Communication is of the utmost importance for effective teamwork, yeteffective communication and overcoming the cultural belief that conflict iskey challenges for leaders. To provide optimal patient care, perioperaleaders should assess the culture in which they work and develop strategisolid credible relationships within their teams.
This article introduces the Complex Adaptive Leadership Model, whichpinnings in complexity science, as a means to promote culture change anproductive conflict. The concepts and relationships presented in this moreal-world situations and provide strategies for leadership and team develop
Myriad issues face any nursetoday’s world. One challenmunication. Everyone on t
tive team wants to be heard; when comost issues usually are related to comor the lack thereof. Health care organno longer function under the traditionthe “machine model,” where standardcontrol are the primary drivers, and ssuccess. Nurse leaders must have a vskills to promote healthy communicatate successful and effective teams, apositive culture changes. The challencurrent environment is that there is nframework for nurse leaders in the fi
This article introduces a new conccalled the Complex Adaptive Leaders(CALM), which clarifies the underpinrelationships among OR staff membemodel is intended to provide supporttance to guide nurse leaders in proactating ongoing changes and creatingthe complex OR environment.
The model illustrates a number ofthe relationships among those concepthree-dimensional framework of interrals that intersect at various points, dspiral ladder, where the concepts actuthe points of intersection. By understcomponents of the CALM, leaders castaff member and physician behaviortions—ranging from early adoption oto complete resistance—and facilitatewhich it is acceptable to agree to disproviding strategies to move key initas culture change, forward. By applyframework in the nursing communityers will have the tool they need to gitions the opportunity to remain compa leadership standpoint during these dtimes.
STATEMENT OF PURPOSEThe motivating force of this work ithe survival of core nursing principthat assist nurses in assessing patiensponses to treatments. As leaders, wallow the impact of nursing to be mbecause of the many constraints faccare. When navigated with confidenCALM is intended to help physiciahealth care personnel evolve as memsuccessful and effective team.
While observing the workings ofvironment, it became clear to me thto make sense of all the complex inrelationships and power struggles thplace in an environment filled with
a multitude of educational backgrounds.
l model,odel
s ofisssis-facili-within
pts andis ang spi-d as a
fuse atg theicipatereac-
iativeslture inwhile
s, suchise lead-
ganiza-e fromlt
nsurehosee-nnotizedealthe
d otherof a
R en-eedediningkele from
dition to hours of observation and t
ing of these observations, I conduct
tivities that resulted in the developm
CALM.
I started by reviewing the literatur
had already been written to explain w
can be so chaotic yet accomplish so
a short time. Then, I conducted a sur
Jefferson Scale of Attitudes Toward
Nurse Collaboration from the Jefferso
College in Philadelphia, Pennsylvaniabaseline measure of the OR environm
the Kirtonch literaturetive) researchme timewas obtainedhD, from thesylvania. Dr
1 with me
model I se-f the variety
d to measureation.
January 2010 Vol 91 No 1 CHADWICK
REVIEW OF THE LITERATUREI conducted a review of the literaturefollowing databases: CINAHL, MEDness Source Premier, PubMed, and Greview was conducted to find literatuplains the way people work togetherbest create a culture that embraces diticularly in a group that comprises mvaried educational levels, from highmedical school. Additionally, my puridentify the best strategies for gettinggroups of people to embrace strategicsuch as the Surgical Care Improvemethat, as an organization, Saint VincenCenter is providing patients with opti
Figure 1. The Jefferson Scale of Attitudperceptions as they related to collabor
retrieved between June 5, 2007, and Se2007, that describe complexity scienceCheese Model,3,4 quantum theory,5 andAdaptation-Innovation Theory.6 Researincludes three correlational (ie, descriparticles2,8,9 that were retrieved in the saframe. The Jefferson Scale2 (Figure 1)in 2007 from Mohammadreza Hojat, PJefferson College in Philadelphia, PennHojat also shared two other articles10,1
related to the Jefferson Scale.
Theoretical LiteratureComplexity science is the conceptuallected to explain the underpinnings o
ward Physician-Nurse Collaboration, which was use
es To
icles3-6 of issues that affect the surgical suite in any hos-
at, as
here
t mus
, ultim
rman
heory
s—th
w the
howl also
ts of
ated i
scie
based
ant m
”7(p4)
t the
orkin
r a th
o mai
epts s
the
ery.
omp
ly be7(p7)
leader
ho, a
of bei
er, lea
l and
tions.
e is m
t bec
tions
aders
een
ring t
t phil
ared
ce he
der the op-aos.plexity sci-eloped by1990.3 The
st complexing theof processas the cumu-just one
series ofer, create ain Swiss
er, if it doesccur), then aough ther).eral safetytionally orms in healthay, seven
rather than how they should behave.”is an incredibly difficult concept for
grasp, particularly for nurse leaders w
cians, hold themselves to a standard
to “control” a clinical situation. Rath
need to let go of the desire to contro
that with the ability to facilitate situa
This concept of complexity scienc
challenge the status quo; leaders mus
comfortable with uncomfortable situa
as facilitating productive conflict. Le
clearly understand the difference betw
tional management theories (ie, adhe
mand, control, and micromanagemen
phies) and complexity science. Comp
traditional thinking, complexity scien
make sense of the chaotic environment tha
the
are a
t occur
ately,
et al,
. It is
e pat-
y are
out-stated,
living
n tradi-
ntific
on the
etaphor
The
health
g with
ird set
ntain
uch as
human
lexity
haveThis
s to
s clini-
ng able
ders
replace
eant to
ome
, such
must
tradi-
o com-
oso-
with
lps
call health care, and it affords the leaportunity to create order out of the ch
A second model that explains comence is the Swiss Cheese Theory, devBritish psychologist James Reason infact that health care is one of the mohuman systems lends itself well to usSwiss Cheese Model for the analysisweaknesses. The model, also knownlative act effect, shows that it is notevent that triggers a catastrophe but asmall events that, when added togethdisaster. The random pattern of holescheese does not often line up; howevline up (ie, a series of small events otrajectory could travel all the way thrcheese (ie, a patient event could occu
Patient events often occur after sevpoints have been violated either intenaccidentally, and the safety mechaniscare are ideally running 24 hours a ddays a week. As Reason pointed out,
In the ideal world each defensivebe intact. In reality, however, theylike slices of Swiss cheese, havingholes—though unlike in the cheeseare continually opening, shutting,their location.4(p769)
Reason’s concern regarding adverse ewho is at fault for the event, but howthe safety mechanisms failed.
The third model to support compleis the principle of quantum theory. Lare able to thrive on the cusp of quanhave the ability to grasp the ongoingin health care as well as energize thoserve. As Porter-O’Grady and Malloc
Quantum theory has taught us thanot a thing or an event but ratherthat is constitutive of the universe.not avoid change since it is everywthey can influence its circumstance
t we consequences.5(p6)
AORN Journal 157
r muentbersy ene, w
it ande coney co
mplextion Tff meto poodyendprefe
with mxity.”
novafor w
tendnk ‘ou
f memse catoplecan b
ient ca
s toolurse perioping thn atteion.”2
particudy wan-nuplex
eir dither g
’s findingsantly moreir physician
by Rileyn the com-eons andearchers usedservations
fferent oper-cated thate instrument
eries inble to loseidentifiedheld inexpe-
ion of thecolleagues.8
ve environ-
f the latitude
en conduct-
ower rela-
aditional,
hips, but
urse interac-
xperienced
ght of thent, whiched to bed be the pre-
of the in-r’s role is tonforce to thes regardlessience. It isin the work
vel increases,h it, so does
tients
January 2010 Vol 91 No 1 CHADWICK
To effectively lead change, a leadebe able to assess the current environmreference to what motivates staff memphysicians. Change is inevitable in anment, so leaders must seize the changit is, not to control it but to managetate the tough dialogues or productivthat need to take place between the kents of an issue.
The fourth model that supports coence is the Kirton Adaptation-Innovawhich allows a leader to “clump” staand physicians into categories relatedsolving skill sets.6 As identified by M“Individuals who are on the adaptivecontinuum tend to be methodical andcise instructions, reporting difficultytasking and increases in work compleConversely,
individuals who tend to be more incognitive style report a preferencecomplexity and a variety of tasks,ate well in a crisis, and like to thithe box.’6(p200)
Leaders can identify colleagues, stafand physicians who fit into each of theLeaders need to understand how the peserve are motivated so that interactionslored to ultimately result in quality pat
Research LiteratureUsing the Jefferson Scale of Attitudechi conducted a study of physician-ntions related to collaboration in the parena.2 Sterchi’s premise for conductwas that perceptions “are important ito understand and improve collaborattotal of 65 physicians and 72 nursesin the study. The aims of Sterchi’s stgain greater understanding of physicilationships and collaboration in a comdiverse setting, as well as examine thperceptions of collaboration and whe
length of experiences, or nursing specialty
158 AORN Journal
st firstwithand
viron-hateverfacili-
flictsnstitu-
ity sci-heory,
mbersroblem-
et al,of ther pre-ulti-
6(p200)
tive inork
to oper-tside
bers,egories.theye tai-re.
, Ster-ercep-
erativee studympting(p46) Aipatedere to
rse re-andfferentender,
fected those perceptions.2(p49) Sterchiindicated that the nurses were significpositive toward collaboration than thecounterparts.2
An ethnographic study conductedet al8 identified power relationships imunication interactions between surgnurses during the surgical count. Resdata collected during 230 hours of obby 11 participating nurses in three diating suites in Australia. Results indinurses used critical thinking during thcount process for small incision surgwhich it would be physically impossian instrument.8(p371) Additionally, anoutcome was that experienced nursesrienced nurses to a stricter interpretatcounts policy than their experiencedMore importantly, from a collaboratiment standpoint,
Surgeons seemed to be unaware o
that nurses afforded themselves wh
ing the surgical count . . . These p
tionships were not limited to the tr
hierarchical nurse-doctor relations
also included hierarchical nurse-n
tions between experienced and ine
nurses.8(p371,372)
These findings are interesting in liconcepts of crew resource managemereinforces that the same checklists neused consistently.1 In the OR, it coulprocedure final time-out or the timingstrument and needle count. The leademaintain a sense of vigilance and reisurgical team the fallibility of humanof the level of competence and experhuman nature to become comfortableenvironment; however, as comfort levigilance starts to slip, and along witpatient safety.
In a case study of the flow of pa
af- through the surgical arena, Fowler et al9 rein-
nd complexted in blue,nce of lead-ed in green.se it is thef ideas
e spiral isLeadershipasses of
en variousional staff.le of genera-a leader’sd providethe strategicBy providingautono-
el that em-e.“The rolelationshipsn emerge
CREATING ORDER OUT OF CHAOS www.aornjournal.org
forced that the OR can be viewed aadaptive system.
In a complex adaptive system, onetions change the context for otherHealth care organizations are comeach having unique histories, cultuprocesses that have evolved over tim
Their study involved observing 96 stemployed in all aspects of surgical setotal of 103 hours. The investigatorsstaff members spent an average of 33per eight-hour shift dealing with defefailures.9(p202) The results of this studthe use of ongoing feedback. The invconcluded, “Leaders are needed whoculture of openness and encourage thof all events—both clinical errors anlated to processes.”9(p206)
FindingsThe research literature added the valumining how to assess OR team dynamthough traditional relationships in heahierarchical in nature and may have bful in the past, hospitals must sustaintive environment with diverse professachieve positive patient outcomes. Ththe literature reveals that complexitythe multitude of theories that supportSwiss Cheese Model, quantum theorytion-Innovation Theory) will providetion for future leadership growth. Hotheories go from very broad in termsenvironment (ie, quantum theory) tolevel (ie, the Swiss Cheese Model) toual level (ie, innovation-adaptation).portant to synthesize these theories ation for the CALM in the perioperati(Figure 2).
CONCEPTUAL DEFINITIONSTo understand the model, it is imporstand the operational definitions of it
� within leadership,� generative relationships, and
� within concept of team,� lens of complexity,� paradox and tension, which in
listening,� multiple actions at the fringes,� situational awareness,� cooperation and competition, a� creative destruction.
In the model, color is used specificforce the combination and fluidity ofnents: culture is depicted in yellow aadaptive system7 principles are depicwhich when combined with the guidaership result in the team being depictLeadership is depicted in gray, becaucement that holds this fluid jumble otogether.
LeadershipOne of the sides, or scaffolding, of ththe leadership of a given department.is defined as the ability to represent mpeople by facilitating dialogue betwelevels of professional and nonprofessThe complex adaptive system principtive relationships is demonstrated byability to set the general direction andepartmental structure that is tied toinitiatives of his or her organization.this structure, staff members functionmously via a shared governance modpowers them to “own” their workplac
As identified by Zimmerman et al,of the leader is to foster generative reand learn from results, letting directio
instead of being set in advance by a central
AORN Journal 159
ngoing
January 2010 Vol 91 No 1 CHADWICK
Figure 2. The Complex Adaptive Leadership Model is a framework to guide nurse leaders in the o
changes in the complex perioperative environment to create order out of chaos.
160 AORN Journal
hat th
partic
leade
pt of
e nee
then
t the
gic g
to lif
ation
litate
ct an
onme
ten, a
maint
righ
nel th
e lea
ect o
base
leade
h can
ironm
archa
o can
depar
epend
ltures
relati
.
ys to
but th
l . . .C
boratleade
buil
eader
ironm
uctive
the compo-: lens ofltiple actionscooperationtion. Thent, alongptive systemlts in thef team iseffective-
nd weak-ledging and
the complexing all oft forward inrganization.
o view one’splexity canre who isent. As pre-l,7 many
achine or athe surgeons,ent depart-challenge
“control”ith traditionalssume every-way. Thiserceiving a
. As leaderstable withlong been
ght down toiterature re-lth care,ne will comeadaptable isy.”7(p25)
s terms, thex and ten-
CREATING ORDER OUT OF CHAOS www.aornjournal.org
authority.”7(p155) The expectation is t
ership structure in this framework is
in nature. One key component to the
aspect of this framework is the conce
leadership. When the leader meets th
those he or she serves, staff members
the entire department forward to mee
ment goals that roll up into the strate
the organization and ultimately bring
mission and vision of a given organiz
Leaders also must be able to faci
ability of the team members to refle
brief on the situations and the envir
within which they all work. Too of
is told he or she is responsible for
department morale. In fact, with the
set, the leader can challenge person
rale is everyone’s responsibility. Th
must first recognize the need to refl
personnel perform as a team from a
standpoint.
CultureThe other side of the spiral, opposite
is the culture of the department, whic
defined as the general tone of the env
it positive, fun loving, negative, patri
portive, or disruptive. The culture als
synonymous with the identity of the
such as independent identity versus d
The ways to change unproductive cu
been discussed in the literature, with
and communication being pinpointed
Pilette stated, “There are many wa
form red-zone and ho-hum cultures,
ping point is at the conversation leve
sation is the gossamer thread of colla
teamwork.”12(p26,p28) It is grassroots
that creates the necessary relationship
that effects culture change. It is the l
and responsibility to create a safe env
which difficult conversations or prod
flict based on honesty and truth can take p
e lead-
ipative
rship
servant
ds of
move
depart-
oals of
e the
.
the
d de-
nt
leader
aining
t skill
at mo-
der
n how
line
rship,
be
ent, be
l, sup-
be
tment,
ent.
have
onships
trans-
e tip-
onver-
ion andrship
ding
’s role
ent in
con-
Concept of TeamThe interconnections of the spiral arenents of the complex adaptive modelcomplexity, paradox and tension, muat the fringes, situational awareness,and competition, and creative destrucfusion of the culture of the departmewith the concepts of the complex adaas facilitated by leaders, is what resuconcept of the “team.” The concept oreally the combination of the leader’sness in identifying all the strengths anesses within the department, acknowassessing the various components ofadaptive system principles, and meldthese together to move the departmenlight of the mission and vision of the o
Lens of complexity. The ability torganization through the lens of combe refreshing to a leader in health catrying to make sense of the environmviously identified by Zimmerman et aorganizations are compared with a mmilitary operation. The variability ofthe patients, the staff members, differments, and more, presents an extremefor individuals who seek to maintainover processes. The basic problem whierarchical thinking is that leaders aone should think and act in the samephilosophy results in staff members plack of respect for their individualityin health care, we need to be comforletting go of control. Health care hasmodeled after the industrial sector, rithe work shifts. As identified in the lgarding the various challenges in hea“Predicting when and where the next ois futile. Learning to be flexible andthe only sustainable leadership strateg
Paradox and tension. In layman’complex adaptive principle of parado
lace. sion means the ability to get comfortable with
AORN Journal 161
musse gry chaot havcus og theinvolv
grow
rtableof ex
chalnd unte conenessing sft usrelati
atile sssue cs: “Her intion ond aln hise situontino allol atta. Theng isnd te
A cauhaveysiciafact,hysicThis
tables toproc
supply costsny time
processthe groupever, thered, frankly,e as the
imately leadsomplex adap-iple actionsbest opera-cess. Staffore open tond workingther thana huge pro-ertain.change, and
cope with,directions atcy leadersf control is aople cannotbut they can
uences.”5(p6)
d facilitateia of the sta-nizations.
ept of situa-involves hu-ours thatithstand
nmentissues in
an connecte to thent. Crewted,
training,
e perfor-
n intense
ct with high-
January 2010 Vol 91 No 1 CHADWICK
uncomfortable environments. Leaderscomfortable embracing conflict becaupainful, so when facilitating especialling conversations, the leader needs nend point in mind. Leaders should foting the issues on the table and lettinpoint reveal itself among the partiesthe conflict, because this is when truehappens for an organization.
The ability of leaders to get comfouncomfortable situations takes yearsand many good mentors. A particularfor leaders is personal introspection astanding their trigger points. As Pilet“With genuine introspection, defensivvantageous as ‘an early internal warnwhich can be used to consciously shiconflict generating posture to one ofbuilding.”12(p27)
The ability to not only diffuse voltions but also get to the core of the iaccomplished with three simple wordunderstand.” There is incredible powsomeone to explain his or her percepevent; it conveys a genuine interest athe angry party to take time to explaiperception, which will help diffuse thand get to the real issue rather than cescalate the negative energy. This alsleader time to regroup from the initiawhile listening to the parties involvedto develop the skill of actively listenito navigating the waters of paradox a
Multiple actions at the fringes.anxiety for many leaders is that theyperception that staff members and phpect them to have all the answers. Inopposite is true; staff members and poften want to be part of the solution.means the leader needs to be comforallowing staff members and physiciancalculated risks, such as piloting new
they relate to throughput, on-time starts, m
162 AORN Journal
t beowth islleng-e an
n get-ended inth
inperiencelengeder-cluded,is ad-
ystem,’out of aonship
itua-an beelp measkingf an
lowsor heration
ue tows theck
abilitycritical
nsion.
se ofthens ex-theiansalsowithtakeesses as
ment of inventory, and negotiation ofwith vendors. The challenge is that asomeone takes a risk, the chance of afailing or not working quite the wayexpected is part of that equation; howis much to be learned from failure anthe final solution to an issue may comresult of a failed intervention that ultto an effective solution. This is the ctive system principle known as “multat the fringes.”7 The concept can betionalized as piloting a project or promembers and physicians are much mpiloting something on a small scale aout the bugs or changing direction raputting large amounts of energy intocess change when the outcome is unc
The one constant in health care isas challenging as this is for leaders tothe ability to be flexible and changea moment’s notice is a key competenmust develop. The ability to let go okey quality of successful leaders. “Peavoid change, since it is everywhere,influence its circumstances and conseqThe ability of leaders to recognize anchange rather than feed into the inerttus quo will result in successful orga
Situational awareness. The conctional awareness is multifaceted andman factors such as extended work hcause fatigue, ability or inability to wstress, and being aware of the enviroaround us and comfortable addressingthat environment as they arise. One cthe components of complexity sciencpremises of crew resource managemeresource management, as Oriol indica
uses techniques of simulation, team
interactive group briefings, and th
mance improvement process with a
focus on how human factors intera
anage- risk and high-stress environments.1(p402)
nt exfor a
se anery intifiedefore
at alld estaion.”1
n thre
ch anEPPe Perof therenese teammemonce
and Qexityour cleademutuaders
le tors theave aus thehalle
ay beerna
rogrent? Aawareedgework
nothat leaorkpetit
to, cooperate,provoked to
, tough andcouragecooperationve forward.
in conflict, ity has 10atus. Thisen rooms;sthesia carech OR mustete in thehe 10 roomsor any nursesment of per-een nurseswhich he or
t the leaderadaptive
oster ac-ation that
ex adaptiveon is veryrs. There aresses thatcare system.ay be the
ace. As Zim-
ve destruc-g systemso rigid,responsivenity (or
ction at mynal time out
of surgery.erceived thaty when, in
CREATING ORDER OUT OF CHAOS www.aornjournal.org
The surgical time out is an excelleof situational awareness and the needvolved in the surgical procedure to umunicate their perception of the surgthey are about to participate. As idenPatterson, “The briefings, held right bincision, are an expanded time-out thteam to check critical information anand atmosphere of open communicatAgain, communication is the commoven through this concept.
The Agency for Healthcare Researity introduced the concept of TeamSTTeam Strategies and Tools to Enhancmance and Patient Safety). The goalkit was “to encourage situational awacommunication by all members of thto foster mutual respect among teamregardless of their roles.”14(p20) The cthe Agency for Healthcare Researchidentified can be supported by compland complex adaptive systems. The fments identified by Clancy are teamsituational monitoring or awareness,port, and communication.14 Nurse leahave situational awareness and be abup and advocate for the staff membeIn times of high census, do leaders hspot of the total number of beds versnumber of staffed beds? Do leaders cadministration that nurse retention mproved by implementing a shared govmodel of leadership that includes a pclinical ladder program of developmetionally, leaders must use situationalassess staff member fatigue, acknowltion, and not ask exhausted nurses totional shifts.
Cooperation and competition. Acomplex adaptive system principle thmust be able to master in this framewbalance between cooperation and com
one who knows how to, and prefersbut is also a skillful competitor whencompetition (that is, a nice, forgivingclear person).”7(p42) The ability to enhealthy competition intertwined withis essential for the organization to moAlthough this concept appears to bereally is not. For example, our facilitORs “competing” for on-time start stprovides a level of competition betwehowever, the nurse, scrub person, aneprovider, and surgeons assigned to eacollaborate with one another to compbigger entity to determine which of thas consistent on-time starts. A key fleader is to establish a baseline assesceptions related to collaboration betwand physicians in the organization inshe works. This evaluation will assisin determining which of the complexsystem principles to implement and fcording to the baseline level collaboris assessed.
Creative destruction. The complsystem principle of creative destructithreatening to all health care providemany entrenched behaviors and proceprotect the sacred cows of the healthThe concept of creative destruction mmost challenging for leaders to embrmerman et al indicated,
In human organizations, the creatition phase may require dismantlinand structures that have become tohave too little variety and are notto the current needs of the commumarket).7(p174)
A good example of creative destrufacility is the implementation of the fiprocess immediately before the startThe challenge was that all surgeons pthey were doing the time out correctl
ld be fact, some did not participate at all. We hung a
AORN Journal 163
-outrlineil allteres
lievedtice. Tn anthat tiewswas
e finaisionis ising m
disrup
ATIO
physrticipinitia
baseleveliansJefferand ctweenshingof cosoug
ng hathan
sicianationg.
omple allre inse, I mthe u
anesthesiadoing a good
diverse edu-, which leadse event (eg,
essionalsis correct toof the de-
open
as compara-on Scale ofs the differ-on 15 vari-ollaboration.res of thecores of thetest.
ff and con--bed com-sylvania.esiologists,
ence sampler OR, and
well as sur-erson Scale54 RNs, 61
ho comprised2007.
nnel had tor OR, or
esiologiststhrough the
k. The sur-
January 2010 Vol 91 No 1 CHADWICK
poster in each OR with the final timements and used the analogy of the aithat the case could not “take off” untelements of the time-out were met. Insome surgeons were outraged and bewas a huge mockery of medical pracgeons were then asked if they were oplane, would they not want to knowwas consistency in what the pilot revthe plane takes off? The compromiseall surgeons actively participate in thout and have them be part of the revfinal time-out posters in each OR. Thample of creative destruction: somethneeded to happen as the catalyst forstatus quo.
PHYSICIAN-NURSE COLLABORSURVEYA challenge for any leader is gettingand staff member buy-in or active pathe day-to-day operations and qualityTo do this at my facility, I needed aderstanding of the perception of the llaboration between nurses and physicperioperative arena. I discovered theScale as part of my literature reviewto measure levels of collaboration beand physicians. In addition to establiline understanding of the perceptionstion between physicians and nurses, Idetermine whether nurses in this settidifferent attitude toward collaborationcians. I also sought to determine phyceptions on building collaborative relwith nurses in the perioperative settin
AssumptionsIt is the leader’s role to use various cadaptive system principles to facilitatof communication and delivery of cagical environment. That being the cathe following assumptions related to
the Jefferson Scale:
164 AORN Journal
require-industryof thetingly,
thishe sur-
air-herebeforeto havel timeto thean ex-ajorting the
N
icianation intives.
ine un-of col-in thesonhose itnurses
a base-llabora-ht tod aphysi-
s’ per-ships
exaspectsthe sur-
adese of
� Professional nurses, surgeons, andcare providers all place value onjob at caring for patients.
� The above entities all come fromcational and training backgroundsto varying perceptions of the sama surgical procedure).
� Although all of these diverse profmay have the knowledge of whatdo at any given time, the culturepartment may inhibit effective andcommunication.
DesignThe type of research design I used wtive-descriptive in nature. The JeffersAttitudes tool examines and describeences between physicians and nursesables related to their perceptions of cThe results showed the individual scorespective groups. Additionally, the stwo groups were compared using a t
Population and SampleThe population I drew from is the statracted physicians who work in a 380munity hospital in northwestern PennThis population includes RNs, anesthand surgeons.
Sampling MethodThe investigation included a conveniof nurses from the OR, cardiovasculapostanesthesia care unit (PACU), asgeons and anesthesiologists. The Jeffand a cover letter were distributed tosurgeons, and 11 anesthesiologists wthe main users of the OR in October
Sampling CriteriaAn inclusion criterion was that persobe members of the OR, cardiovasculaPACU staff to participate. All anesthwere included because they all rotatemain OR as part of their normal wor
geons surveyed were those who had used the OR
s thaN anR sue the
tsval frint JoHealtinvepleteants wof theinvestat wage, p
ich aponducs, aneralincludse 1
re resom Dt leashe fond exof ad item
ith ts co
the se scoee �
d o t4, str
of a
an-nurse
formation onpal investiga-dual whostatisticiandata as they
e statistics
ng a two-stics soft-
to assesstudied. Thed gender,spondentsing respon-surveys sent
n 83.3% re-to physicians4 were re-hysician’sresults be-ompleted.ing groups
n 12 of thepondents,
of the 24d 14 of thethe 15 ques-
uctions, thesed to fill in
ian domi-ant differ-39). With, there alsothe twoeal that there
CREATING ORDER OUT OF CHAOS www.aornjournal.org
in the previous 12 months. The groupspecifically excluded were certified Rtists, the surgical technologists, the Ostaff members, and schedulers becauswas specific to RNs and physicians.
Protection of Human ParticipanThe required documentation of approinstitutional review boards at both SaCollege of Maine and Saint Vincentter was obtained to proceed with thistion. Completion of the tool was comuntary, and the anonymity of participmaintained. Participants’ completionimplied consent to participate in theThe only demographic information thquested (ie, optionally) was gender, asion, and specialty.
SettingThe setting was an 11-bed OR at whmately 6,500 surgeries per year are cthe fields of neurosurgery, orthopedicripheral vascular, open heart, and genThe PACU staff members also werePACU consists of 10 bays where phaery takes place.
MeasurementI used the Jefferson Scale to measubased on the following directives frjat. The respondents must answer a(80%) of the 15 items; otherwise, tshould be regarded as incomplete afrom the data analyses. In the casedent with three or fewer unansweremissing values should be replaced wmean score calculated from the itempleted by the respondent. To scoreitems, numbers 8 and 10 are reversstrongly agree � 1, strongly disagrother items are directly scored baseLikert values (ie, strongly agree �
disagree � 1). The score is the sum
item scores. The higher the score, the m
t wereesthe-pportsurvey
om theseph’s
h Cen-stiga-ly vol-
astool
igation.s re-rofes-
proxi-ted in
d pe-surgery.ed; the
recov-
ponsesr Ho-
t 12rmcludedrespon-
s,hem-calered (ie,4); the
heironglyll
positive the attitude toward physicicollaboration.
Data Collection and ProceduresThere was no personal identifying inthe surveys that could lead the princitor or anyone else back to any indiviparticipated in this investigation. Theand I double-checked the spreadsheetwere entered into Minitab15 to run thon the data.
Data AnalysisStatistical analysis was conducted usisample t test and Minitab as the statiware. Descriptive statistics were usedthe demographics of the population sdemographics included profession anrespondents by profession and age, reby specialty and profession, and nursdents by educational level. Of the 54out to RNs, 45 were completed for aturn rate. Of the 72 surveys sent out(ie, surgeons and anesthesiologists), 2turned for a 33.3% return rate. One psurvey had to be eliminated from thecause fewer than 12 questions were c
Of the total respondents, the followanswered fewer than 15 but more thasurvey questions: of the 45 nurse resone answered 14 of the 15 questions;physician respondents, three answere15 questions and one answered 13 oftions. Therefore, per Dr Hojat’s instrmean of their remaining scores was uthe unanswered questions.
FindingsWith respect to perceptions of physicnance (Figure 3), there was a significence between the two groups (P � .0respect to nurse autonomy (Figure 4)was a significant difference betweengroups (P � .001). These results rev
ore is a statistically significant difference between the
AORN Journal 165
nursecare abeliein pa
ns do
nd teferenes leacticeterpag (Fi
physisult ielieve
ial and edu-
he percep-ans andortant firste best courseprocess. Thischallenge ofolder nursesiarchal or
was an thehysicllabor
statind phent w
ork—Therethat nursesice environ-, which is notre socialized
There wasindicating
ed thatial and
January 2010 Vol 91 No 1 CHADWICK
nurses and physicians with regard tovolvement with decisions on patienticy development, meaning the nursesstrongly that they should be involvedand policy decisions and the physiciashare that same sentiment.
With respect to shared education a(Figure 5), there was a significant dif.001). This result means that the nurstoward embracing a collaborative praronment than do their physician coun
With respect to caring versus curinthere was no difference between theand nurse groups (P � .234). This rethat both the physicians and nurses b
Figure 3. Physician dominance—theresignificant difference in opinion betweegroups about whether the role of the pshould be authoritative in nature or co
Figure 4. Nurse autonomy—There was asignificant difference between nurses’ aopinions with regard to nurses’ involvem
decisions on patient care and policy developm
166 AORN Journal
s’ in-nd pol-vetientnot
amworkce (P �
n moreenvi-rts.gure 6),cianndicates
that
nurses positively affect the psychosoccational needs of patients.
Summary of FindingsEstablishing baseline data related to ttion of collaboration between physicinurses in the surgical arena is an impstep for nurse leaders to determine thof action in the change managementgeneration of nurse leaders faces thebridging the generation gap betweenand physicians, who may have a patr
twoianative.
sticallyysicians’ith
Figure 5. Shared education and teamwwas a significant difference indicatinglean more toward a collaborative practment than their physician counterpartssurprising based on how both groups ain health care.
Figure 6. Caring as opposed to curing—no difference between the two groups,that both physicians and nurses believnurses positively affect the psychosoc
ent. educational needs of patients.
the yo beject ag thenderl
ons tomber
wershou
n comsurveose inons’sentmay-antiIn adthis sfor thfact wts aners.
THE
fromflict iomplenflictramewewontrolrgani
embearede wejectivtionleadeonal.
urselvesgood of the
is that it istested and
, no researchmework;support its
pinning forr nurses new
teams withd leaders,ams toplementingractice
y of thiser, whetherations for hisp.ing thisutcomes ofompliancen. Data fromProjectApril 2006
%,
rs—93%,at 6 AM on
nts—50%.
e fall ofoutcomes
t compliancen accordings Surveil-riod from
CREATING ORDER OUT OF CHAOS www.aornjournal.org
hierarchical view of health care, andgeneration, which expects everyone tas equals. The completion of this proin formulating the CALM by revealinsity within the group as well as the uconflicts.
LimitationsThe following were potential limitatiinvestigation. The short-stay staff mework in the preoperative holding areavertently excluded, and future studiesclude this group in the sample size. Icating directions on how to send thesurgeons, it was not made clear to ththat the return envelopes on the surgeneeded postage added, and they werewithout postage. The lack of postagepartially accounted for the lower-thanreturn rate for the surgeons’ surveys.to being the principal investigator inI am also the administrative directorcardiovascular OR, and PACU. Thislined in the letter to all the participanhave influenced the participants’ answ
ASSUMPTIONS THAT SUPPORTMODELAn assumption that is a radical shifttional thinking is that productive conbad and should be embraced in the ctive system. The ability to manage cotively is what causes growth in this fAn additional assumption of this framthat leaders, by giving up personal coally gain more power to move their oforward. Therefore, the more staff mphysicians are empowered through shnance philosophies, the more effectivcome as leaders. The ability to be obfacilitating dynamics is a key assumpframework, and holding oneself as ahigher level of objectivity is not opti
necessary to have the skill set to recognize
oungertreatedssisteddiver-
ying
thiss whoe inad-ld in-muni-
y out tovolvedsurveysouthave
cipatedditiontudy,e OR,as out-
d may
tradi-s notx adap-effec-ork.
rk is, actu-zationsrs andgover-be-e whenof thisr to aIt is
own biases and be able to look past oto the bigger picture and the greatersituation.
LIMITATIONS OF THE MODELA major limitation of this frameworknewly introduced and will need to befine-tuned as it evolves. Additionallyhas been conducted related to this fraresearch will need to be conducted toreliability and validity.
IMPLICATIONS FOR PRACTICEThis model can be used as the underleadership orientation, specifically foto leadership and the interdisciplinarywhich they work. For the experiencethis framework can be used to take tehigher-level achievements, such as ima shared governance or professional pmodel of care delivery. The flexibilitframework is that it provides the leada novice or an expert, with the foundor her continued journey in leadershi
One may question the effect of usmodel on quality initiatives such as oSurgical Care Improvement Project cand incidence of surgical site infectioan initial Surgical Care Improvementbaseline assessment at my facility forto June 2006 were as follows:
� antibiotics within one hour—93.8� antibiotic selection—96.1%,� antibiotics discontinued in 24 hou� glucose level less than 200 mg/dL
postoperative day 1—96.4%, and� normothermia for colorectal patie
The CALM was implemented in th2007 at my facility, and we measuredof Surgical Care Improvement Projecand incidence of surgical site infectioto the National Nosocomial Infectionlance system during the three-year pe
our 2006 to 2008 (Figure 7). Saint Vincent Health
AORN Journal 167
, withCareo comal intionent Hrs forr 200ata.
Nave mre of
mall piecether thanact as judge,words may
e culturesthe onlythis frame-schools, itat a certainhypercritical
nt healthnot be toler-
ical CareProject
on measureate andinfectionmeasured byosocomial
rveillance), at Sainth Center,
the firstdar yearhroughr calendar08).
January 2010 Vol 91 No 1 CHADWICK
Center was in the top 10% nationally98.36% compliance rate for Surgicalprovement Project outcomes related tquality score and total cost by hospitHospital Quality Incentive Demonstra(Figure 8).16 Additionally, Saint VincCenter was one of the low cost leadeyear from October 2007 to Septembewas an improvement from baseline d
IMPLICATIONS FOR EDUCATIOThis framework has the potential to hramifications in education for the futu
Figure 8. Data taken fromCenters for Medicare& Medicaid Services,Premier, Inc. The whitedots represent the 223hospitals that participatedin the Hospital QualityIncentive DemonstrationProject; the blue dot isSaint Vincent HealthCenter. The upper rightcorner of this graph is thetop 10% in highest qualityand lowest cost leading tothe best value for the
patient.
168 AORN Journal
aIm-posite
theProjectealththe
8. This
ajornurs-
ing. Too often individuals have one sof information about an event and raseek to understand, these individualsjury, and executioner. Although theseseem harsh, this is the reality of somwithin health care organizations, andway to fix it is to acknowledge it. Ifwork is used in nursing and medicalcan teach prospective practitioners thamount of conflict is healthy, but theenvironment that consumes our currecare system is unacceptable and willated as the norm.
IMPLICATIONS FOR RESEARCHResearch related to testing targeted infrom the various principles of this fraboth alone and in combination with ois certainly necessary. Application ofwork to studies of leadership effectivsettings outside the surgical suite alsosary. These types of studies could adof knowledge related to leadership inand the collaborative practice that res
CONCLUSIONS ANDRECOMMENDATIONSThe CALM integrates traditional theocomplexity science and provides todaative leaders with real-time tools to acultural transformation needed to runOR. This is being presented as a framthe practice of nursing leadership; thesearch will need to be conducted to tability and validity of these conceptswork is a usable model based on myas well as patient outcomes as a resumenting the CALM. This model suppthat dialogue promotes understandingparties in conflict and that the resultastanding promotes trust between diveThis is a trust that is earned betweennary teammates and is based on the fis respect for one another’s opinion amembers are willing to listen and shapoints openly. This leads to a strongebetter patient outcomes. This model rand when leaders promote an environwhich they are comfortable taking onlenging dialogues (ie, productive concan effectively lead change and buildthe perioperative setting.
Editor’s note: CINAHL, CumulativeNursing and Allied Health Literaturetered trademark of EBSCO Industriesham, AL. MEDLINE and PubMed artrademarks of the US National Libra
cine, Bethesda, MD. Business Source is a
ntionsork,other,
rame-in care
eces-he bodyntions
witherioper-in thecessful
rk fore, re-e reli-frame-
rienceimple-the ideaeender-tities.
discipli-at thereat teamew-
ands that ifin
chal-they
ect in
toregis-
ming-isteredMedi-
tered trademark of EBSCO Publishin
MA. Google is a trademark of Googl
Mountain View, CA. Minitab is a reg
trademark of Minitab, Inc, State Coll
Acknowledgements: The author than
lowing individuals for their assistanc
ment of the Complex Adaptive Leade
her daughter, Maggie Trott, who spe
sisting her in counting results of data
the Jefferson Scale investigation; Car
MBA, CSSBB, Lean Six Sigma facilit
Vincent Health Center, Erie, PA, who
with running the statistics; and Janet
RN, DNSc, faculty at a distance, Sain
College of Maine, Standish, Maine, f
couragement and guidance, which al
creation of a workable model.
References1. Oriol MD. Crew resource management:
healthcare organizations. J Nurs Adm. 2406.
2. Sterchi LS. Perceptions that affect physlaboration in the perioperative setting. A86(1):45-57.
3. Reason J. Human factors: a personal pesented at: Human Factors Seminar; FebHelsinki, Finland. http://www.vtt.fi/liitetHFS06Reason.pdf. Accessed August 26
4. Reason J. Human error: models and ma2000;320(7237):768-770.
5. Porter-O’Grady T, Malloch K. QuantumTextbook of New Leadership. Sudbury,Bartlett Publishers; 2003:6.
6. Moody RF, Pesut DJ, Harrington CF. Shospital nursing units: human performanzational system factors that make a diffSaf. 2006;2(4):198-205.
7. Zimmerman B, Lindberg C, Plsek PE. Esights from Complexity Science for Heaers. Irving, TX: VHA, Inc; 2001:4-7, 25155, 174.
8. Riley R, Manias E, Polglase A. Governcount through communication interactiofor patient safety. Qual Saf Health Care369-374.
9. Fowler PH, Craig J, Fredendall LD, Daerative workflow: barriers to efficiency,faction. AORN J. 2008;87(1):187-208.
10. Yildirim A, Akinci F, Ates M, et al. Tuof the Jefferson Scale of Attitudes TowNurse Collaboration: a preliminary stud
asp/Main.aspx?pg�prmSpc&fid�128&pCrumbId�3&prCrumbName�HQID%2%20Quality%20Scatter%20Diagrams&M-C3PIMSTRIS05.Outpatient%2BQuality%2BReporting.0_&subProduct�*-*-1.*Accessed April 27, 2009.
Maureen Melia Chadwick, RN, MBC, is the director of perioperativeSaint Vincent Health Center, Erie, Padjunct faculty member at Penn Sta
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