Clinical Nurse Leader Workshop: Leadership/Systems

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Clinical Nurse Leader Workshop
Leadership/Systems

• Dr. Kia James, EdD, RN, CNL

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CLINICAL NURSE LEADER

• How did the role come about?
• What were precipitating factors/studies/reports
  that helped innovate this new role?
• What is this role supposed to do?
• Define the role

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10 Assumptions for cnl role

• Practice at the microsystems level
• Client care outcomes are measure of quality
  practice
• Practice guidelines are evidence-based
• Client centered practice is INTRA- and
  INTER-discplinary
• Information will maximize self-care and client
  decision-making
• Nursing assessment is the basis for theory and
  knowledge development
• Good fiscal stewardship is a condition of quality
  care
• Social justice is an essential nursing value
• Communication technology will facilitate the
  continuity and comprehensiveness of care
• The CNL must assume guardianship for the nursing
  profession.

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10 Assumptions for cnl role

• Practice at the microsystems level
• Client care outcomes are measure of quality
  practice
• Practice guidelines are evidence-based
• Client centered practice is INTRA- and
  INTER-discplinary
• Information will maximize self-care and client
  decision-making
• Nursing assessment is the basis for theory and
  knowledge development
• Good fiscal stewardship is a condition of quality
  care
• Social justice is an essential nursing value
• Communication technology will facilitate the
  continuity and comprehensiveness of care
• The CNL must assume guardianship for the nursing
  profession.

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HEALTH CARE SYSTEMS AND ORGANIZATIONS

• Systems theory
• Traditional organizational theory
• Hierarchy
• Scientific management
• Traditional role of nursing in health care system
• New theories to attend to growing complexities of
  health care system

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System Levels
Example
Frontline Patient Care Units
Nursing Divisions
Nursing Services
Source Henriks, Bojestig, Jonkoping CC Sweden
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Key functions as a leader in the CNL Role

• Horizontal leadership
• Effective use (and knowledge) of self in caring
  and facilitating change for patients
• Advocacy
• Conceptual analysis of CNL role
• Lateral integration of care for a unit of
  care/population

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Leadership

• Leadership practice at the microsystems level
• Leadership vs. Management
• Leadership theories
• Great Man
• Situational
• Leadership style
• Servant leadership
• Transformational leadership
• Complexity science leadership

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New ORG Theories for health care system

• Learning organization theory
• Chaos theory
• Complexity science theory
• Change theories
• Lewins force field
• Rogers - Diffusion of innovation model
• Complexity science strange attractor
• New role for a new organization CNL
• The Clinical Nurse Leader is the frontline change
  agent in health care organizations

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ORG THEORIES for Health care systems

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

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The Learning Organization

• Adaptive (single-loop) Learning
• Involves coping with a situation
• Limited by the scope of current organizational
  assumptions
• Occurs when a mismatch between action and outcome
  is corrected without changing the underlying
  values of the system that enabled the mismatch.
• Generative (double-loop) Learning
• Moves from COPING to CREATING an improved
  organizational reality
• Necessary for eventual survival of the
  organization
• Both are central features to the learning
  organization
• Synergy and nonsummativity are Important

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The Learning Organization

• Through communication, teams are able to learn
  more than individuals operating alone.
• Leadership is a key element in creating and
  sustaining a learning organization.
• Leaders are responsible for promoting an
  atmosphere conducive to learning
• CREATIVE TENSION

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New Directions in Org theories for health care

• Chaos theory
• Every complex system has a life of its own, with
  its own rule book.
• Change is normal chaos is part of change look
  for the patterns that emerge out of the chaos
• Fractals
• Theorists Fritjof Capra

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New Directions in Systems Thinking

• Organizations as Complex Adaptive Systems aka
  Complexity Science Theory Leadership and the
  New Science (Wheatley, 2006).
• Organizations are adaptive, living organisms with
  a life of their own
• Not predictable yet adaptable
• Complex systems are self-organizing.
• Small changes can have big effects
• Relationships are all there is
• Information is the life force of any organization
• It is normal for organizations to grow, die and
  reinvent themselves
• A static organization is a dead organization

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Lewins change theory

• Force Field Analysis
• Begin change by analyzing the entire system in
  order to identify the forces for and against the
  change driving restraining forces
• Need to add driving forces or remove restraining
  forces
• Change Model
• Unfreezing
• Change
• Refreezing

(Lewin, 1951)
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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
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Rogers Diffusion of Innovation Model
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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?

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Traditional vs PD Problem Solving Approach
PD Flows from identification and analysis of
successful solution to problem solving
Traditional Flows from problem analysis towards
solution


Actual Problem Parameters
Fixed Solution Space
Actual Problem Parameters
Expanded Solution Space
Perceived Problem Parameters
Perceived Problem Parameters
Perceived Problem Parameters
Actual Problem Parameters
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why focus on the clinical microsystem?

• Basic building block of health care as a
  system.
• Unit of clinical policy-in-use.
• Locus of most workplace motivators and many
  demotivators
• Most variables relevant to patient satisfaction
  controlled here.

• Where good value and safe care are made.
• Where most health professional formation occurs
  after initial preparation.
• Its the front line
• Its where everything happens with, to and for
  the patient and family

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The CNL Can assess the Clinical Micro-system with
the 5 Ps

• Purpose
• Patients
• Professionals
• Processes
• Patterns

Nelson, Splaine, Godfrey, et al, JQI, Dec. 2000.
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HEALTH CARE QUALITY Patient safety

• Institute for Healthcare Improvement (2004)
  Patient Safety Initiative
• Apply methods and tools of industrial quality
  improvement
• Process improvement and team problem solving

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Quality

• Must be defined measured
• Is a moving target - must always be current
• Provides a competitive edge
• Doing things right the first time
• Focus on results - outcomes
• Must be strongly embedded in culture
• Must be linked to costs

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Quality Improvement

• IOM Report (Crossing the Quality Chasm)
  recommends six dimensions as potential themes for
  quality improvement
• Safety
• Effectiveness
• Patient-centeredness
• Timeliness
• Efficiency
• Equity

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Quality improvement Tools and Techniques

• PDCA
• Plan-Do-Check-Act
• Plan-Do-Study-Act (Deming, 1993)
• Other Problem-solving tools
• Process mapping
• Flow charts
• Check sheets
• Pareto analysis
• Cause and effect diagrams

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PDSA
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AONE Core Patient Safety Technology Competencies

• Systems Process management process improvement
• Human factors
• Failure Mode Effects Analysis/Root cause analysis
• Safety rounding
• Teaming
• Risk management

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Failure mode effects analysis (FMEA)

• FMEA purpose Eliminate or reduce failures/harm
• Failure mode manner in which failure occurs and
  is observed
• Failure effect consequences of failure
  (prioritized by severity)
• Root cause analysis
• Common cause analysis

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When Solving Problems

• Focus on prevention, not blame
• Realize a cause never stands alone
• A problem description is not analysis
• Start analysis with an impact to the goals not
  the causes
• Apply the basics of cause and effect, avoid
  buzzwords
• Analyze all - not only problems but success to
  determine cause and effect
• (Galley, 2007)

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Client centered practice is intra- and
inter-disciplinary

• Effective communication skills listen, listen,
  listen
• Team coordination and collaboration
• Delegation and supervision
• Interdisciplinary care and roles of the health
  care team
• Group process
• Handling difficult people
• Conflict Resolution
• Leadership is all about communication

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Social justice

• An essential value for the CNL
• Demonstrated through compassion, cultural
  competence, patient advocacy and an understanding
  of health disparities
• Support that health is a right not a privilege

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CNL is the Guardian of the Nursing profession

• CNL role is helping professional nursing to
  evolve to a higher level of maturity and
  complexity
• CNL role helps to maintain focus of all
  activities on patients and their
  well-being/safety
• CNL role continues to demonstrate that nursing is
  more than just a job its a vocation
• CNL role exemplifies the responsibility of
  knowledge workers in an information society

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References

• American Association of Colleges of Nursing
  (2007). White paper on education and the role
  of the Clinical Nurse Leader. Washington, DC
  American Association of Colleges of Nursing.
• Institute of Medicine (2000). To err is human
  Building a safer health system. Washington, DC
  National Academy Press.
• Institute of Medicine (2001). Crossing the
  quality chasm A new health system for the 21st
  century. Washington, DC. National Academy Press.
• Nelson, E. C., Batalden, P. B. Godfrey, M. M.
  (2007). Quality by design A clinical
  Microsystems approach. San Francisco
  Jossey-Bass.
• Wheatley, M. (2006). Leadership and the new
  science Discovering order in a chaotic world
  3rd ed. San Francisco Berrett-Koehler.