser L. Designing your future (video). Brighton (CO): Brighton Books; 1993. 3. Tresolini CP, the Pew-Fetzer Task Force on Health Profession's Education and Relationship-Centered Care. Relationship-centered care. San Francisco: Pew Health Profession Commission; 1994. 4. Gunden E, CrissmanS. Leadershipskillsfor empowerment. Nurs Admin Q 1992;16(3):6-10. 5. Senge E The leaders' new work: building learning organizations. Sloan Management Rev 1990;32(1):7-23. 6. Barker JA. Future edge: discovering the new paradigms of success. New York: William Morrow & Company; 1992. 7. Kawamoto K. Nursing leadership: to thrive in a world of change. Nurs Admin Q 1994; 18(3):1-6. 8. Porter O'Grady T. Of mythspinners and mapmakers: 21st century managers. Nurs Management 1993;24(4):52-5.
KARREN KOWALSKI is an assistant vice president and a d m i n i s t r a t o r at Women's and Children's Hospital, director of Patient Care Services, and associate professor and chairperson of the Department of Maternal Child Nursing, Rush-Presbyterian-St. Luke's Medical Center, Chicago, III. LAUREL BURTON is chairperson of Religion Health and Human Values, professor of Religion and Medicine, and professor of Health Systems Management, Rush-Presbyterian-St. Luke's Medical Center, Chicago, III. MAUREEN REHWALDT is a research assistant at Rush University, Chicago, III. Kowalski, Burton, and Rehwaldt
223
In a rapidly changing health care environment, nursing must continually transform itself. For this to occur, nursing leaders must be willing to commit to a vision of relationship-centered care that includes the behaviors of team building, participatory decision making, trustworthiness, positive self-esteem, low control needs, trust in self and others, and openness to explore new programs and gain new knowledge.
M
ax DePree described leadership as an art, ~and as in most forms of art, it is also committed work. This committed work of leadership is at the heart of this article. Faced with the task of leading their nursing staffs--and others--through the myriad of changes facing health care in the last years of the twentieth century, nurse leaders must build a new vision of the health care enterprise and nursing's role for the twenty-first century. Because nursing leadership is faced with the task of creating nursing services and education that will flourish in the twenty-first century, Leland Kaiser, the well-known health care futurist, has said, "We can create our future by choosing what we focus on. ''2 One vision for nursing leadership focuses on creating a healing place for staff as well as for patients and families. To create this type of healing environment, it is necessary to
Nurs Outlook 1997;45:220-3. Copyright © 1997 by Mosby-Year Book, Inc. 0029-6554197155.00 + 0 3511184214
220
Kowalski, Burton, and Rehwaldt
have constructive, productive, accountable, and humanistic relationships within the health care team. Such relationships and their impact on patient healing have been described by the Pew-Fetzer Task Force in a document entitled "Relationship-centered Care. ''3 In most facilities, numerous relationship conflicts exist. These conflicts may be between doctors and nurses, nurses and administration, nurses and other nurses, nurses and other health care providers, or nurses and patient families. A clear goal of relationship-centered care is to promote positive encounters and to diminish negative interactions among health care providers and recipients. Realization of this goal eliminates "grousing," gossiping, blaming, and making other team members wrong. Relationshipcentered care helps caregivers focus on their purpose for working in a given specialty or setting: providing quality care to patients. It creates a positive, supportive, and nurturing environment. Consequently, interactions between staff members and patients
and families in crisis look quite different, with staff members being less likely to react negatively to patients and families and to label them as "difficult" or "out of control." Staffmembers are also more likely to search for solutions to problems when relationship-centered care is used as a model. This enables patients and families to focus their energy on coping and healing and to leave the health care facility without additional psychological baggage such as anger or negative judgments about their treatment. To this end, all provider-patient interactions must be therapeutic. A goal such as this requires additional interpersonal skills and personal insight on the part of the staff. It requires the transformation of staff interactions.
A clear goal of relationshipcentered care is to promote positive encounters and to diminish negative interactions among health care providers and recipients. This transformative restructuring of staff relationships requires four phases: revisioning, reeducating, regenerating, and recommitting. The task of nursing leaders is to help nursing staff re-vision their relationship-centered roles vis&-vis the changes in health care; to reeducate staff members, giving them tools that are immediately accessible for use in achieving and fostering these new roles; to regenerate a sense of purpose, including elements of pro-
VOLUME 45 • NUMBER 5
NURSING OUTLOOK
ductivity, innovation, and "creating value"; and finally, to help staff members recommit themselves to the values of the profession. Three separate but related programs were offered to the staff members of one division in an academic medical center. Each program is related to one of the first three phases. The rccommitrncnt phasc is a continuing process.
REVISIONING The program for the revisioning phase, called "Navigating Change," explores one view of what is happening in health care and the vision of how staff members in one given specialty area can address these changes most effectively. N a v i g a t i n g Change is a 2-day program (lasting approximately 10 hours each day) that explores the dynamics of change, personal responsibility, and teamwork. This program is open to all staff members, from those in housekeeping to physicians. It concludes with an opportunity to "break through" personal and professional obstacles that stand in the way of successfully coping with change. Participants learn about effective personal and team strategies such as collaboration and goal setting through a variety of games and group exercises. Several experiential learning activities exemplify the business dimensions of health care and the importance of cooperation as opposed to intra-organizational competition. During the debriefing period after the games and exercises, participants explore personal learning and team learning. Each person is introduced to "The Rules of the Game" (Box 1). These basic agreements provide a structure for interpersonal relationships. Each employee also agrees to a "Commitment to the Team to Realize a Best Practices Culture" (Box 2). The four areas of best practices reflect the values of the institution and constitute demonstrations of these values. Staff evaluations of this program suggest that it is helpful in the revisioning phase: "We have more tolerance for diversity of opinions; there is less gossiping and less blaming; coworkers are more caring and friendlier." RE-EDUCATING Once staff members become familiar with the new vision through the Navigating Change program, the work of aligning behaviors with the vision begins. The "ArtNURSING OUTLOOK
1. 2. 3. 4. 5. 6.
7. 8. 9. 10. 11. 12. 13.
Be willing to support (name of hospital) game, purpose, rules, and goals. Speak supportively. Correct supportively. Acknowledge whatever is being communicated as true for the speaker at that moment. Complete your agreements. When a problem arises, first use the system for corrections. Then communicate the problem with alternative solutions to the person who can do something about the problem. Be effective and efficient. Optimize every event. Create more with less. Work smarter, not harder. Have the willingness to win and to allow others to win. Focus on what works. When in doubt, check out feelings. Agree to disagree until reaching consensus. Tell the truth from the point of personal responsibility.
works Core Course" is used because it provides a powerful framework that can be used by each staff member to view how this new vision relates to her or him personally and corporately. Furthermore, staff members can explore the actions that are needed to enable this vision to become a fuller reality. The Core Course lasts approximately 21/2 days (24 hours) and is based on a model that focuses on principles of acceptance, responsibility, trust, and the ability to take c o m m i t t e d a c t i o n (B. Adamski, personal communication, 1995). The course facilitators help re-educate participants about how their own sense of purpose and the needs of relationship-centered care can come together. Often staff members reframe current views of reality (i.e., alter perceptions and beliefs) so that they can imagine new possibilities, rather than remaining "stuck" or limited by fears and anxiety. Each participant has the opportunity to speak about her or his purpose, desired outcome, fears, obstacles, and so forth. A series of presentations and exercises inform and underscore the learning. An example of one part of the content is the "Spoken Frames of Action" (Box 3). It is theorized that people in general and people in health care specifically spend more time focusing on emotional themes (the right column in Box 3) rather than on potential solutions or paths to solutions (the left column in Box 3). People can get "stuck" in their opinions, positions, reasons, interpretations, perceptions, or judgments. The potential for relationship-centered care is greatly enhanced when people move from
SEPTEMBER/OCTOBER1997
being stuck to seeing new possibilities and from speaking about one's purpose rather than one's position, what one promises to do rather than one's reasons for what one has done, and one's requests of another rather than one's interpretation of the other's behavior. Focusing on the purpose for being in the work setting rather than taking "positions" or making judgements about others supports a different perspective. Making commitments to process and outcomes rather than believing that others are wrong because of their differing points of view constitutes a significant shift in behavior. One participant commented after the core course, "I am now more open to change and have more opportunities to grow and practice new skills."
REGENERATING Nursing, by definition and practice, has become a "generative" profession; that is, nurses seek to generate competence in their patients and themselves and create value and new learning through their work. Maintaining this generative focus can be difficult for nurses, especially during times of downsizing. Much of this focus is reclaimed through the revisioning and re-educating phases of our approach. It is the task of the regenerating phase, through the "Vision in Action" and "Leadership" programs, to consolidate these phases and foster them in day-to-day practice by providing monthly meetings among staff and administration. One or both of the monthly sessions are open to everyone who has completed Navigating Change and the Artworks Core Course. Kowalski, Burton, and Rehwaldt
221
As individuals, we make a difference. Those of us involved in the provision and delivery of health care commit ourselves to a team effort with our co-workers and with the institution to live out the values of the institution to create a "best practices" culture and community where people are expected and empowered to make a difference.
Excellence We continually improve the way we administer services to ensure the highest quality patient care, education, research, and community service. • I will work to anticipate the needs of those people I serve. • I will work continuously to search for ways to improve the services I provide. • I will work hard and make an extra effort to be sure the right job is done right. • I will take pride in my work. Compassion We treat all people in a caring way, with respect and dignity. • I will always act in a courteous way toward patients and co-workers. • I will recognize and use the contributions of people from diverse backgrounds. • I will show respect for the feelings and concerns of others. • I will honor the privacy and confidence of others. Social Responsibility Obligation to serve is appropriately linked and balanced with responsible stewardship of resources. • I will confront bias and intolerant behavior when I see it. • I will act in keeping with the mission and values of the institution. • I will find ways to personally contribute to the well-being of the greater community. • I will find ways, in my own work, to manage material resources responsibly. Faith in Self and Others We believe in each person's ability and willingness to work together to do what is right. • I will demonstrate a strong sense of ethics in my work. • I will develop and sustain cooperative relationships. • I will not blame others. • I will focus on solving problems, not making others wrong.
Possibilities Purpose Promises Requests Declarations Commitment
Opinions Position Reasons Interpretations Perceptions Judgments
The Vision in Action and Leadership programs provide the necessary coaching, open communication, and positive reinforcement needed to continue work on the promises made and shared during the Core Course. Usually a particular topic related to the information, methodology, or promises made during the Core Course is addressed. The discussion is lively and free-wheeling, as the professional (and sometimes personal) relationships of the participants become the topics or projects presented by group members 222
Kowalski, Burton, and Rehwaldt
for review and intense work. Both support and confrontation are part of this process, but the atmosphere is always respectful and focused on learning. One person who said she had difficulty being direct with a challenging co-worker promised to seek coaching to support her desire to be clear and direct with this coworker and then follow through and report back. She used the "Leadership" session as a way of gaining additional support for changing her behavior and also began to learn how to move the interactions between herself and her co-worker in a more positive direction for both of them. The Leadership program has the additional feature of being intentionally supported by a core group of unit directors who, along with staff members, have each chosen to work on a particular project. Participants use the monthly Leadership meetings to review progress, to provide feedback regarding the status of these projects, and to get new ideas for ways to approach ob-
stacles that block the project's success. Staff members report that these sessions offer a place to talk about what is and what isn't working as they seek to become more relationship focused. These interactions set the stage for constructive feedback via the coaching, teaching, and role-modeling that have been shown to be effective empowerment strategies. 4 As one person explained, "Each of us is a support for everyone else who has attended and a role model for those who have not." The Vision in Action and Leadership programs promote and foster the characteristics exemplified in learning organizations as described by Peter Senge. s Senge suggests that sharing a vision, challenging assumptions, and understanding the interrelationship of problems and causes is essential for building such an organization. It is during this regenerating phase that participants ask again and again, "What do we want to achieve ?" Answers to this question help to build a learning organization
VOLUME 45 • NUMBER 5
NURSING OUTLOOK
in which answers are lived rather than merely discussed.
RECOMMITTING The underlying philosophy of all of these programs is that all people have value and make contributions. To be successful in the future, people in health care must increasingly function as a team. To work closely together, team members must demonstrate mutual respect and support, remain accountable to each other, and promote ongoing innovation and creativity. Joel Barker said, "A leader is a person you will follow to a place you wouldn't go by yourself. ''6 The recommitment of nurses and nursing leadership to the success of the twenty-first century health care enterprise will mean leading staffmembers to a place they wouldn't go by themselves. The emphasis on p o s i t i v e reframing, m a k i n g choices, accountability, and innovation in the context of teams will be increasingly necessary for success. This recommitting process, while important for staff members, is especially important for nursing leadership. That is why unit leaders--each of whom has participated in all aspects of the program described h e r e - - h a v e regular meetings. In these meetings the various methodologies are reinforced through mutual problem solving, shared goal setting, and team learning. Individual coaching sessions are used. Persons choose to become coaches on the basis of interest and demonstrated skill. These nursing leaders are recognized and rewarded for "walking the talk" through such mechanisms as public recognition, written feedback on performance appraisals, and merit increases.
SOME INITIAL RESULTS In 1988 a biannual employee opinion survey was initiated to assess employee attitudes across the medical center. The survey was administered to a majority of employees. Early in 1995 the identified division participated in a "targeted survey" that focused on that operating unit alone. Although only slightly better than a 50% return rate was obtained, the results were interesting when compared with the all-employee survey of 1992 (which included this division as well). First, the employees' assessment of upper management's effectiveness increased from 29% to 61.5%, an increase of 112% over the 1992 survey (significant at p < 0.01 ). Second, staff members in this operating unit indicated that they
NURSING OUTLOOK
were well informed about the division, an increase from 49.2% to 68% (up 58.5% from 1992, significant at p < 0.05). Third, staff members believed that they were involved in job decisions, an increase from 44% to 59.3% (up 34.9%). W h e n the responses of persons in non-nursing job classes were reviewed no significant differences were found in ratings of the work e n v i r o n m e n t , perhaps because the staff f u n c t i o n s more as a team, not as separate, different, and competing groups. Many variables could have influenced attitudes: • In the spring of 1993, more than 800 full-time equivalent positions were cut throughout the entire institution • In the summer of 1993, new leadership for this specific area began work focusing on i m p l e m e n t a t i o n of the aforementioned programs • In 1994, a 5% reduction in work force across the institution occurred • In 1995, another 5% reduction occurred with the new budget year A number of open-ended questions included along with the targeted survey asked staffmembers to describe any changes in their work environment, a content analysis of these responses was done. Whereas 26% mentioned the visible changes ofdownsizing and cutbacks in staff, 29% described an improved relationship among physicians and nurses and between units. In addition, these respondents said that more teamwork and increased communication was taking place and that management was more effective. Ten percent described more visibility and role modeling by management. Because these data are only inferential, a rigorous study of this overall programmatic approach is currently under way. Such an improvement in positive responses from this division in 1 9 9 5 - - after the fourphase program was instituted--compared with the 1992 data is worth further investigation. Whereas these programs may not be the only ones that can help move an organization toward its vision, they have worked well to revision, re-educate, regenerate, and recommit the nursing and support staff in one operating unit. The success in implementing the overall program has been the result both of the efforts and support of administration and the response of managers and staff. The organization's values have been put into operation in a way that helps empower staff to change and
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grow (see Box 2). A n added advantage is having people from administration facilitate many of the programs, which increases their visibility, availability, and approachability with staff, thus reinforcing commitment to a shared vision.
CONCLUSION In today's rapidly changing h e a l t h care e n v i r o n m e n t , nursing must c o n t i n u a l l y transform itself. For such t r a n s f o r m a t i o n to take place, we need nursing leaders who are willing to commit to a vision of r e l a t i o n s h i p - c e n t e r e d care t h a t includes the following behaviors: team building, participatory decision making, trustworthiness, positive self-esteem, low c o n t r o l needs, trust in self and others, and o p e n ness to explore new programs and gain new knowledge. 7' 8 •
REFERENCES 1. DePree M. Leadership is an art. New York: Doubleday; 1994. 2. Kaiser L. Designing your future (video). Brighton (CO): Brighton Books; 1993. 3. Tresolini CP, the Pew-Fetzer Task Force on Health Profession's Education and Relationship-Centered Care. Relationship-centered care. San Francisco: Pew Health Profession Commission; 1994. 4. Gunden E, CrissmanS. Leadershipskillsfor empowerment. Nurs Admin Q 1992;16(3):6-10. 5. Senge E The leaders' new work: building learning organizations. Sloan Management Rev 1990;32(1):7-23. 6. Barker JA. Future edge: discovering the new paradigms of success. New York: William Morrow & Company; 1992. 7. Kawamoto K. Nursing leadership: to thrive in a world of change. Nurs Admin Q 1994; 18(3):1-6. 8. Porter O'Grady T. Of mythspinners and mapmakers: 21st century managers. Nurs Management 1993;24(4):52-5.
KARREN KOWALSKI is an assistant vice president and a d m i n i s t r a t o r at Women's and Children's Hospital, director of Patient Care Services, and associate professor and chairperson of the Department of Maternal Child Nursing, Rush-Presbyterian-St. Luke's Medical Center, Chicago, III. LAUREL BURTON is chairperson of Religion Health and Human Values, professor of Religion and Medicine, and professor of Health Systems Management, Rush-Presbyterian-St. Luke's Medical Center, Chicago, III. MAUREEN REHWALDT is a research assistant at Rush University, Chicago, III. Kowalski, Burton, and Rehwaldt
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