Clinical Nurse Clinical Nurse Leader Workshop: Leader Workshop: Leadership/SystemsLeadership/Systems

Dr. Kia James, EdD, RN, CNLDr. Kia James, EdD, RN, CNL

CLINICAL NURSE CLINICAL NURSE LEADERLEADER

• How did the role come about?How did the role come about?

• What were precipitating What were precipitating factors/studies/reports that helped factors/studies/reports that helped innovate this new role?innovate this new role?

• What is this role supposed to do?What is this role supposed to do?

• Define the roleDefine the role

10 Assumptions for 10 Assumptions for cnl rolecnl role

1.1. Practice at the Practice at the microsystemsmicrosystems level level2.2. Client care Client care outcomesoutcomes are measure of are measure of quality quality

practicepractice3.3. Practice guidelines are Practice guidelines are evidence-basedevidence-based4.4. Client centered practice is Client centered practice is INTRA- and INTER-INTRA- and INTER-

discplinarydiscplinary5.5. InformationInformation will maximize self-care and client will maximize self-care and client

decision-makingdecision-making6.6. Nursing assessment Nursing assessment is the basis for theory and is the basis for theory and

knowledge developmentknowledge development7.7. Good fiscal stewardshipGood fiscal stewardship is a condition of quality is a condition of quality

carecare8.8. Social justiceSocial justice is an essential nursing value is an essential nursing value9.9. Communication technology will Communication technology will facilitate the facilitate the

continuity and comprehensiveness of carecontinuity and comprehensiveness of care10.10.The CNL must The CNL must assume guardianship for the nursing assume guardianship for the nursing

profession.profession.

10 Assumptions for 10 Assumptions for cnl rolecnl role

1.1. Practice at the Practice at the microsystemsmicrosystems level level2.2. Client care Client care outcomesoutcomes are measure of are measure of quality quality

practicepractice3.3. Practice guidelines are Practice guidelines are evidence-basedevidence-based4.4. Client centered practice is Client centered practice is INTRA- and INTER-INTRA- and INTER-

discplinarydiscplinary5.5. InformationInformation will maximize self-care and client will maximize self-care and client

decision-makingdecision-making6.6. Nursing assessment Nursing assessment is the basis for theory and is the basis for theory and

knowledge developmentknowledge development7.7. Good fiscal stewardshipGood fiscal stewardship is a condition of quality is a condition of quality

carecare8.8. Social justiceSocial justice is an essential nursing value is an essential nursing value9.9. Communication technology will Communication technology will facilitate the facilitate the

continuity and comprehensiveness of carecontinuity and comprehensiveness of care10.10.The CNL must The CNL must assume guardianship for the nursing assume guardianship for the nursing

profession.profession.

HEALTH CARE SYSTEMS HEALTH CARE SYSTEMS AND ORGANIZATIONSAND ORGANIZATIONS

• Systems theorySystems theory

• Traditional organizational theoryTraditional organizational theory• HierarchyHierarchy• Scientific managementScientific management

• Traditional role of nursing in health Traditional role of nursing in health care systemcare system

• New theories to attend to growing New theories to attend to growing complexities of health care systemcomplexities of health care system

Mesosystem

Microsystem

Macrosystem

FrontlinePatient

CareUnits

Nursing Divisions

Nursing Services

Example

System Levels

Source: Henriks, Bojestig, Jonkoping CC Sweden

Key functions as a Key functions as a leader in the CNL Role leader in the CNL Role

• Horizontal leadershipHorizontal leadership• Effective use (and knowledge) Effective use (and knowledge) of self in caring and of self in caring and facilitating change for facilitating change for patientspatients

• AdvocacyAdvocacy• Conceptual analysis of CNL Conceptual analysis of CNL rolerole

• Lateral integration of care Lateral integration of care for a unit of care/populationfor a unit of care/population

Leadership Leadership

• Leadership practice at the microsystems Leadership practice at the microsystems levellevel

• Leadership vs. ManagementLeadership vs. Management

• Leadership theories: Leadership theories: • Great ManGreat Man• Situational Situational • Leadership styleLeadership style• Servant leadershipServant leadership• Transformational leadershipTransformational leadership• Complexity science leadershipComplexity science leadership

New ORG Theories for New ORG Theories for health care systemhealth care system

• Learning organization theory Learning organization theory

• Chaos theoryChaos theory

• Complexity science theoryComplexity science theory

• Change theories:Change theories:• Lewin’s force fieldLewin’s force field• Roger’s - Diffusion of innovation modelRoger’s - Diffusion of innovation model• Complexity science – strange attractorComplexity science – strange attractor

• New role for a new organization: CNLNew role for a new organization: CNL• The Clinical Nurse Leader is the frontline The Clinical Nurse Leader is the frontline

change agent in health care organizationschange agent in health care organizations

ORG THEORIES for Health ORG THEORIES for Health care systemscare systems

Learning organizationsLearning organizations•Organizations are living and Organizations are living and thinking open systems that thinking open systems that learn from experience and learn from experience and engage in complex mental engage in complex mental processes.processes.

Theorist: Peter SengeTheorist: Peter Senge

The Learning OrganizationThe Learning Organization

• Adaptive (single-loop) LearningAdaptive (single-loop) Learning• Involves coping with a situation Involves coping with a situation • Limited by the scope of current organizational Limited by the scope of current organizational

assumptionsassumptions• Occurs when a mismatch between action and outcome Occurs when a mismatch between action and outcome

is corrected without changing the underlying values is corrected without changing the underlying values of the system that enabled the mismatch.of the system that enabled the mismatch.

• Generative (double-loop) LearningGenerative (double-loop) Learning• Moves from COPING to CREATING an improved Moves from COPING to CREATING an improved

organizational realityorganizational reality• Necessary for eventual survival of the organizationNecessary for eventual survival of the organization

• Both are central features to the learning Both are central features to the learning organizationorganization

• Synergy and nonsummativity are ImportantSynergy and nonsummativity are Important

The Learning OrganizationThe Learning Organization

• Through communication, teams are Through communication, teams are able to learn more than able to learn more than individuals operating alone. individuals operating alone.

• Leadership is a key element in Leadership is a key element in creating and sustaining a learning creating and sustaining a learning organization.organization.

• Leaders are responsible for Leaders are responsible for promoting an atmosphere conducive promoting an atmosphere conducive to learningto learning

• CREATIVE TENSIONCREATIVE TENSION

New Directions in Org New Directions in Org theories for health caretheories for health care

Chaos theoryChaos theory• Every complex system has a life of its Every complex system has a life of its own, with its own rule book.own, with its own rule book.

• Change is normal – chaos is part of Change is normal – chaos is part of change – look for the patterns that change – look for the patterns that emerge out of the chaosemerge out of the chaos

• FractalsFractals

Theorists: Fritjof CapraTheorists: Fritjof Capra

New Directions in Systems New Directions in Systems ThinkingThinking

Organizations as Complex Adaptive Systems Organizations as Complex Adaptive Systems aka Complexity Science Theory – Leadership aka Complexity Science Theory – Leadership and the New Science (Wheatley, 2006).and the New Science (Wheatley, 2006).

• Organizations are adaptive, living organisms with a life Organizations are adaptive, living organisms with a life of their ownof their own

• Not predictable yet adaptableNot predictable yet adaptable

• Complex systems are self-organizing.Complex systems are self-organizing.

• Small changes can have big effectsSmall changes can have big effects

• Relationships are all there isRelationships are all there is

• Information is the life force of any organizationInformation is the life force of any organization

• It is normal for organizations to grow, die and reinvent It is normal for organizations to grow, die and reinvent themselvesthemselves

• A static organization is a “dead” organizationA static organization is a “dead” organization

Lewin’s change theoryLewin’s change theory

Force Field Force Field AnalysisAnalysisBegin change by analyzing Begin change by analyzing the entire system in the entire system in order to identify the order to identify the forces for and against forces for and against the change: driving & the change: driving & restraining forcesrestraining forces

Need to add driving Need to add driving forces or remove forces or remove restraining forcesrestraining forces

Change ModelChange ModelUnfreezingUnfreezingChangeChangeRefreezingRefreezing (Lewin, 1951)

Rogers’ (1995) Diffusion of Innovation

Stages of adoption:

Awareness - the individual is exposed to the innovation but lacks complete information about it

Interest - the individual becomes interested in the new idea and seeks additional information about it

Evaluation - individual mentally applies the innovation to his present and anticipated future situation, and then decides whether or not to try it

Trial - the individual makes full use of the innovation

Adoption - the individual decides to continue the full use of the innovation

Roger’s Diffusion of Roger’s Diffusion of Innovation ModelInnovation Model

Positive Deviance• Identifies change process by looking at the solution first then designing the change process around success• Define• Determine• Discover• Design

• Answers the question:• What enables some members of the community (the “Positive Deviants”) to find better solutions to pervasive problems than their neighbors who have access to the same resources?

Fixed Solution Space

Traditional

Flows from problem analysis towards solution

Expanded Solution Space

PD

Flows from identification and analysis of successful solution to problem solving

Actual Problem

Parameters

Actual Problem

Parameters

Actual Problem

Parameters

Perceived Problem

Parameters

Perceived Problem Parameters

Perceived Problem

Parameters

Traditional vs PD Problem Solving Approach

• Basic “building block” Basic “building block” of health care as a of health care as a system.system.

• Unit of clinical Unit of clinical policy-in-use.policy-in-use.

• Locus of most workplace Locus of most workplace “motivators” and many “motivators” and many “demotivators”“demotivators”

• Most variables relevant Most variables relevant to patient satisfaction to patient satisfaction controlled here.controlled here.

• Where “good value” and Where “good value” and “safe” care are made.“safe” care are made.

• Where most health Where most health professional “formation” professional “formation” occurs after initial occurs after initial preparation.preparation.

• It’s the front lineIt’s the front line

• It’s where It’s where everything everything happenshappens with, to and for with, to and for the patient and familythe patient and family

2020

why focus on the why focus on the “clinical microsystem?”“clinical microsystem?”

•PurposePurpose

•PatientsPatients

•ProfessionalsProfessionals

•ProcessesProcesses

•PatternsPatterns

2121

The CNL Can assess the The CNL Can assess the Clinical Micro-system with the Clinical Micro-system with the

“5 P“5 Pss””

Nelson, Splaine, Godfrey, et al, JQI, Dec. 2000.

HEALTH CARE QUALITYHEALTH CARE QUALITY& Patient safety& Patient safety

• Institute for Healthcare Improvement Institute for Healthcare Improvement (2004) Patient Safety Initiative(2004) Patient Safety Initiative

• Apply methods and tools of industrial Apply methods and tools of industrial quality improvementquality improvement

• Process improvement and team problem Process improvement and team problem solvingsolving

QualityQuality

• Must be defined & measuredMust be defined & measured

• Is a moving target - must always be Is a moving target - must always be currentcurrent

• Provides a competitive edgeProvides a competitive edge

• Doing things “right” the first timeDoing things “right” the first time

• Focus on results - outcomesFocus on results - outcomes

• Must be strongly embedded in cultureMust be strongly embedded in culture

• Must be linked to costsMust be linked to costs

Quality ImprovementQuality ImprovementIOM Report (IOM Report (Crossing the Quality Chasm) Crossing the Quality Chasm) recommends six dimensions as potential themes recommends six dimensions as potential themes for quality improvement:for quality improvement:

1.1.SafetySafety

2.2.EffectivenessEffectiveness

3.3.Patient-centerednessPatient-centeredness

4.4.TimelinessTimeliness

5.5.EfficiencyEfficiency

6.6.EquityEquity

Quality improvement Quality improvement Tools and TechniquesTools and Techniques

• PDCAPDCA• Plan-Do-Check-ActPlan-Do-Check-Act• Plan-Do-Study-Act (Deming, 1993)Plan-Do-Study-Act (Deming, 1993)

• Other Problem-solving toolsOther Problem-solving tools• Process mappingProcess mapping• Flow chartsFlow charts• Check sheetsCheck sheets• Pareto analysisPareto analysis• Cause and effect diagramsCause and effect diagrams•

PDSAPDSA

AONE: Core Patient Safety AONE: Core Patient Safety Technology CompetenciesTechnology Competencies

• Systems: Process management & process improvement

• Human factors

• Failure Mode Effects Analysis/Root cause analysis

• Safety rounding

• Teaming

• Risk management

Failure mode effects Failure mode effects analysis (FMEA)analysis (FMEA)

• FMEA purpose: Eliminate or FMEA purpose: Eliminate or reduce failures/harmreduce failures/harm• Failure mode – manner in which Failure mode – manner in which failure occurs and is observedfailure occurs and is observed

• Failure effect – consequences of Failure effect – consequences of failure (prioritized by severity)failure (prioritized by severity)

• Root cause analysisRoot cause analysis

• Common cause analysisCommon cause analysis

When Solving When Solving Problems…Problems…

• Focus on prevention, not blameFocus on prevention, not blame

• Realize a cause never stands aloneRealize a cause never stands alone

• A problem description is not analysisA problem description is not analysis

• Start analysis with an impact to the goals not Start analysis with an impact to the goals not the causesthe causes

• Apply the basics of cause and effect, avoid Apply the basics of cause and effect, avoid buzzwordsbuzzwords

• Analyze all - not only problems but success to Analyze all - not only problems but success to determine cause and effectdetermine cause and effect

(Galley, 2007)(Galley, 2007)

Client centered practice is Client centered practice is intra- and inter-disciplinaryintra- and inter-disciplinary

• Effective communication skills – Effective communication skills – listen, listen, listenlisten, listen, listen

• Team coordination and collaborationTeam coordination and collaboration• Delegation and supervisionDelegation and supervision• Interdisciplinary care and roles of the Interdisciplinary care and roles of the health care teamhealth care team

• Group processGroup process• Handling difficult peopleHandling difficult people• Conflict ResolutionConflict Resolution

• Leadership is all about communicationLeadership is all about communication

Social justice Social justice

• An essential value for the CNLAn essential value for the CNL

• Demonstrated through compassion, Demonstrated through compassion, cultural competence, patient advocacy cultural competence, patient advocacy and an understanding of health and an understanding of health disparitiesdisparities

• Support that health is a “right” not a Support that health is a “right” not a “privilege”“privilege”

CNL is the Guardian CNL is the Guardian of the Nursing of the Nursing

professionprofession• CNL role is helping professional nursing to CNL role is helping professional nursing to evolve to a higher level of maturity and evolve to a higher level of maturity and complexitycomplexity

• CNL role helps to maintain focus of all CNL role helps to maintain focus of all activities on patients and their well-activities on patients and their well-being/safetybeing/safety

• CNL role continues to demonstrate that CNL role continues to demonstrate that nursing is more than just a job – it’s a nursing is more than just a job – it’s a vocation vocation

• CNL role exemplifies the responsibility of CNL role exemplifies the responsibility of knowledge workers in an information societyknowledge workers in an information society

ReferencesReferences

• American Association of Colleges of Nursing (2007). American Association of Colleges of Nursing (2007). White paper White paper on on education and the role of the Clinical Nurse education and the role of the Clinical Nurse Leader.Leader. Washington, DC: Washington, DC: American Association of American Association of Colleges of Nursing.Colleges of Nursing.

• Institute of Medicine (2000). Institute of Medicine (2000). To err is human: Building a safer To err is human: Building a safer health systemhealth system. . Washington, DC: National Academy Press.Washington, DC: National Academy Press.

• Institute of Medicine (2001). Institute of Medicine (2001). Crossing the quality chasm: A new Crossing the quality chasm: A new health system health system for the 21st century. for the 21st century. Washington, DC. Washington, DC. National Academy Press. National Academy Press.

• Nelson, E. C., Batalden, P. B. & Godfrey, M. M. (2007). Nelson, E. C., Batalden, P. B. & Godfrey, M. M. (2007). Quality by Quality by design: A clinical Microsystems approach. design: A clinical Microsystems approach. San Francisco: Jossey-Bass.San Francisco: Jossey-Bass.

• Wheatley, M. (2006). Wheatley, M. (2006). Leadership and the new science: Leadership and the new science: Discovering order in a Discovering order in a chaotic worldchaotic world 3 3rdrd ed. San ed. San Francisco: Berrett-Koehler.Francisco: Berrett-Koehler.