Summative Conclusions

(Sheehan, n.d.)

I love to run. It is a five a.m. gut-wrenching, lung-stabbing, leg-murdering war with myself. Every day, my alarm clock rings and it begins. My brain says, “Stay and sleep a little longer.” But I get up anyway. In the first few minutes, my legs whisper, “Just go a little slower.” But I keep pace. Halfway through, my lungs scream, “Cut it short!” But then I see the sunrise over the trees, and push the full distance. It is ugly and shout-y and I will never win anything ever because I am not fast.

But when I get home, breathless and sweaty and shaking, it is worth it. Every single step. I’ve won again against my (worser?) self.

This is leadership. And growth. And life. It is a series of small, unromantic, difficult steps. It is listening to the small things inside my head and choosing what to believe and how to act it out. It is, as Ann Voskamp says, the physical and mental brokenness of running that reminds me I am strong (Voskamp, 2016, 18 October).

The “people” parts of leadership are just as painful (for me) as running. My strong Introverted-Intuitive-Thinking-Judging (INTJ) personality says, “You don’t have to care about other people. Emotions aren’t important” (16Personalities, 2017). My rational side says, “You can skip the relationship. More work will get done that way.” My anger says, “Just get it out. Everyone will feel better” (Thomas & Killman, n.d.). My conflict style says, “Make sure and get your way because you are definitely right” (Ingram & Johnson, 2010).

(Tolkien, n.d.)

Of course this is all terrible advice. People matter. Relationships matter (Porter-O’Grady & Malloch, 2015). And just because these awful thoughts and feelings and beliefs come naturally does not mean that I should trust them. Listen to them? Of course. It is critical to hear and acknowledge yourself, but that is only the first step on the world’s longest five a.m. slog (McHugh, 2013, 15 February). The conversation sounds something like this, “Yes, I feel like I should push ahead but I am going to stop and take time for relationship.” And if you are like me, it is thousands of these internal assessments that build up to growth.

When the slog gets especially dreary, I fall back on the “why” (Sinek, 2009, 28 September). For running, reviewing my long family history of early death from diabetes, heart disease, and obesity pretty much does the trick. As a nurse I am well aware that even the most perfect lifestyle does not come with a guarantee, but this is not an excuse to make poor choices. Besides, how else am I supposed to stay in good enough shape to “wide bikes to the pway-gwound” with the two best little girls in the world?

My nursing and leadership “whys” are rooted more deeply. I am a nurse because “being with” someone at his or her most vulnerable is a powerful and humbling experience. I would happily give up the whole list of nursing tasks, technology, and procedures for the privilege of supporting a dying patient and their loved ones.

(Angelou, n.d.)

Seriously….how much more meaningful and real can it get? (Not much more).

The leadership part is tough. I am not naturally sparkly. The emotional, feeling, “soft” side comes with much difficulty when it is a colleague instead of patient on the other side. And so why am I a leader? Some days I am not sure. Other days, when I have removed a barrier or taught something new or just listened and I see the nurse connect the dots…I remember that my leadership “why” springs from wanting others to know theirs. Unfortunately this means I have to step outside myself and get curious (McHugh, 2013, 15 February). I have to reach out, learn about uniqueness, and change my approach appropriately. I have to give my fellow introverts the time and space to think and process. I must be sparkly enough to engage those pesky extroverts because I am the leader and it is my job to seek them out (Cain, 2012, 2 March). One team I lead is an interesting mix. In meetings I come prepared to be bright and talkative, and make sure I spend time with the two extroverts just “chewing the fat.” Later that day I seek out the introvert in the group, and solicit her feedback in a conversation that is filled with thoughtful silence. This works well, and I get really incredible input from all three colleagues. It is in stark contrast to just a few months ago when I was less thoughtful about my approach. The extroverts dominated meetings and said I did not seem engaged because I was “too quiet”. The introvert would provide input in a hallway conversation days after the meeting when it was too late to change course. It was a disaster. Learning to manage this team (and myself) has been tough. The whole growth process is not about me and sometimes deep down (or not so deep down) I don’t like it.

To top it off, I must do all this messy sweaty growing in public (Brown, 2010, June). For all to see. Because the best leaders are comfortable with change and live it out loud. How else will others learn how it’s done? I cannot expect anything from anyone that I refuse to do myself. For example, as a quality professional much of my work involves asking others to change their practice. Good leadership says that therefore I must be willing to change my own practice (Porter-O’Grady & Malloch, 2015). This means listening to ideas, changing the plan (or scrapping it and starting over), and acknowledging that there may be a better way. And as I said before…I have to do this ugly vulnerable work where others can see. The perfectionist part of me HATES this. I would rather practice something a thousand times in private than mess it up once while someone else is watching. Unfortunately, this pursuit of perfection does not accomplish anything (Goldman, 2015, 15 January). It simply perpetuates the silent, error-shunning culture that stifles good healthy transparency (Goldman, 2015, 15 January). It begs the question…What if we all were open and honest about our mistakes? How much more would we know today if we owned up to what went wrong? Would our patients be safer? The concept of just culture (focusing on transparency and systems-level management of errors while holding staff responsible for behavior) says yes to all three of these questions (Porter-O’Grady & Malloch, 2015). And this culture begins with me. The leader. Modeling it and expecting it (Porter-O’Grady & Malloch, 2015).

The rational part of me (which is most of me) wants to stop here. So let’s stop. Because up to this point, I’ve referenced high concepts and used metaphors and talked about things like growth and struggle. And it’s been good and thought-provoking and perhaps insightful. Unfortunately, fancy high-level talk only gets a person so far. It is the actual implementation of actual behavior that actually makes a difference.

(Lewis, n.d.)

So how do I, the rational (somewhat unfeeling) introvert of introverts, put over eight hundred words of my own advice into action? First, I need to get out of my own way (Abraham, 2015, 24 March). I must stop agonizing over the “right” answer and instead seek out and engage colleagues in honest collaboration (Abraham, 2015, 24 March). In getting out of my own way, I must acknowledge my own fallibility and come to terms with how failure (in public) feels (Ledgerwood, 2013, 22 June). It might never be comfortable, but it will always be critical. A few weeks ago, I had an opportunity to practice this at work. I participated in an event targeted at improving the hospital value analysis process. This process involves the nitty gritty details of finding great patient care products, getting everyone to agree that said products are great, getting the financials and logistics all worked out, and then planning for implementation. Unfortunately I was asked for input because I had recently made a rather large oversight error in the “getting everyone to agree that said products are great” step. The error was absolutely related to defects at the systems level, but I still felt terrible. I wanted to hide. Instead, I bucked up and talked about what happened and how it affected staff. Through this, I learned that others had made a similar mistake, and I was able to contribute to a systems-level solution. I still felt vulnerable and kind of terrible, but at least it was productive!

So that was step one…being vulnerable (yuck!).

The real work comes next. Engaging others is hard. I must be curious about my colleagues and seek to know them (McHugh, 2013, 15 February). I must learn how every colleague lands on the introvert/extrovert continuum (Cain, 2012, 2 March). Knowing (in part) a team member’s uniqueness allows me to frame communication and assign work in the best possible way (Semler, 2015, 15 February). This transformative leadership style honors everyone, facilitates group ownership of the project, and levels the playing field to maximize productivity (Porter-O’Grady & Malloch, 2015). 21^st century leadership principles suggest that motivation is primarily intrinsic, supporting the need for relationship and trust-building in the search for long-term success and sustainability (Porter-O’Grady & Malloch, 2015). As Dr. Tim Porter-O’Grady said in a 2016 presentation, “You cannot have accountability without ownership” (2016, 23 April). I am currently applying this incredible insight to my work with pressure injury prevention. As I round with nurses, I focus first on their perception of this critical indicator, and ask for feedback. I try and say things like, “This is your patient, and you know them best. What do you think about (x)?” Of course I still provide correction if necessary, but in a more collaborative way that respects the nurse’s expertise. It is too early to see an effect in patient outcomes, but each conversation feels more engaged and meaningful (Gawande, 2012, 2 November).

(King, n.d.)

A simple illustration called The Elephant and the Rider breaks staff engagement and change management down beautifully (4-H iGrow Video Resources, 2014, 25 September). The first step to getting an elephant and its rider to take a new path is to give clear directions. I use this a lot in my work. Communication is key here, “Use this new checklist.” Hard-wired alerts in the electronic health record are also helpful, “Are you sure you want to order this medication?” Quality improvement teams appreciate clear direction as well, “Our short term goals are x and x. These small steps will build to achievement of our long term goal of y.” After experience as a nursing leader and quality professional, this step is pretty easy. Simple messages, tools, and resources delivered at the right time and at sufficient volume tell the rider where to go (4-H iGrow Video Resources, 2014, 25 September). Jesus exemplifies this servant leadership mentality. He understood what the people needed through the principle of “being with” and came up with simple solutions. Think about it! In Matthew 22:37-39, He condenses life into two edicts; Love your God and love your neighbor (New International Version). Amazing stuff. It tells the rider exactly where to go.

And hence lies the sticky piece…motivating the elephant (4-H iGrow Video Resources, 2014, 25 September). Because the rider and elephant only go there if they want to (Porter-O’Grady & Malloch, 2015). This is where the transformative leadership as discussed above kicks in. And it is hard. I’ve talked a lot about how I plan to do this (seeking to know others and individualizing my approach accordingly) so I won’t waste time rehashing. What I will say is that the most successful projects are deeply owned by the team (Sinek, 2009, 28 September). Everyone is invested and cares fiercely about the work and one another. In my experience, if you can get to this point with a team, you’ve got it made. One of the teams I lead is like this. We can accomplish more in a thirty-minute meeting than most other groups can in six months. We all want the project to succeed because it is ours, and so everyone comes prepared to plan and leaves ready to do what needs to be done. I can’t take credit for it entirely. It’s a variety of things coming together; amazing executive leadership, the right mix of staff, and several years of sweaty effort. This work is saving lives, and if I could bottle it I would…well I would still probably work because nursing is the best but I’d also have a yacht or something. It’s that good.

(Safina, 2013, 28 June)

Once you have (magically?) convinced that elephant that it wants to move, you smooth the path (4-H iGrow Video Resources, 2014, 25 September).  This step is unglamorous and frustrating and infuriating and satisfying all at the same time. It’s about busting assumptions, knocking down barriers, and finding a new way to go (Porter-O’Grady & Malloch, 2015). It is being like Jesus and doing what needs to be done so that others can move forward. Think about Jesus for a minute. He suffered. Washed feet. Made wine. He loved and lost and cried and taught and performed incredible miracles. And then he died so that we could find our way to The Father. He smoothed the path.

Of course I will never measure up to Him. But I can sure try. I must listen closely and devote my time and the team’s time to making it easy to do the right thing (Porter-O’Grady & Malloch, 2015). Through this, if the way is clear and smooth and looks pretty good, the traffic will come (4-H iGrow Video Resources, 2014, 25 September). In my work, this step is rooted in strategies like automation, keeping information to a one-sided, large print document, and minimizing steps. A great example is my organization's work on sepsis. We have a nurse-initiated process that empowers those at the bedside to assess and act. It is great. Really great. However, two years ago I was getting a lot of feedback about the many steps it took for the nurse to complete not only patient care, but also notification of other team members (provider, laboratory, patient placement, pharmacy, IV team, etc.). To smooth the path, a group of nurses and I designed and implemented an automated pager-related communication that sent an urgent message to the team when the nurse placed the process initiation order in the the electronic health record. It only saves about two minutes, but our process use rate went up. Way up. More patients with sepsis were being identified early all because of a (relatively) small improvement. The hospital really is a complex adaptive system (Porter-O'Grady & Malloch, 2015)! In more traditional, machine-like systems there is no way a two-minute reduction would have such a large effect on the whole process (Porter-O'Grady & Malloch, 2015). In general, smoothing the path works, especially when the rider helps by pointing out the bumps. 

(Diamond Roads US, 2017)

Wow. Step two of “Better Leader 2017” got wordy. So let’s recap. Step one…get out of my own way. Step two…engage others because they matter. Step three…repeat steps one and two over. And over. And over. Fail publicly. Grow where others can watch. Get out and run.

References

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