Creating Healthcare Environments
Where Nurses Thrive
A Plexus Institute Workshop Hosted By
Hunterdon Medical Center and Co-Sponsored By
The College of New Jersey School of Nursing
September 30 – October 1, 2004
Flemington, New Jersey
PROCEEDINGS
Highlights of our Conversations
THURSDAY SEPTEMBER 30, 2004 ................................................................... 2
WELCOME AND OPENING REMARKS ............................................................................................................ 2
STORIES ABOUT ENVIRONMENTS WHERE NURSES THRIVE ............................................................ 3
REFLECTIONS – ROUND I ................................................................................................................................ 4
THE HUNTERDON MEDICAL CENTER STORY ............................................................................................ 4
RESEARCH BRIEFS ............................................................................................................................................. 6
FRIDAY OCTOBER 1, 2004 ..........................................................................10
REFLECTIONS FROM DAY 1 & OPENING THOUGHTS FOR DAY II .................................................... 10
KEEPING PATIENTS SAFE: TRANSFORMING THE WORK ENVIRONMENT OF NURSES ............ 11
STEPS WE CAN TAKE TOGETHER ................................................................................................................ 13
REFLECTIONS ON OUR MEETING DESIGN .............................................................................................. 16
CONFERENCE PARTICIPANTS ......................................................................17
RESOURCES AND LINKS ............................................................................19
WEAVING COMPLEXITY AND BUSINESS: ENGAGING THE SOUL AT WORK ....................................................... 19
APPRECIATIVE INQUIRY ....................................................................................................................................... 19
OPEN SPACE ........................................................................................................................................................... 19
RESEARCH BRIEFS – RUTH ANDERSON’S POWER POINT SLIDES ....................................................................... 20
COMPARISON - TRADITIONAL MANAGEMENT PARADIGMS WITH MANAGEMENT STRATEGIES USING A
COMPLEXITY SCIENCE FRAMEWORK ..................................................................................................................... 32
PRE-CONFERENCE HANDOUT FROM RUTH ANDERSON ........................................................................................ 34
RESEARCH BRIEFS – JIM BEGUN’S POWER POINT SLIDES ................................................................................. 35
Creating Healthcare Environments
Where Nurses Thrive
Thursday September 30, 2004
Note: Together, we experienced many rich conversations and robust learnings, in our paired
conversations, café conversations, tours and personal reflections. These notes highlight some of
our large group conversations, including contact information of attendees, links and resources.
Enjoy! And, expect surprise, as your conversations and these ideas continue to weave in your
present and future work.
WELCOME AND OPENING REMARKS
Linda Rusch, CNO, Hunterdon Medical Center, “This is a historical moment in my career…This is the
beginning of national conversation. We have a ‘good enough plan’, and on a national level, with enough
noise, we can together continue creating environments safe for patients where nurses really love
their jobs!”
Robert Wise, CEO of Hunterdon Medical Center, “Like we know in The Lord of the Rings, a simple
man, an average person, a hobbit, was chosen for a dangerous mission. He has no formal power, no
authority; he only has to get to middle earth. He succeeds by taking the precious ring and throwing
it away. You too will have to give up something in order to create a new environment….You will have
to be visible and invisible…. The responsibility for safety is yours.
Susan Blackwell-Sachs, Dean of College of Nursing, College of New Jersey, “We celebrate our long
time partnership with Hunterdon and our deep interest in practice.”
Curt Lindberg, President of Plexus Institute, Curt – “Let me add my welcome to you all, and add my
hope to Linda, that our time together over the next two days is an important step, in our journey
together. Take time to connect with new people, recognize that small actions matter; diversity,
variability and connections matter. There will be surprise and improvisation in this design, and all of
us have a very important role to play in this planning and how we unfold our learning together.”
Members of the planning committee were welcome and introduced. Roger Lewin and Birute Regine,
long time friends and story tellers with Plexus, authors of The Soul at Work
were also introduced. Roger will write the story of our history as it unfolds at
this conference. Thank you Robert Wood Johnson Foundation.
And Jim Begun and Diana Crowell, were welcomed and introduced, playing the
role of commentator, reflector, amplifier, provocateur during our time together.
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 2
STORIES ABOUT ENVIRONMENTS WHERE NURSES THRIVE
Trish Fazonne and Susie Hull introduce Appreciative Inquiry, and invited participants to pair up,
and each take turns telling and hearing a personal stories about an environment, an experience
where nurses thrive (in pairs, then in foursomes). Trish helps us get into our stories, through
asking all of us, “What does it mean to thrive?” and then guided imagery:

Recall a time you deeply remember, bring it forward, into the living present.

What made this experience so powerful for you?

What did you to contribute to that experience? What did you discover about yourself?

Who else was involved and what did they contribute?

How did new patterns of relationship, meaning, and identify emerge?

What aspects of the setting, environment or situation helped make it so special?
We invited one foursome to reenact one story, exchanging roles, uncovering the emotions of the
experience. The story we experienced was that of Tracey, a quiet and reserved nurse, as she
receives the employee of the month award, in part due to her flowers painting, nominated by new
nurse manager. From all of our stories, we detected these patterns - common dynamics, conditions
and assets that made our stories possible.

All about relationships

Taking risk and having profound trust
that things will work out

Trust

Positive attitude


Level of self-reflection to perk the
experience
Element of hard work – but feeling that
hard work was wonderful and worth it

Balance – work and professional life

Self-thriving was about facilitating
someone else’s thriving

Element of surprise! About what
outcome is – better than ever imagined!

Letting go


Common sense
Acknowledgement about how good it felt
to be valued

Clear about outcome, but not being too
attached

Feeling that you made a difference


Environment that fosters creativity and
growth
There was something in what happened
that supported our own values of what
nursing is

Each story told an emotional story

Vision of leader being instrumental

Freedom to try new things


Power of working on problems
collectively versus imposing solutions on
others
Organization doesn’t always give you
time, you have to create time

Stories were a long time ago – question is
why are we not thriving NOW?

Recognizing moment when something
different and you had possibility to BE
different

Empowering others

This identified why we are here and
what we want to take home with us

Partnering

3 of our 4 stories were about HOME –
we are curious about why and how it is
easier to be free in that context?
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 3
REFLECTIONS – ROUND I
Jim Begun
“I’m struck by a commentary in Newsweek, from some time ago, when David Broder spoke of
nursing as ‘the noblest profession’. These stories (this morning) were about connecting with
human beings at a deep level, at an emotional level. This is not like the scientists, who
experience complexity science for theory building, for business people talking about
complexity science and getting a better bottom line. Here, you are talking about very
important emotional events…You are touching people at their most vulnerable times and you
are creating relationships that are most powerful. This is why this thing about relationships
resonates so deeply. You don’t find this among other professionals.”
Diana Crowell
“Here was I trying to come up with something profound – and as I experienced your
conversations, you have the answers.”
“My story as nurse was at Harford hospital, when I was on the float team. I really went
back to feeling my shiny white shoes and my uniform and feeling very good at the end of my
shift and feeling so supported. I remember making rounds on the surgical step-down floor,
and found a man, terribly anxious. And as I helped him, another nurse said, ‘you are so good
at this, let us see how we can take your assignment so you can do this’. I remember feeling
each time I entered the hospital that I was supported. This was our craftsmanship.”
“When you are directed from above to make a change, your energy sinks and you have a
tendency to implode with energy rather than explode. During the reenactment, I could see
the energy of your connections. And thanks to Susan and Trish for creating environment
for us to thrive.”
THE HUNTERDON MEDICAL CENTER STORY
Linda Rusch and Jim Begun, a living room conversation, excerpts
Linda – “People seem curious; they sense something very palpable in our experiences. They are
curious if this can be duplicated and replicated.”
“Leadership is fractal, and as I think of who I am with my leader, I can be who I am, then I hope,
my directors can be who they are. The fractalness is self-similar. I am not outside this fractal
system, I am embedded in it.”
Jim – “I work in an organization where I cannot thrive. It isn’t so great out there and you are in a
unique system. I want to know you better. I’m curious how you got here and how you became a
goddess?”
Linda – “I was brought into this from Witt Keiffer – to heal…. The greatest joy is working with
these people out there, my department heads. They bring me joy each day. I try to focus my time
on meaningful conversations, and not be so focused on the clock ware.”
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 4
Linda – “I’m remembering the very famous APACHE study at Beth Israel, when the nurses in the
ICU did not have good relationships with their MDS, patient mortality went up. My question is, ‘if
our leaders spend time with our staff, will this make a difference in patient outcomes?’”
Jim – “Look at your impact over time. How long did it take for you to create a critical mass?”
Linda – “Having Bob’s support made a difference. You don’t need everyone’s support, but you do need
your boss’s. The shadow system is much easier to work in. I work in it everyday, because, it is
intuitive.”
“10 years ago, when we took leaders to Plexus conferences in Philadelphia – they became groupies. I
think it was soulful. When we appreciate what nature is and what relationship are. We use words
like LOVE here. I care deeply about this hospital and the people who work here. What I do with
my 15% is the question I ask each day.”
Jim – “So there is hope for me? You tell me I can work in the shadow system, find the 15% I can
work in?”
Linda – “I’m wondering if in your organization if people are not tending to their gardens? …I mean
there are some very oppressive people in organizations, who are destructive. Here at Hunterdon,
we have a meeting called Liberation. We look at who in our organization needs love…who needs
pruning…..Nurses don’t thrive where other nurses are not nice, who have negative attitudes, who are
not pulling their weight. I think we need to spend time tending to our garden.”
“What makes me thrive is the ability to make a difference. I want so much to make a difference
and I want so much for every patient who comes into a hospital around the US to feel they have
great experience and feel better when they leave than when they came.
“Every month we have a session in our management council called Lessons Learned. We don’t always
use it, but often do. There is nothing more important in a complex adaptive system than to get
feedback on itself. Our meetings are noisy, robust. Leadership is not about having all the answers.”
Jim - “You look like you are 38 and your soul is ageless!”
Jim – “You talked about shared governance. I know this has meaning for many nurses, but not to me.
Linda – “Nursing is an accountability-based practice and nurses share governance for their practice.
This is not a program, it is a culture, in fact people wouldn’t it even recognize it. I don’t run the
management council meeting – I let another nurse run it each year. And we have staff nurses at our
management council. We need them; we need their knowledge to shape us. We encourage them to
have a voice and be heard and they feel like they are thriving – they have a voice.”
Jim – “So, I should invite students to faculty meetings?”
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 5
RESEARCH BRIEFS
Research about Nursing Work Environments, Complexity and Quality, New CNL role
Ruth A. Anderson
Associate Professor, Duke University School of Nursing
See annotated notes and slides, in the Resource Section of this document, “Managing for Success in
Healthcare Leadership”. Also, see handout from pre-conference, “Comparisons between Traditional
Newtonian and New Science Management”.
“In 1996, I started seriously looking at complexity science and management practices as a
means for improving clinical care and patient care outcomes. My work has been with Rueben
McDaniel and Donde Ashmos, using tools informed by complexity science.”
“I began by asking, where is the power in the system? One of the characteristics of
complex systems is self-organization. Most of my work has been in nursing homes. What
emerges through self organization may or may not be positive. How do we get it to work for
us in the direction of improving patient outcomes?”
“The question becomes how to influence these system control parameters (participation), as
a way to get new behavior in the system – versus the way we work in nursing homes, the
hammer, “wash your hands.”
“Managers often think - If I get participation to go up, cost will go up – this is not what we
are finding in our studies. We began to look at which of these activities are most
important. We found that raising the issue and informal meetings – are the most important
factors we discovered in nurses feeling like they have influence (hospital setting). In a
public health setting/sample, choosing the alternative and informal meetings and chance
encounters are the most significant.”
“With my study with Donde Ashmos, 1998, we looked at cost/outcome as variable. What
accounted for cost? Bringing in MDs and RNs into participation in decision making had
greater cost savings per admission, than just bringing in another level of management.”
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 6
Marge Wiggins
VP Nursing , CNO, Maine Medical Center
See website, with many resources, including Marge’s PowerPoint slides Health Care Today – The
Perfect Storm, (look at the CNL Implementation Conference, June 16-17, 2004
http://www.aacn.nche.edu/NewNurse/index.htm
“Nurses work at a staccato pace. I’ve never seen people work so hard. In the Anita Tucker
study, ‘a day in the life of the nurse’, we learned that nurses spend 9% of their time,
handing problems (44 minutes per shift) – and only 25 minutes per day with patients….Is
this inevitable availability or is it fatal availability?”
Situational Constraints
Summary Statistics
F or a n ave rage 8-hour shi ft
•
• 6 patie nts (on ave rage)
166 problems
• “Costs” of these problems:
• Comple ted 160 tasks
• Av erage ta sk time 00:02:48
 Time spent on problems (35
min/shift – 8%)
• Av erage 4.7 interr uptions
• Av erage 6.5 problems per shift
• 35% of time spent in di rect care - 25 min/ pati ent
A. Tucker, 2001
 Delay to patient care
 Interruption to nurse
“We work with a complexity of multiple dependent system and agents – all the while we
expect the nurse to perform miracles…. And keep our patients safe.”
“To attract nurses, we have moved to 12 hr schedules, part time staff have diminished the
continuity of care and ongoing monitoring of patients…shift work is replacing continuity of
care and who knows the patient’s story from beginning to end?”
“We think the CNL role may help us avoid the storm”
Joan Stanley
AACN Director of Education Policy
Review full reports, background, white paper, and updates on website:
http://www.aacn.nche.edu/NewNurse/index.htm
“We have 84 schools of nursing and 200 institutions, with 79 partnerships (still growing).
People are already beginning to implement the role on both the education and practice side.
½ of task force members are on practice side, including the former CNO (newly retired) of
INNOVA Health Care System.”
“We realize that the role just can’t be developed and inserted into our current delivery
system; both the role and delivery system must change.”
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 7
“Complexity science helps us see system differently than we have before. One of primary
roles of the new CNL will be ‘systems analyst and risk anticipator’. This new role is really to
address and improve patient safety – we want to be aggressive and enthusiastic to make
patient care safer.”
“When we first identified the role and developed this profile, it was not tagged onto an
educational model. This is a generalist role not a specialist role. We have also developed
paper to differentiate this from CNS role….. We have come to the conclusion that this must
be a master’s prepared role.”
Jim Begun
Dean Health Care Administration, University of Minnesota
See related attachment, PowerPoint slides, “Searching for Nurses Future.”
See related paper, a handout at conference, “Altering Nursing’s Dominant Logic: Guidelines from
Complex Adaptive Systems Theory,” Complexity and Chaos in Nursing, Summer, 1995, 2(1), 5-15.
“What is nursing as a complex adaptive system? I invite you to step outside of your current
role and your daily work and look with me at how your profession is evolving.”
“The question to bear is: How can I shape its evolution, not just accept its evolution? How
can we influence the systems future? How can we shift the dominant logic?
Signs of a Tipping Point?
 How
could one recognize a tipping point in
a large, diverse, loosely coupled complex
adaptive system?
 Confluence of positively reinforcing
events?
 Era of transformation?
“Big complex adaptive systems have “dominant logic” – simple rules in its deep structure,
vision, and values.”
“How can we shift size and diversity as inertia, as weighting the system down,, to
strengths?.... It is helpful for me to think of the Nursing Profession with an “s” – The
Nursing Professions, as a means to use size and diversity as strengths…There are 2.5 million
nurses, among 10-12 million other health care workers.”
“Here is where I get my optimism. I see so many exciting things going on in nursing now.
There is something different in what’s happening today. For example, the Magnet Status,
which raises the image of nursing for board members, for consumers. ‘A Summit of Sages’ –
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 8
is a program coming up at our campus. Garrison Keeler is speaking – and will waive his fee to
speak to a group of nurses. You can’t get a ticket to this!”
http://densfordcenter.ahc.umn.edu/whats_new/sos_main.html
Marilyn (Dee) Ray
Professor of Nursing, Florida Atlantic University
”We are celebrating our 20th anniversary of this institute, the Center for Complex Systems
and Brain Sciences. Many of you know Dr. Scott Kelso, eminent scholar and Larry S.
Liebovitch who have contributed much to our understanding of complex systems and nonlinear dynamics. We are planning one of the next Plexus conferences in the spring of 2005.”
“I am student of Dr. Madeleine M. Leininger. I began to study hospitals as culture, as
microcosms of a larger culture. And, noted that they reflected a more global culture.”
“I developed the theory of ‘bureaucratic caring’, taking elements of bureaucracy (economic,
technologic, legal and political caring) and synthesizing these with caring (social, ethical and
spiritual dimensions). I have been studying the link between technology and caring: the
ethical realm and the dominant realm between technology and caring. In the economics of
caring, of the nurse patient relationship – there is a fundamental resources in goods,
resources and relationships….For over a decade my colleague Marion and I have been
studying the relationship between caring, nurse patient relationship and economic
outcomes.”
“My future is interested in helping students integrate complexity science and technology.
Another is trust and complexity science, and a critical nursing theory of vulnerable
populations in complex environments; the changing global culture of India…I’m writing a
book, developing new methods, to examine how hierarchal modeling might be helpful for nonlinear research.”
“I’m also involved with Holy Cross Hospital in Ft. Lauderdale, bringing in complexity science
to an organization that has achieved magnet status. And, I’m interested in the CNL role and
complexity science.”
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 9
Friday October 1, 2004
REFLECTIONS FROM DAY 1 & OPENING THOUGHTS FOR DAY II
Jim Begun
“Some MDs at one of our recent conferences, were exploring physiology and illness. They
spoke of our needs to look at patient as whole systems, talk to patient’s family, and consider
the whole social context etc. I asked them, ‘do you want to become nurses?’ We worry
about curing, they worry about caring – there is a need for more recognition of the
interdependence.”
“My point relates to the affinity of complexity science and nursing, with the systems
approach to nursing which has been historical. For example, Martha Rogers work is so
consistent with complexity science. I looked at Hildegard Peplau, Ida Jean Orlando, who all
said that the individual is a unique system, one you cannot separate from their environment.
Also, nurses are scientists. Complexity science is a pure basic hard science. This is
different than business people who are attracted to results, rather than a science. And,
there is a feminine quality in complexity science that makes sense to nurses.”
“One additional reflection on the small group discussion I was part of yesterday. We
choose to focus on problems in nursing, like retention, recruiting, lack of males, and lack of
respect of nurses in some locations. Within the hour, we felt the depression of the same
old thing, being stuck in the pattern. It would have been more helpful to focus on what does
work and build on nursing as a powerful force, with passion for changing health care
delivery.”
“Every year the Gallup polling organization asks the public who they trust. Every year,
nurses are at the top and what is amazing is the gap to other professionals. In rating of
honesty and trust, Nurses were at 83%, MDs 53% , Congressmen ( ), Chiropractors, 17 %,
and HMO managers at 11 %. As a sociologist from the outside, this is remarkable. If I’m
interested in designing a health care system around patients and what patients want, who
would I go to? Those who are most trusted by patients to do what is in best interest of
patients, as opposed to a self interested view. “
Diana Crowell
“24 hours ago, when Linda and Jim did the living room conversation I had these impressions.
Jim asked questions that were very much in a fractal mode – i.e. how do you translate your
relationship, nurse to patient, nurse to other nurses, and nurse to other nurse managers –
how do we grow? Fractals are iterations from small to large, and also are developmental.
As each nurse develops and works with one patient, this iterates in all of our other
relationships to each other, to our manager, to the whole health care system. These are
the same patterns.”
“You better be caring, committed and have a lot of passion. How do you quantify that?
Reflecting on the research: we have done it and worked hard and we know. We know. We
know. How do we get the word out to others? Intuitively we know the better our
relationships are, the better our outcomes.”
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 10
“In the perfect storm when Marge talked about nurses as complexity workers – and the
schism that exists in how nurses on a daily basis are complexity workers. The nurse
adjusts, adjusts, and adjusts – surprise, surprise, surprise. Then there is the schism
between the nurse who does this every day, yet is afraid of change. Yet the way the nurse
does work, is embracing change, on a continual basis. How do we create the link between how
nurses work and grow this into change?”
“Did you read the AJN recently, about study of hospital system, with 20 hospitals, where
hospital administrators, pharmacist and nurses – looked at errors. Interesting enough,
pharmacists were the most logical and objective. Physicians didn’t see errors at all and
didn’t see things as problems, and nurses behaved in a similar way. Over 90% of all 4 groups
believed that nurses are responsible for safety. Yet less than 8% of the MDS felt that
nurses should be part of the decision making team.”
“Jim challenged us to look at our dominant logic and how we might change this…..We know,
we know, we know – and now we have the evidence. So how do we take this and DO
something? The truth is insight without action is Bullshit….We have to start now to use the
tools we have in complexity science and do something!”
“This kind of conference is extremely demanding of your presence. Yet, I’ve seen so many
bright eyes. You become clear and sharp, the eyes are sparkling. When you are that open,
clear, sharp and present, synchronicities will occur. When we are open and present, the
answers will come to us…. Be who you are, and be present. The essence of nursing is
presence, it is being there. This is also the essence of nursing. This is the essence of
leadership.”
KEEPING PATIENTS SAFE: TRANSFORMING THE WORK ENVIRONMENT OF NURSES
Linda Rusch
See conference handout, titled same, developed by nurses at Hunterdon, in response to the 2004
IOM Report.
“I truly believe that if we took the latest IOM report and created a work environment
where we keep patients safe, we would create a work environment where nurses thrive. It
is all interrelated. “
“I truly believe that the health care system is truly broken. We have 98,000 deaths per
year (hospitalized patients) as a result of medical incidents. That is more than motor
accidents, AIDS and…put together. We need to do something very, very quickly. Why is
this happening? Most health care systems are centralized silos, inflexible, hierarchies. We
are not looking at this as complex system where there are a lot of interdependencies.”
“What does complexity science teach us about creating a culture of safety? What can you
do as leaders, what can you take home. We have learned a number of things:
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 11
1.
If you are going to put in a program, you can self destruct. This is not a program, an
overlay. This is about non linear dynamics and using your 15%. Can you imagine what
would happen if you tell your organization that you are going to implement 474
pages?
2. Small, multiple actions on the fringe. Some will work, some won’t. Everyone uses
their 15%.
3. You cannot force the river to change, because if flows on its own.
4. Use the IOM report, or the Hunterdon Medical Center story, as a catalyst.
5. Our managers and patients were involved. We dedicated this work to our patients.
6. Every department should be talking about safety every day. What is important,
what is not safe?
7. You need to ask the wicked questions, and teach others to do so.
8. What if you made safety rounds every week? You respect what you inspect. It was
hard for us to start doing this first. We learned to ask good questions.
9. Observe and ask your staff what kind of ‘hunting and gathering’ they are doing every
day. When we interrupt our work, we risk making a mistake. This was probably one
of the most profound exercises we did here at Hunterdon.
10. And we are fixing these things. It is unacceptable for nurses not to have needed
supplies
11. It’s conversation and then exposing the paradox. Money and safety.
12. Acknowledging that there is deviant behavior and work arounds.”
13. Complexity science is the study of patterns and relationships. If you want a culture
of safety, you must pay attention to those patterns and relationships.
“We are working to improve the elasticity of staffing, and buying equipment. But what I’m
most interested is in the language of culture and safety. Paying attention to the language
helps with the transformation.
“What we have learned in the IOM report is there are system failures. This is only worth
90%. 10% is the unsafe and incompetent practitioner and we are accountable to weed them
out.”
“We have the data now. Nurses are central to patient safety, ‘inseparably linked.” So, now
that we have the data, what is holding us back? How do we create the environment?
“Let me tell you about a butterfly who lives here 12 hours a day. Let me tell you about how
this butterfly needs to be a nurse, is a provocateur, and as a butterfly, is crossing over
boundaries, sharing information from one boundary to another, someone who disturbs the
equilibrium of the system. This is literally, someone who can provoke the system. Stephanie
Daughtery (Patient Safety Officer, Hunterdon) is honored.”
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 12
STEPS WE CAN TAKE TOGETHER
Curt invites participants to nominate open space conversations (per wonderful method developed by
Harrison Owen), and self-select, using simple rules of open space:
1.
Whoever comes are the right people.
2. Whatever happens is the only thing that could have.
3. When it starts, it is the right time.
4. When its over, its over
5. The law of two feet: if at any time you find yourself in any situation where you are neither
learning nor contributing – use you two feet and move to some place more to you liking.
Complexity and curriculum – Liz, Michael

How does complexity science inform our undergraduate and graduate education and
learning?

We are all in the Midwest – Kansas, Nebraska and Missouri

We want to form a learning network of nurse educators in the Midwest

Many of us use complexity science in our curriculum already, mostly at master’s level. Some,
are using in the framework of their dissertations

“We need more education about the science. Telling stories and relating to science isn’t
enough….We don’t know enough yet, about where and how we infuse it.”

We want to have 2 conferences (1) an invitational conference for deans, faculty and
practice partners; and then (2) a more national-based conference where we would invite
faculty to explore how to put complexity science into the curriculum.

We also were challenged about the need to connect our language and work on it – and the
power of story.

Other comments:
o
Susie introduces idea about accelerated design.
o
Trish – RWJ has model to combine learning network and product development. Also,
suggests having a special panel at MWNRS (Midwest nursing research society) to
explore this; Pioneer grants might support this
Complexity and Strategic Planning - Jean

Context: our organization is deeply invested in 5 year plans. We as department heads have
been asked to give input into the planning

Connecting the language and getting rid of fear and anger in organization when readying for
change

Look at current planning process to make it more fluid

Current models involve permission – reframe as opportunity for conversation, rather than
defaulting to permission mode

Complexity is a lens and a philosophy of how you live your life
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 13
IOM Group – Mary Jo

Further explore IOM Report at Hunterdon and complexity science underpinnings

Importance of relationships, interdepartmentally, and the diversity of frame they bring (i.e.
pharmacy)

Role of safety officer and 3 year journey at Hunterdon

4 hospitals in 80 mile radius (competitors) – took 7 national patient standards and decided
how they would practice in the same way (i.e. “x” to mark surgical site) so that as
practitioners go from hospital to hospital (in Lincoln Nebraska area), practices standard

Shared ideas
How do we nurture change in a profession steeped in tradition – Claire

We all had different view on things we wanted to change

We ended focusing on retention of new nurses

“Eat your young phenomena”

New graduates need relationships, mentoring relationships

How do we create mentoring relationships when the system tends to “gobble them up”

Small changes we can do of change within individuals and locally

Other comments:

Trish:
o
Consider PDSA models, even for small changes, and keep track of these so we can
continue to learn
o
Don’t miss opportunity to focus on the small changes
o
Large scale changes via small scale local changes
Nursing Theory – Jim
 Context: why nursing theory is, how complexity science fits

Dee Ray was a wonderful resource for group, of her work on nursing theory, and role model
for how theory can grow from the ground up – taking stories of current nurses experience,
making links to theory and to complexity science

We did not throw out nursing theory from the curriculum

Nor are we willing to turn nursing theory over to complexity science, but rather view this as
one set of tools for practicing nurses to use for their work. For some an umbrella, for
others, one theory.

Nursing should reach out to other related groups to share science of relationships and
caring – across boundaries of other clinical and administrative disciplines
CEO of Self - Mary Ellen
 Context: How do we get nurses, from leadership to front line staff to take on the mindset
of being the CEO of themselves, of their work, of their organization? Herman Cain, author
of same, says you need to be CEO of self, if you are not, you are second to yourself.

We had rich dialogue
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 14

How to become centered yourself and how do we help others, especially in crisis mode we
are often in?

On patient care unit, how do we understand who your stakeholders are and having your own
board to surround you (ie physicians, pharmacist, case managers etc)?

Energy of self – how you want to be perceived and how you want others to know you?

We focused on values. For example, joy, that Linda spoke of yesterday. How we give and
receive. Trust.

It starts with us first, as our lens, our way of being, and it naturally shares to others.
How do we continue from here? Henri, Curt

Context: How we can continue working together on CS and nursing to improve nursing work
environments and patient care

For the CNL program, how do we incorporate concepts of complexity into the design and
process of implementation, as well as content of curriculum itself? How can we participate
in the design of upcoming meetings (complexity inspired) – regional meetings?

Teaching and learning – how can lens of complexity science impact the teaching methods and
creating learning environments, as well as the content itself? What about Faculty
development?

Create local or regional networks to bring complexity science insights and practices into
routine operations of our health care organizations. For example, how do we recreate
existing meetings, with lens of complexity science? How do we build on what is – in our
current work?

“Everybody knows the meeting is not working, but we still meet once a month.”

Learning networks at multiple levels

Periodic gatherings, face-to-face, as complement to on-line or telephone conversation

We have a critical mass in New Jersey – as learning lab and experiment which might help
other regions.

Accelerated design sessions, for co-development and experimentation with tools, resources
and assets.

Learning networks, of couples/pairs, co-coaches

More ideas than resources to do
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 15
REFLECTIONS ON OUR MEETING DESIGN
Henri Limpanowicz
These process ideas - characteristics of healthy and complex systems - have guided our meeting.
They may be very useful back in your organizations, for other gatherings, meetings, daily work.
These characteristics include:
 Information rich
 Distributed control
 Self organization
 Emergence
 Networks/Connectedness
 Adaptation
 Fractals
For example, we started our meeting with telling stories versus giving an immediate presentation.
This was a richer experience and the information we shared, was full of context, rather than what
you often experience in PowerPoint. We were paying attention to information and to distributed
control. Within 10 minutes, everyone is involved and contributing their voice. We each bring
content and our experience. We had 100 people talking immediately! And, we each had the
opportunity to contribute to our beginning organization.
The other thing we did, at the end of the exercise, was asking you to collect patterns. Like
fractals, we were collecting patterns. Within one hour, we tapped into the fractal nature of
ourselves, as we are all natural pattern detectors. We can recognize patterns. The process of
gathering information from pattern recognition (versus data analysis, or one-way presentations)
about conditions is something we can all do naturally. And, the level of interaction increased
dramatically.
And we experienced some of the process of appreciative inquiry, building on what works. “Bringing in
stories is the most powerful thing we can do.”
In the conversation cafes, we experienced another example of creating conversation by shaping it
amongst yourselves. The control was distributed, no one was in charge. Patterns emerge, people got
connected. The open space process was designed again to promote self-organization. We created
space for self-organization to take place, and surprise to emerge.
The Living room conversation, gave us opportunity for improvisation, listening to conversation as
opposed to presentation. Your ability to connect is so different. The language of conversation is
familiar to us, rather than the language of presentation.”
How risky is this? Well, often, provocative questions, wicked questions emerge (like they did for
Jim).
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 16
CONFERENCE PARTICIPANTS
Contact
Ann H. Cary
Anne M. Barker
Anne Fereday
Anne Marie Taggart
Ardath Youngblood
Audrey Kuntz
Barbara S. Snyder
Betsy Cotter
Birute Regine
Carla Hronek
Carolyn Swithers
Carrol A. Fiorino
Catherine J. Malone
Charlotte L. Mazak
Cheryl Portwood
Christine Cochrane
Christine Kowalski
Claire E. Cole
Claire Lindberg
Claire Roche Long
Colleen Kosiak
Connie K. Schultz
Curt Lindberg
Darlette J. Tice
David Keifer
Diana Crowell
Donna Cole
Donna J. Fritts
Donna James
Donna Reragan
Ed Quinones
Elizabeth A. Buck
Eric V. Pakutka
Gail Johnson
Gail Snow
Henri Lipmanowicz
James W. Begun
Jane Rudolph Skokan
Jean L. Withers
Jeanne Whaley
Jennifer Duncan
Joan M. Stanley
Joan P. Roche
Joanne Borduas
Judith K. Lindberg
Julie Weidemier
Karen A. Grigsby
Karen Beam
Company
UMASS- Amherst
Sacred Heart University
Central Maine Medical Services
Shore Memorial Hospital
Hunterdon Medical Center
Vanderbilt University Medical Center
The College of New Jersey
Cheshire Medical Center
Harvest Associates
University of Kansas School of Nursing
Diabetes Health Center
Hunterdon Medical Center
Robert Wood Johnson Foundation
Hunterdon Medical Center
Drexel University
Hunterdon Healthcare System
Hunterdon Medical Center
Chilton Memorial Hospital
The College of New Jersey
Hunterdon Medical Center
University of Kansas School of Nursing
Frances Mahon Deaconess Hospital
Plexus Institute
Forbes Regional Hospital
Christiana Care Health Services
Leading Your Life
Hunterdon Medical Center
Warren Hospital
Christiana Care Health Services
Hunterdon Medical Center
Hunterdon Medical Center
Washington University Medical Center
Hunterdon Medical Center
Capital Health System
Waterbury Hospital Health Center
Plexus Institute
University of Minnesota
Minneapolis VA Medical Center
Solaris Health System
Hunterdon Medical Center
University of Kansas School of Nursing
American Assoc of Colleges of Nursing
University of Massachusetts Amherst
Waterbury Hospital Health Center
Bon Secours HS-St. Anthony Hospital
Waterbury Hospital Health Center
University of Nebraska Medical Center
Hunterdon Medical Center
Title
Director Graduate Distance Learning
Associate Professor of Nursing
Director, Cardiovascular Services
Nurse Manager Critical Care
Perinatal Nurse Educator
Perioperative Nurse Educator
Assistant Professor
Senior Director, Ambulatory Nursing
Author
Doctoral Student
Director
Nurse Manager-3 West
Program Associate- Nursing Team
Nurse Manager - 5 South
Adjunct Professor
Dir., Acute Behavioral Health-Addiction
Director, Staff Development
Perioperative RN Manager
Associate Professor
Director GI/Patient Safety
Clinical Nurse Educator/Doctoral Student
Senior Consultant
President
Vice President, Operations & CNO
Senior Software Development Engineer
Consultant
Director, Surgical Services
Clinical Coordinator
Project Manager
Staff Nurse, Operating Room
Assistant Director, ED
Academic Dean, Division of Nursing
Assistant Nurse Manager, SDC/ATC
Director, Professional Practice
Assistant Clinical Director
Chair
James A. Hamilton Term Professor
Director Oncology Services
Director MNCC
Doctoral Student
Director of Education Policy
Director Outpatient Services
Vice President - Patient Care Services
Assistant Clinical Director
Associate Professor
Assistant Manager - Pediatrics
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 17
Karen Ott
Kate Cronin
Kate Randolph
Kathleen Perez
Kimberly A. Palazzi
Linda Ries
Linda Rusch
Loraine M. Skeahan
Marcia Blicharz
Marie Schickler
Marilyn Ray
Marjorie J. Bott
Marjorie S. Wiggins
Marjorie Whelan
Mark Tino
Mary Bochicchio
Mary Ellen Clyne
Mary K. Pierce
Mary L. Kinnaman
Mary Prybylo
MaryJo Loughlin
Maureen Clark-Gallagher
Michael R. Bleich
Nancy Espenhorst
Pat McCabe
Patricia A. Balaziuk
Patricia A. Otaegui
Patricia Welch Dittman
Patricia Fazzone
Patricia Longworth
Patricia Psenisky
Patricia Steingall
Pete Carlson
Phyllis McBride
Prucia Buscell
Rebecca Vaughn
Rhonda Bauman
Rita Saenz
Roger Lewin
Ruth A. Anderson
Sandra Iadarola
Stephanie Dougherty
Susan Bakewell-Sachs
Susan Hull
Susan Manzolino
Tania Cutone
Theresa M. Brodrick
Tona Leiker
Victoria Weisfeld
Department of Veterans (108)
Cheshire Medical Center
Plexus Institute
Hunterdon Medical Center
Hunterdon Medical Center
Hackettstown Community Hospital
Hunterdon Medical Center
Hackettstown Community Hospital
The College of New Jersey
Virtua Memorial Hospital
Florida Atlantic University
University of Kansas School of Nursing
Maine Medical Center
Hunterdon Medical Center
VHA East Coast, LLC
Waterbury Hospital Health Center
Clara Maass Medical Center
Tucson VA Medical Center
Univ. of Missouri-Kansas City Sch of Nsg
Waterbury Hospital Health Center
Hunterdon Medical Center
Capital Health System
University of Kansas School of Nursing
Plexus Institute
Central Maine Medical Center
Warren Hospital
Shore Memorial Hospital
Holy Cross Hospital
Southern Illinois University - Edwardsville
Hunterdon Medical Center
Hunterdon Healthcare System
Hunterdon Medical Center
Peter E. Carlson & Associates
Quality Partners of Rhode Island
Plexus Institute
University of Kansas School of Nursing
Minneapolis VA Medical Center
Academy for Coaching Excellence
Harvest Writers
Duke University School of Nursing
Waterbury Hospital Health Center
Hunterdon Medical Center
The College of New Jersey
Wellspring Research & Consulting
Waterbury Hospital Health Center
Chilton Memorial Hospital
Virtua Health, W. Jersey Voorhees Hosp.l
University of Kansas School of Nursing
Robert Wood Johnson Foundation
Program Dir. Academic/Legislative Affairs
VP, Nursing Operations
Managing Director, Learning & Education
JCAHO & Cultural Renewal Coord.
Chief Nurse Executive
Vice President, Patient Care Services
Emergnecy Department Nurse Manager
Professor
Director Maternal Child Health
Professor
Associate Dean for Nursing Research
Vice Presient of Nursing
Director, Critical Care & EDServices
Director, Performance Improvement
Assistant Clinical Director
Vice President, Patient Care Services
Cardiology Nurse Practitioner
Clinical Instructor, PhD Student
COO, VP Patient Care Services
Director Inpatient Surgical Care
Divisional Director-Clinical Education
Assoc Dean for Clinical & Comm. Affairs
Office Manager
Manager, Cardio-pulmonary
Director Perioperative Services
Nurse Manager
Director, Nursing Research Quality
Department Chair and Professor
Asst. Director Medical Specialty Unit
Assistant Director Surgical Services
Director, Patient Care Services
President
Project Coordinator
Office Coordinator
Director of Clinical Svcs/Doctoral Student
Staff Nurse
CEO
Author
Associate Professor
Director, Medical Units
Director, Patient Safety
Dean
Principal
Assistant Clinical Director
Nurse Manager
Doctoral Student
Senior Communications Officer
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 18
RESOURCES AND LINKS
Weaving Complexity and Business: Engaging the Soul at Work
by Roger Lewin, Birute Regine
http://www.amazon.com/exec/obidos/ASIN/1587990431/qid=109699731
6/sr=2-1/ref=pd_ka_2_1/102-5092119-2693766
Appreciative Inquiry
The Appreciative Inquiry Commons
http://appreciativeinquiry.cwru.edu/
In the years since the original theory and vision for "Appreciative Inquiry Into Organizational Life"
was articulated by two professors at the Weatherhead School of Management, Case Western
Reserve (see David Cooperrider and Suresh Srivastva, 1987) there have been literally hundreds of
people involved in co-creating new concepts and practices for doing AI, and for bringing the spirit
and methodology of AI into organizations all over the world. The Commons is a wonderful resource
and website.
Appreciative Inquiry is:
 A strategy for purposeful change
 Concentrates on the best of “what is”
 Seeks possibilities of “what could be”
 A cooperative search for strengths already present
Includes Four Phases
 Discovery - the best of what is (our first story telling experience)
 Dream - what might be
 Design - what should be
 Destiny - how to empower, learn & adjust
Open Space
http://www.openspaceworld.com/
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 19
Research Briefs – Ruth Anderson’s Power Point Slides
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 20
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 21
Management
Practice
System Parameters
• Work Environment
• Rate of information flow
• Participation in decision
making
• Nature of interconnections
• Communication
Openness
• Diversity within/between
cognitive schema
• Leadership behaviors
• Workforce diversity
Better & IMPROVED
Outcomes
Self
Organization
Management
Practice
• Participation in
decision making
Use of new or existing
organizational
relationships to
exchange information in
decision making
System Parameters
• Rate of information flow
• Nature of interconnections
• Diversity within/between
cognitive schema
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 22
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 23
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 24
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 25
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 26
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 27
Management
Practice
• Communication
Openness
People can say what
they mean without fear
of repercussion—during
vertical and horizontal
information exchanges.
System Parameters
• Rate of information flow
• Nature of interconnections
• Diversity within/between
cognitive schema
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 28
Management
Practice
• Leadership
behaviors
Relationship-oriented—
product of human
interaction and
communication
between manager and
worker
System Parameters
• Rate of information flow
• Nature of interconnections
• Diversity within/between
cognitive schema
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 29
Management
Practice
• Formalization
Centralized control
using job descriptions,
surveillance, and
procedures and rules to
ensure predictability
System Parameters
• Rate of information flow
• Nature of interconnections
• Diversity within/between
cognitive schema
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 30
Management
Practices
System Parameters
• Work environment
• Rate of information flow
• Communication
• Nature of interconnections
• Participation in decision
making
• Diversity within/between
cognitive schema
• Leadership behaviors
• Workforce diversity
Self
New Behaviors
Organization
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 31
Comparison - Traditional Management Paradigms With Management Strategies Using A
Complexity Science Framework
(Adapted from: McDaniel, R. R. (1997). Strategic leadership: A view from quantum and chaos theories.
Health Care Management Review, 22(1), 21-37.)
TRADITIONAL MANAGEMENT PARADIGM
 Based on Newtonian physics – organizations are machines – orderly, predictable and stable
 Therefore, change should be orderly and regular
 The role of health care managers is decision making, with the ability to predict possible
outcomes of alternative courses of action
 ASSUMPTIONS:
o Cause and effect relationships are linear
o If something works once, it will work again
o If managers identify worker needs, managers can use this knowledge to manipulate
workers on behalf of organizations
o Each person has a clearly defined role or job description and confine him/herself to
the prescribed behavior for that role
o Organizational structure is fixed and lines of authority and information flow are the
same
ORGANIZATIONS MUST GIVE UP THEIR OBSESSION WITH CONTROL, KNOWING WHAT IS GOING ON
AND SEEKING STABILITY. MANAGERS CANNOT BE IN COMMAND, HAVE CONTROL, PREDICT THE
FUTURE OR PLAN FOR SUCCESS.
PRINCIPLES FROM QUANTUM THEORY:
 The world is fundamentally unknowable and unpredictable
 Every attempt to know one attribute of a system reduces our ability to understand other
attributes – be careful what we measure!
 The world is not independent of the observer
 It is connections or relationships between things that count – NOT the things themselves
PRINCIPLES FROM CHAOS THEORY:
 The unfolding of the world over time is unknowable – therefore, leaders cannot control long-term
outcomes for organizations
 Small differences in initial conditions can quickly lead to large differences in the future state of a
system – need to pay more attention to the little things!
THREE PRIMARY LEADERSHIP TASKS:
I.
SENSE MAKING – meaning comes through the making of sense – not finding predictability, but
to make predictability through:
 Paying attention: create time for attention; structure patterns of relationships that enable
individuals to become more careful observers
 Complicate yourself: key strategy – make organizations more diverse – encourage
heterogeneity by emphasizing the value of diverse points of view
 Develop collective mind: a social entity built of ongoing interrelating and dense
interrelationships tied together by trust
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 32
II.
LEARNING
 Learning in real time: trial and error action taken in real time and reflecting on those actions
as we take them
 Learning skills: exploration of new possibilities vs. exploitation of old certainties; need to
develop learning skills from samples of one – each experience must become a learning
experience
III.
DESIGNING – organizations are in a constant state of becoming – must have rich and varied
sources of new information about internal and external situations
 Connections: the quality of connections between people is more important than the quality of
the individuals
 Diversity: when a variety of people from diverse backgrounds have important seats at the
decision making table, they see and interpret events differently, bringing a richer level of
understanding and sense-making
 Self-organization: occurs when interactions and dialogues between group members produce
coherent behavior regardless of whether or not there is a hierarchy, e.g., informal networks
and coalitions
PROVIDING LEADERSHIP IN UNCERTAIN TIMES:
 GIVE UP PLANNING AND CONTROL
 MOVE TO THE EDGE OF CHAOS: present groups with ambiguous challenges that facilitates
creative tension – provoke the kind of emotion and conflict that leads to an active search for new
ways of doing things
 CREATE NEW ORGANIZATIONS WITH NEW FORMS: leadership must come from everywhere in
the organization
 DEVELOP SELF-REFERENT ORGANIZATIONS: systems with a strong sense of self change in ways
that remain consistent with themselves in the environment
 ENHANCE THE QUALITY OF CONNECTIONS: capacity to carry rich exchanges of information; a
willingness to experiment with new ways of communicating
 TEACH PEOPLE WHAT OTHER PEOPLE ARE DOING: workers must see the overall direction of the
organization, and they must be aware of their responsibility for the whole product or service.
 CREATE LEARNING ORGANIZATIONS
 THINK ABOUT ORGANIZATIONAL DESIGN AS AN ONGOING PROCESS
 DON’T BE RESPONSIBLE FOR SETTING GOALS FOR WORKERS OR FOR ORGANIZATIONS:
increased emphasis on cooperation, not competition
 WORK SMARTER: working collectively smarter, working reflectively smarter and working
spiritually smarter
 PROVIDE FOR THE EMERGENCE OF VISIONS AND VALUES
9-24-04
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 33
Pre-Conference Handout from Ruth Anderson
Traditional Newtonian
New Science
Management
Wholism
 Whole is
greater than
the sum f
parts
Implications
Stability, equilibrium
 Fluctuations and
disturbances viewed as
signs of trouble
 (Target goals, budget
variances, critical paths)
Strong, clear boundaries
 Departmental, position,
institutional: Every part
knows its place.
 people need rigid structure
in order to work
effectively.
 Rigid chain of command
Linear cause and effect
Edge of chaos
 Irregularity is
a sign of life
and health

Changing, fluid
boundaries

Nonlinear cause
and effects

Replication of "proven"
processes
Patterns never
repeat

Predictable and controllable
 Manager sees role as one
of control: “it is my job to
make sure that you do your
job.” (Regulations,
guidelines, time clocks,
policies, procedures)
Objective reality-measurable
“I see it so it is.”
Observer is separate from
what is to be measured
Unpredictable and
uncontrollable

Subjective

No one reality. Multiple observers may be
better when deciding action
Observer
inseparable from..

We will change what we attempt to
measure (not always for the better!).
Reducible to parts
 Machine-like: Reduce to
parts, interchangeable
functions and roles.
 Study the parts and
understand the whole.







Old: Individual’s success and work
performance depend on innate ability,
training and access to necessary resources
New: Individual's success depends on
players and the moment.
Replacing individuals in roles means that
system will change….
Dissipative structures give off the old in
order to regenerate
Disorder can be source of order.
Growth in disequilibrium
Structures emerge, but only as temporary
solutions that facilitate rather than
interfere (p. 16).
Unique identity, clear boundary, merged
with environment- history is tied to larger
environment.
Small interventions may have great effect
and vice versa. DON't always need "large"
interventions
Sensitivity to initial conditions (history,
uniqueness)
"Roll out" programs may be doomed from
the start
Order comes from a few guiding formulae
or principles.
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 34
Research Briefs – Jim Begun’s Power Point Slides
Searching for Nursing’s Future
James W. Begun
Plexus Institute
September 30, 2004
Strategic Adaptation of the Health
Professions
Success stories: physical therapy, allopathic
medicine, optometry
Mixed/troubled histories: pharmacy,
chiropractic, nursing, occupational therapy
Strategic Adaptation of Nursing
It is a paradox that despite the considerable
responsibility assumed by professional
nurses for the treatment and care of
patients, their organizational role in
hospitals and elsewhere is so lacking in
autonomy and authority characteristically
associated with professional status.
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 35
Strategic Adaptation of Nursing
It is a paradox that, at any one time, a third of
those qualified to practice as RN’s choose
not to.
Strategic Adaptation of Nursing
It is a paradox that, in popular parlance, the
same, unmodified nouns “nurse” and
“nursing” should be applied so
indiscriminately to a wide variety of health
care activities, and to an occupation that
includes some of the least-educated
members of society and some of the most
educated.
Strategic Adaptation of Nursing
It is a paradox that, whereas other occupations
in America accorded the prestigious title of
profession have long since established the
bachelor’s degree as a minimum
prerequisite for practice, professional
nursing continues, despite historic and
bitterly fought battles, to rely
overwhelmingly on the services of persons
who have not received a college education.
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 36
Strategic Adaptation of Nursing
Source?
 Fred
Davis, pp. vii-viii in The Nursing
Profession: Five Sociological Essays (New
York: Wiley, 1966)
Strategic Adaptation of Jim Begun
Q: How can I make the biggest impact on
improving healthcare delivery?
A: Apply knowledge to the advancement of
nursing.
The Questions
can nursing’s interests as a profession
be met and maximized for the public good?
 How
 How
can the advancement of nursing be
leveraged to improve healthcare delivery?
 How
can nursing develop and exert its
collective will more effectively?
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 37
Science of Complex Adaptive Systems
 systems
consisting of multiple, diverse,
interconnected elements
 evolution
and emergent characteristics of
nonlinear dynamical systems over time
Applying Complexity Science
 Understand
the system
 Exert influence over the system
Understanding the System
 Nursing
is a nonlinear dynamical system
 Nursing is complex and adaptive
 Pace of change in the health sector, and
effect of changes on the professions, are
quickening. The requires health systems to
change.
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 38
Understanding the System
 Powerful
“dominant logic” drives the
system. [Deep structure. Vision, values,
simple rules.]
 Huge
size creates inertia
 Significant
diversity of internal segments
The Dominant Logic of Systems
 Data
(input) is filtered through underlying
beliefs
 System
learning is affected
Dominant Logic of Nursing
1.
Nurses want to be “professionals”
2.
Nurses are oppressed, are victims
3.
Nurses focus on “caring”
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 39
1. Nurses want to be “Professionals”
 Raise
entry level education
 Standardize curricula
 Insist on workplace autonomy
 Service orientation
 Specialized, unique knowledge base
2. Oppressed Status
 Dominated
 Nursing
by physicians
95%+ female
3. Focus on “Caring”
 Essential
feature of nursing practice
 Differentiates
nursing role from physician’s
(“curing”)
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 40
Huge Size as Source of Inertia
 “.
. .structural inertia increases with size
for each class of organization”
 2.5
million RNs of 10-12 million health
care workers
Diversity of Internal Components
 Nursing
Organization Liaison Forum: 70+
member organizations
 Many orgs. founded 1980+: NPs, spinal
cord injury nurses, managed care nurses,
holistic nurses, psychiatric nurses,
dermatology nurses, directors of nursing
administration in long term care, neonatal
nurses, chemical dependency nurses, nurse
massage therapists, forensic nurses, . . .
Influencing the System’s Future
 Shift
the dominant logic.
 Use size and diversity as strengths.
 Build on small successes and opportunities.
Celebrate and diffuse them.
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 41
Dominant Logic Shifting?
1.
Nurses want to be “professionals.”
Nursing is a unique profession. Entry to
all of its segments is not protected by high
educational standards.
Dominant Logic Shifting?
2.


Nurses are oppressed; are victims.
All clinicians are oppressed, by
administrators and managed care
companies.
Both the myth and reality of victimization
are fading with growing knowledge base
and power.
Victim vs. Leader
 Nursing
has defended patient interests by
resisting efforts of delivery organizations to
cut costs.
vs.
 Nursing has led innovations in efficient and
effective utilization of resources to enable
delivery organizations to compete and to
improve quality.
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 42
Dominant Logic Shifting?
3. Nurses focus on “caring.”
Nurses “care,” but more importantly,
they have highly specialized, scientific
knowledge about caring and about a wide
array of other means of health promotion
and prevention and treatment.
Use Size and Diversity as Strengths
 “The
Nursing Professions” vs. “The
Nursing Profession”
 Nursing education as a foundation for a
variety of careers and lifestyles and life
choices, emphasizing opportunity and
diversity
 Build relationships, linkages across diverse
segments
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 43
Build on Small Successes and
Opportunities
 Magnet
Status
 Institute of Medicine report
 Patient Safety movement
 Clinical nurse leader movement
 Nurse staffing research
 Shortages
Opportunity?
 “The
nursing workforce crisis dominates
the imagination of both institutional leaders
and policymakers in health professional
education and service delivery.”
--Ed O’Neil, 2004
Opportunity?
 Decrease
nursing education programs by
10-20%, with closings coming in associate
and diploma degree programs.
 Increase
masters level NP programs.
--Pew Commission
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 44
Other Evidence of Change
 “100
Most Powerful”
 Weinberg, Code Green, as case study in
how not to lead
 Nursing leadership development activities
(RWJ, local universities, Center for Health
Professions)
 Success stories like Hunterdon
Signs of a Tipping Point?
 How
could one recognize a tipping point in
a large, diverse, loosely coupled complex
adaptive system?
 Confluence of positively reinforcing
events?
 Era of transformation?
Conclusion
 Welcome
to the future of nursing.
Plexus Nursing Conference, Sept. 30 – Oct. 1, 2004
Proceedings pg. 45