Week 1: Intro To Leadership

WEEK 1: INTRO TO LEADERSHIP LEADERSHIP: defined as a process that involves influencing the thinking and actions of others with respect to achieving a goal, and a person can be a leader without having the formal authority of a management position (Kelly & Quesnelle, 2013 pg 170). LEADERSHIP THEORIES: • Behavioral- Autocratic, Democratic, Laissez-Faire • Contingency- Other factors in the environment influence outcomes as much as leaderships style • Leader effectiveness is contingent upon something other than the leaders behavior • Contemporary- Leadership functions necessary to develop learning organizations and lead the process of transforming change. • Charismatic, Transformational, Servant TRANSFORMATIONAL LEADERSHIP: In nursing, builds relationships and trust, creates empowerment and a culture of learning, leads and sustains change, and balances a complex system. RNAO conceptual model for developing and sustaining leadership is a nurse’s guide to their own leadership development toward achievement of health work environments. CRITICISM OF TRANSFORMATIONAL LEADERSHIP Conceptualizing leadership as dichromatic (either transformational or transactional) • Privileging commitment to organizational goals • Conceptualizing power as top-down • Privileging stereotypical male charisma and ethnocentrism • Romanticizing charisma and relying on self-report • Emphasizing formal leadership roles • Overlooking integrity and effectiveness • Overlooking commitment to employee welfare MANAGEMENT THEORIES • Scientific management- The organization is a machine that has to be run efficiently • Bureaucratic management- A hierarchy with clear superiors-subordinate communication and relations. • Administrative principles- General principles such as planning, organizing, directing, coordinating and controlling. Only one supervisor for one group of managers ESSENTIAL NURSE LEADER COMPETENCIES FOR 2020 • A global perspective or mindset regarding healthcare and professional nursing issues • Technology skills which facilitate mobility and portability of relationships, interactions, and operational processes • Expert decision-making skills rooted in empirical science • The ability to create organization cultures that permeate quality healthcare and patient/worker safety • Understanding and appropriately intervening in political processes • Highly developed collaborative and team building skills • The ability to balance authenticity and performance expectations • Being able to envision and proactively adapt to a healthcare system characterized by rapid change and chaos RELATIONSHIPS AND MOTIVATION • Human relations- People benefit and are more productive and satisfied when they participate in decisions about their work environment • Motivation theories- Motivation is a process that occurs internally to influence and direct our behaviour to satisfy our needs. Content motivation- Maslow, Two-factor theory Process motivation- Theory X,Y, & Z, and Expectancy Theory TWO FACTOR THEORY OF MOTIVATION Motivators: Achievement, recognition, the work itself, responsibility, advancement, growth Hygiene Factors: Company policies, supervision, relationships, work conditions, remuneration, salary, security THEORIES X, Y Z, Theory X - Assumes employees prefer security, direction, low responsibility - Coercion, threats, & punishment are used for control - Employees may not “want” to do the jobs (low motivation). Theory Y - Assumes that under the right conditions work can be enjoyable - Employees have self-control, discipline, and contribute creatively - Motivation is tied to group, organization, and work being done - Encourages identifying potential, supporting & encouraging employees Theory Z - focusses on motivating people through involvement and development, investing in employees EXPEXTANCY THEORY Force = Valance X Expectancy where: Force - The amount of effort one will exert to reach their goals Valence - The level of attractiveness or unattractiveness of the goal Expectancy - the perceived possibility of achieving the goal. - This calculation is used to predict the motivation of an individual to achieve a goal (negative, neutral, or positive) CLASS 2: DESIGN THINKING STANDFORD DESIGN THINKING PROCESS EMPATHIZE: - Empathy is the foundation of a human centered design process: observe, engage, immerse Uncover needs that people have which they may or may not be aware of Guide innovation efforts Identify the right users to design for Discover the emotions that guide behaviours DEFINE - The define mode is when you unpack and synthesize your empathy findings into compelling needs and insights and scope a specific and meaningful challenge. It’s critical to the design process because it explicitly expresses the problem you are striving to address through your efforts Often, in order to be truly generative, you must first reframe the challenge based on new insights you have gained through your design work. REFRAME THE PROBLEM: CAPTURE YOUR FINDINGS INDIVIDUALLY Goals and wishes: What are your consumers trying to achieve? Insights: New learnings about your consumer’s feelings and motivations- what’s something you see about your consumers expierence they maybe they don’t see? IDEATE - - The mode of your design process in which you aim to generate radical design alternatives. Mentally ire represents a process of going wide in terms of concepts and outcomes: a more of “flaring” rather than “focus” Step beyond obvious solutions Harness the collective perspectives Uncover unexpected areas of exploration Create fluency and flexibility in your innovation options Get eh obvious solutions out of your heads PROTOTYPE - Getting ideas and explorations out of your head and into the physical world Can be anything that takes a physical form: a wall of post it, a role playing activity, a space, an object, an interface, or even a storyboard Learn - Solve disagreements Start a convo Fail quickly an cheaply Manage the solution building process TEST - Testing is the change to get feedback on your solutions, refine solutions to make them better and continue to learn about your suers Prototype as if you know you’re right, but test as if you know you’re wrong To refine your prototypes and solutions To learn more about your user To rest and refine your POV CHARACTERISTICS OF A DESIGN THINKING CULTURE HOLISTIC • OPENNESS TO UNCERTAINTY, THE UNKNOWN • EMPATHETIC • INTUITIVE - BY UNDERSTANDING WHAT HAS BEEN EXPERIENCED THERE IS INCREASED CAPACITY FOR INSIGHTS • OPTIMISTIC INGREDIENTS OF A USER-FOCUSED APPROACH • HUMAN – CENTERED • MINDFUL OF PROCESS • SHOW DON’T TELL • BIAS TOWARDS ACTION • RADICAL COLLABORATION • CULTURE OF PROTOTYPING IDEAS AND TECHNIQUES TO KEEP THE PROCESS FLOWING •ASSUME A BEGINNER’S MINDSET •STORY SHARE-AND-CAPTURE •WHAT? | HOW? | WHY? •INTERVIEW FOR EMPATHY •JOURNEY MAP •I LIKE | I WISH | WHAT IF? SUMMARY OF PRINICPLES • FOCUS ON PEOPLE • BUILD PROTOTYPES FAST • STARTS MOVEMENTS • ENABLE PARTICIPATION • CULTIVATE COLLABORATION • ASK THE RIGHT QUESTIONS “FAIL EARLY, AND FAIL OFTEN! WEEK 4: LEADERSHIP TO SELF BUILDING CAPACITY TO LEAD - Personal capacity Developed social skill and abilities Learned management Environmental survival Cultivated characteristics in personality Choices Resilience MANAGE SELF Cultivation of.. - Self awareness Mindfulness Resilience To effectively engage with - Organizations Peers Patients in a meaningful way! Self-management is a component of a professional requirement for all nurses, to be a selfregulating profession, each member must be able to regulate themselves. This includes determining one’s own fitness to practice, knowledge and competency in any given task or environment, and in maintaining one’s own competence through development and execution of a learning plan. TO KNOW THY SELF IS TO LEAD THY SELF! - Self awareness SWOT analysis (strengths, weaknesses, opportunities, threats) Contributing factors: - Personal characteristics Integrity, resilience, confidence, empathy, intra vs extravert etc FOLLOWERSHIP -the upward influence, individuals behaviours and contribution to their teams that influences outcomes In the time of financial austerity it is important to focus on quality and safety. Near misses. Part of this is the development of high performing teams that can deliver safe, effective, efficient, timely and equitable, patient centered care. Errors can be both system and/or human. System include poor processes, lack of resources….. Errors are more likely when staff experience stress, overload, fatigue or illness Skill based errors include slips and lapses Knowledge-based errors occur because of lack of knowledge, Rules-based errors occur when formal rules such as policies and procedures such as who, what ,where, how and when care is delivered are applied badly. There is a direct link between complexity and the potential for errors and preventing errors requires an understanding of the risks and how to manage them. HERSHEY AND BLANCHARD SITUATIONAL THEORY - The characteristics of followers should dictate the leadership style used by leader! Hersey-Blanchard Model and Leadership Styles Hersey and Blanchard came up with four different types of leadership styles based on the task and relationships that leaders experience in the workplace. According to the model, the following are styles of leadership managers can use: Delegating style: A low-task, low-relationship style wherein the leader allows the group to take responsibility for task decisions. This is best used with high maturity followers. Participating style: A low-task, high-relationship style that emphasizes shared ideas and decisions. Managers using the participating style tend to use it with moderate followers who are not only experienced but with those who aren't as confident to do the tasks assigned. Selling style: Refers to a high-task, high-relationship style, in which the leader attempts to sell his ideas to the group by explaining task directions in a persuasive manner. This, too, is used with moderate followers. Unlike the previous style, these followers have the ability but are unwilling to do the job. Telling style: Refers a high-task, low-relationship style wherein the leader gives explicit directions and supervises work closely. This style is geared toward low maturity followers. - ATTRIBUTES OF GOOD FOLLOWERS Self aware Positive energy Prepared to question and challenge others Culturally sensitive Responsible Managing personal stress 5 FOLLOWERSHIP SYTLES: Effective: a follower who is both a critical, independent thinker and active in behaviour. They exhibit consistent behaviour to all people, regardless of their power in the organisation, and deal well with conflict and risk. They cope with change, put forward their own views, and stay focused on what the organisation needs. They understand how others see them - so are mindful. 12 They make acts of leadership often, and use their referent, expert, network and information power often in service of the organisation. Kelly called this group originally "The Stars". Conformist: this follower type is very busy, but doesn't necessarily engage their brain to think through what it is they are doing. They participate very willingly but don't question orders. They will avoid conflict at all costs and take the quietest path, but will defend their boss to loyal extremes. Kelley originally named this follower type "The YesPeople". Passive: think of a two year old who doesn't want to do something and just goes floppy. This is the passive follower. They don't engage their brain enough, nor do they take concrete action. Robert Kelley called this group "The Sheep". While not showing any initiative nor responsibility, this follower type can be the result of micro-managers or a negative, over-controlling and blameoriented culture. Alienated: this follower thinks extremely well, but for some reason often snipes from the sidelines. They have got stuck where they are, are very negative and feel they have lost their power. They have seen 'too much', have become bitter in their work from being passed over for promotion, or from having stayed too long in one position. Pragmatic Survivor: this follower type I think of as the organisational 'canary in the mine-shaft'. They can flip between different followership styles, to suit each situation, and are our early warning system when the organisation's culture is starting to change for the worse. We all know that there are some people who can see the writing on the wall early: identify them and use them to ensure that your work culture remains healthy at all times. SOCIAL INTELLIGENCE ATTRIBUTES - Verbal fluency and conversational skills Knowledge of social roles Effective listening skills Understanding what makes other people tick Role playing and social self efficacy (can interact with lots of different people) FROM FEAR TO COURAGE - People who succeed just do more Urgent optimism Permission to fail Let go of comparison Drawing confidence “The state of mind Bandura calls self-efficacy is closely related to….creative confidence” CONFIDENCE!! RELATIONAL LEADERSHIP Transactional/Transformational leadership 3 types of leaders    Non-leaders or laissez-faire style Performance - contingent rewards and negative feedback Motivate through vision and inspiration CARNA module – transformational leadership practices endorsed Criticism of transformational leadership - Limitations (Hutchinson and Jackson, 2013) from text  Conceptualizing leadership as dichromatic, binaries  Privileging commitment to organizational goals  Conceptualizing power as top-down  Privileging stereotypical male charisma and ethnocentrism  Romanticizing charisma and relying on self-report  Emphasising formal leadership roles  Overlooking integrity and effectiveness  Overlooking commitment to employee welfare “…the formation of a seeing heart, an informed mind, and a little courage.” (Parks, 2005, p. 245) Other styles of leadership: authentic leadership, Resonant leadership, congruent leadership Relational leadership Leadership is a relational process that occurs and is enacted among people and within context. Involves inter-personal, intra-personal and contextual elements Formal leaders still essential – Storch, Schick-Makaroff, Pauly & Newton (2013). Relational inquiry 2 components: a relational consciousness and inquiry as a form of action – interrelated and overlapping (see Chapter 1). Relational inquiry provides tools to:    See yourself as a leader Critically consider how you are exercising leadership in any particular moment Consciously cultivate your leadership practice Eight practices of Relational Leadership 1. 2. 3. 4. 5. 6. 7. 8. Get on the balcony. Find out where people are Listen to the song beneath the words. Distinguish technical from adaptive challenges Anchor yourself Diagnose the situation Create a sanctuary Enlist your relational inquiry toolbox to help you choose your actions. What is in your relational inquiry toolbox? Curiosity, vulnerability, attentiveness, non-individualist, orientation to well-being, being a do-er, contextual approach, + + + WEEK 5: RELATIONAL LEADERHSIP: WHY YOUR LEADERSHIP MATTERS AS A NURSE DISPARITIES - People can’t read or write Approx. 1 mil. Children die from poverty each year A mill. Children die a year for want of clean water and sanitation 13 billion would satisfy global food, nutrition and basic needs 9 billion would satisfy global water and sanitation needs GLOBAL SPENDING - Basic education in the world $6 B US Cosmetics in the US $8 B US Water and Sanitation for everyone $9 B US Ice Cream in Europe $11 B US Reproductive health for women $12 B US Basic health and nutrition $13 B US Pet foods in Europe and US $27 B US Business entertainment in Japan $45 B US Cigarettes in Europe $60 B US Alcoholic drinks in Europe $205 B US Illicit drug use in the world $600 B US Military Spending $980 B US LEADERSHIP - See the present for what it really is See the future for what is could be And then take action to close the gap IT IS ACTION NOT POSITION CURRENT HEALTHCARE WORKFORCE • Poor work environments • Overtime (paid/unpaid) • Workload • Ill-health • High job strain • Patient safety issues • Poor leadership and supervision PERFERRED FUTURE • Safe quality care based on evidence • Influence patient outcomes • Meaningful work • Effective work • Balance (life and work) • Collaborative multidisciplinary teams LEADERSHIP DISTINCTIONS - Management is doing things right; leadership is doing the right things. - Peter Drucker  Management is about reducing risk; keeping things the same, standardized. Leadership is about taking calculated and planned risk, in order to achieve a preferred future. LEADERSHIP STYLES  How you accomplish leadership.  Reflects your approach to accomplishing the goal  Arises from your self-awareness  Frames your relationships with others  Can lead to good or bad results EMOTIONAL INTELLIGENCE - Self awareness Sociopolitcal awareness Self-management Managing relationships - Resonant Visionary Coaching Affiliative Democratic - Dissonant Pacesetting Commanding VISIONARY LEADERSHIP  Inspiring  Empathy  Achievement focused  Supportive of innovation  Empowering  Integrity  Relationship focused (accessible)  Team-builder DEMOCRATIC LEADERSHIP Empathy Participatory Power & influence sharing Empowering Team-building PACESETTING LEADERSHIP  Lack of empathy  Not participatory  No investment in staff development  Achievement focused  No sharing of power and influence  Not supportive of staff innovation COMMANDING LEADERSHIP  Lack of empathy  Lack of conflict management  No investment in staff development  Non-empowering  No sharing of power and influence  Task versus relationship focused  No recognition of achievement BAD LEADERSHIP Incompetent Leadership Rigid Leadership Intemperate Leadership Callous Leadership Corrupt Leadership Insular Leadership Evil Leadership LEADERSHIP SYTLES FOR NURSES: Reltional - Transformational Sociorelational Emotionally intelligent Resonant Relational Consideration Task focused/ absent - Transactional Instrumental Initiating structure Management by exception Passive avoidant management Laissez-faire RELATIONSHP BETWEEN LEADERSHIP PRACTICES AND PATIENT OUTCOMES  Systematic review through 2007 (7 studies) Transformational leadership is related to - significantly fewer patient adverse events (3 studies) - significantly fewer complications (2 studies) - significantly higher patient satisfaction (2 studies) - significantly lower mortality (1 study) REASONANT LEADERSHIP COMPETENCIES  Inspiring  Empathy  Achievement focused  Supportive of innovation  Empowering  Integrity  Relationship focused (accessible)  Team-builder  Developing others  Conflict management  Participatory  Recognition  Power & influence sharing 1. For improving nurse outcomes through relational Leadership Styles (Cummings et al. 2005, 2007, 2010, 2011) 2. For improving patient outcomes (Cummings et al., 2010, Wong & Cummings, 2007) 3. For improving work environments (Cummings et al, 2010; Schalk et al., 2011) 4. For coaching staff performance (Brady et al., 2011; Carey et al., 2011) 5. For supporting staff to collaborate on care decisions (Cummings et al 2005, 2007) 6. For empowering managers to do their best work (Lee & Cummings 2008, 2008; Brown et al, 2012) WEEK 6: CRITICAL THINKING, RELATIONAL INQUIRY AND SYSTEMS THINKING URL Links for graphics on previous slide ● http://trinityperformancesolutions.com/the-power-in-one/ ● https://actionresearchplus.com/relational-action-inquiry-co-lab/ Learning Outcomes • Define critical thinking • Understand components of critical thinking including dispositions and skills • Understand personal critical thinking strengths and areas for further growth • Explore the role of thinking in nurse leadership • Define systems thinking • Comprehend the uses and application of systems thinking in healthcare • Explore ways to develop design and systems thinking • Compare relational inquiry and systems thinking CRITICAL THINKING “Critical thinking is a discipline that incorporates elements of reflection and thinking process into planning, action and evaluation” (Porter-O’Grady et al., 2005, p. 29) “A mode of thinking about any subject, content, or problem- in which the thinker improves the quality of their thinking by skillfully taking charge of the structures inherent in thinking and imposing intellectual standards upon them” (Scriven & Paul, 2004). Finding out information that is unknown! Discovering/investigating further! Perspectives ● Thinking ahead: anticipating what might happen in a scenario ● Thinking in action: what am I doing right now? ● Thinking back: how might have I done better? How might I do better? Involves: ● Critical reading ● Critical listening ● Critical writing ● Critical speaking Critical Thinking is an umbrella term encompassing the concepts of Decisionmaking and Problem-solving. DECISION MAKING • “Considering and selecting interventions from a repertoire of actions that facilitate the achievement of a desired outcome” (DeLaune & Ladner, 2011). • Individual variables • Creative thinking • Education • Self concept • Context Factors involved in decision making -individual variables- such as experience and knowledge; creative thinking ability, education, self concept and environmental and situational stressors Intrinsic factors:  To gain an objective perspective frame the problem outside of yourself      Subjective perspective is characterized by decision making that considers context and feelings of others. Valuing harmony and use tact with others Knowledge and experience are influenced by past experience that includes education and decision making experiences. Competence: the ability to practice in a specific role, the influence of practice on competence and the integration of knowledge, skills, judgements and abilities Self-confidence in decisions that you make. It is learned through repeated successful application of the decision-making process Stress arises when people perceive the environment to be demanding because it exceeds their resources and personal well being Extrinsic factors    Organizational climate and culture Client choice and rights Legislation and regulation PROBLEM SOLVING An active process like the nursing process • Identify the problem • Gather and analyze data • Generate alternatives • Select an action • Implement • Evaluate Which answer can replace the question mark? What is the 10th number in this sequence? 5, 11, 17, 23, 29, 35, …. A. 51 B. 53 C. 59 D. 61 What is the numerical value of the letter ‘h’ A) B) C) D) 10 8 7 5 A Brief History of Thinking SOCRATES 470 – 399 BC ● Thinking in a systematic way – deeper realities ● Socratic Questioning PLATO c. ? 429 – 347 B.C.E. ● A prolific writer and one of the first philosophers. ● Concerned with Forms and Ideas FRANCIS BACON ● Systematic thinking – Empiricism • Habits of thought • Scientific method c. 1561–1626 René Descartes c. 1596 - 1650 ● Dualism and Rationalism • Principle of systematic doubt ■ Questioned, doubted, tested – what truth can be known can be reasoned out ■ Utilitarianism ● The most good for the most people ■ Secularism ● “focus on the material world, without recourse to religion” (Livingston, 2006, p.273) MODERN THEORETICAL WORK INTO CRITICAL THINKING The Standards must be applied to The Elements as we learn to develop Intellectual Traits INTELLECTUAL STANDARDS What a nurse is using in the moment to make decisions, impacts on one’s ability to make a good decision. What is significant to you may not be significant to others; therefore we have to go meet up with our target community for the project to find what’s significant to people            Clarity Significance Logical Concision Precision Relevance Depth Suitability Accuracy Fairness Breadth  Beauty ELEMENTS OF THOUGHT          My point of view, my train of thought: why did this person do this? What was their train of thought? Purpose Points of View Information Inferences Concepts Implications Assumptions Conclusions Questions at Hand INTELLECTUAL TRAITS          We can grow and evolve these traits to achieve a good nursing lens. We encourage these traits through clinical practice. Intellectual Humility Intellectual Autonomy Intellectual Integrity Intellectual Courage Intellectual Perseverance Fairmindedness Intellectual Empathy Intellectual Curiosity Confidence in Reason CRITICAL THINKING IN NURSING LEADERSHIP  Interpretation o Analysis o Inference o Evaluation o Explanation o Self regulation  Interpretation of data and circumstances  Analysis to identify a structured and intended inferential relationship between processes, structures, statements, concepts descriptors, questions and other frameworks that may be useful  Inference is important to draw reasonable conclusions based on the analysis  Evaluation is about assessing the viability and credibility of the representations, descriptions, perceptions, experiences, situations, beliefs and judgments as a way of assessing and evaluating the strengths of these elements  Create a viable explanation built on the conclusion you have draw from the evaluation. Proof of your decision=making process  Self regulation is about reviewing the thinking process to double-check your decision PROBLEMS ● Problem finding ● Problem solving ● Nursing problem solving – • Nursing process ADPIE • Assessment • Diagnosis • Planning • Implementation • Evaluation GROUP DECISION MAKING ● Nominal group technique ● Delphi technique ● Consensus building ● Group think • Nominal group technique – nonverbal. First no discussion and group members write out their ideas on an issue. Second presentation of the group members ideas with the advantages and disadvantages. Third discussion. Fourth private voting • Delphi – questions are distributed to group members for their opinions and the responses are then summarized and disseminated to the group members. Can be an iterative process, until the full exploration has occurred and a decision can be reached. • Consensus means that all group members fully support the decision regardless of whether they totally agree- requires more time for discussion Talk about Peace and Power • Group think discourages questioning and divergent thinking and can hinder creativity and usually leads to inferior decisions. You know you have group think when group members have an illusion that they can do no wrong, outsiders are stereotyped, and group members reassure one another that their interpretation and perspectives are correct regardless of evidence to the contrary • SYSTEMS THINKING ● “where the whole is more than the sum of the parts”(Stalter & Mota, 2018) • Systems thinking is a holistic approach to analysis that focuses on the way that a system's constituent parts interrelate and how systems work over time and within the context of larger systems. • 6 Fundamental Concepts of Systems Thinking ● Interconnectedness ● Synthesis ● Emergence ● Feedback Loops ● Causality ● Systems Mapping Acaroglu, L. (2017). Tools for systems thinkers: The 6 fundamental concepts of systems thinking. Retrieved online Jan 28, 2020 from https://medium.com/disruptive-design/tools-for-systems-thinkers-the-6fundamental-concepts-of-systems-thinking-379cdac3dc6a The following is copy and pasted from the above website. It is completely the work of Layla Acaroglu. Interconnectedness • Essentially, everything is reliant upon something else for survival. Humans need food, air, and water to sustain our bodies, and trees need carbon dioxide and sunlight to thrive. Everything needs something else, often a complex array of other things, to survive. • “A system is a set of related components that work together in a particular environment to perform whatever functions are required to achieve the system’s objective.” ~ Donella Meadows Synthesis • In general, synthesis refers to the combining of two or more things to create something new. When it comes to systems thinking, the goal is synthesis, as opposed to analysis, which is the dissection of complexity into manageable components. Analysis fits into the mechanical and reductionist worldview, where the world is broken down into parts. • But all systems are dynamic and often complex; thus, we need a more holistic approach to understanding phenomena. Synthesis is about understanding the whole and the parts at the same time, along with the relationships and the connections that make up the dynamics of the whole. Emergence • Emergence is the outcome of the synergies of the parts; it is about non-linearity and selforganization and we often use the term ‘emergence’ to describe the outcome of things interacting together. • A simple example of emergence is a snowflake. It forms out of environmental factors and biological elements. When the temperature is right, freezing water particles form in beautiful fractal patterns around a single molecule of matter, such as a speck of pollution, a spore, or even dead skin cells. Feedback Loops • Since everything is interconnected, there are constant feedback loops and flows between elements of a system. We can observe, understand, and intervene in feedback loops once we understand their type and dynamics. • The two main types of feedback loops are reinforcing and balancing. What can be confusing is a reinforcing feedback loop is not usually a good thing. This happens when elements in a system reinforce more of the same, such as population growth or algae growing exponentially in a pond. In reinforcing loops, an abundance of one element can continually refine itself, which often leads to it taking over. • A balancing feedback loop, however, is where elements within the system balance things out. Nature basically got this down to a tee with the predator/prey situation — but if you take out too much of one animal from an ecosystem, the next thing you know, you have a population explosion of another, which is the other type of feedback — reinforcing. Causality • Understanding feedback loops is about gaining perspective of causality: how one thing results in another thing in a dynamic and constantly evolving system (all systems are dynamic and constantly changing in some way; that is the essence of life). • Causality as a concept in systems thinking is really about being able to decipher the way things influence each other in a system. Understanding causality leads to a deeper perspective on agency, feedback loops, connections and relationships, which are all fundamental parts of systems mapping. Systems Mapping • Systems mapping is one of the key tools of the systems thinker. There are many ways to map, from analog cluster mapping to complex digital feedback analysis. However, the fundamental principles and practices of systems mapping are universal. Identify and map the elements of ‘things’ within a system to understand how they interconnect, relate and act in a complex system, and from here, unique insights and discoveries can be used to develop interventions, shifts, or policy decisions that will dramatically change the system in the most effective way. APPLICATIONS OF SYSTEM THINKING ● View how caregiving decisions have an impact on organizational health outcomes ● Getting out on the balcony ● Reinforce nurses’ roles in safety and quality improvement ● Promoting patient centered care ● Evidence based practice ● Root cause analysis ● Informatics Nurse sensitive outcomes. Helps to think of the interdependencies Patient centered care is promoted and sustained through collaborative practice such as interprofessional rounds, huddles, EBP is integrating current best practice Root cause analysis or near misses to look at system issues that make it possible for errors Using the five w’s to determine causes Root Cause Analysis Repeatedly asking the question “Why” (5 Why’s is considered adequate to get to the root cause) you can: ● peel away the layers of symptoms which can lead to the root cause of a problem. ● Very often the ostensible reason for a problem will lead you to another question. ● Although this technique is called “5 Whys,” you may find that you will need to ask the question fewer or more times than five before you find the issue related to a problem. Benefits of the 5 Why’s ● Help identify the root cause of a problem. ● Determine the relationship between different root causes of a problem. ● One of the simplest tools; easy to complete without statistical analysis. When are the 5 Whys Most Useful? ● When problems involve human factors or interactions. 5 Whys Example A patient is two days post-op from a knee replacement calls for help and reports that they are not feeling well, are cyanotic, report pain on the right side of their chest, are short of breathe, and O2 saturation is only 72% on 2L by nasal canulla. You increase the oxygen and call the doctor who orders a stat spiral CT, suspecting a pulmonary embolism (PE). The CT is positive, and upon review, the team notes that the patient did not receive prophylactic anti-coagulants when they came back from the OR, despite it being ordered. WHY didn’t the patient get the med? 5 Whys Example You review the chart and it appears that the nurse recorded that the medication was not received from pharmacy on the previous shift. There is documentation that a request was faxed down to the pharmacy, but the med did not arrive. This was handed over to the current nurse. You look back further, and see that a request was also sent yesterday. WHY didn’t the medication come up to the patient? 5 Whys Example You follow up with the nurse who cared for the patient on the previous day, and they state that they also faxed a request for the pharmacy to fill the order, but it was not received. They remind you that this was included in the bedside shift report, and that the nurse caring for the patient was aware. WHY didn’t anyone call the pharmacy? 5 Why’s Example You follow up with the nurse who cared for the patient on the previous day, and they state that due to being short staffed yesterday, they didn’t have time to call the pharmacy and wait on hold, so they just included it in the bedside shift report, thinking that it would be addressed the next day. Unfortunately, the night staff didn’t hand this over to the incoming day staff as it wasn’t written down on the kardex or the whiteboard. WHY wasn’t it handed over properly? Why didn’t the pharmacy send the med? 5 Why’s Example You call down to the pharmacy, and the pharmacy tech states that they didn’t receive any of the faxed requests. You print a fax report and it says all the requests were delivered. You follow up with the pharmacy again and the pharmacy tech realizes that the fax machine is out of paper. What were the system problems that contributed to this serious adverse event? DEVELOPING DESIGN AND SYSTEMS THINKING ● Design thinking ○ The design team observes and studies stakeholders for solutions to problems ● Systems thinking ○ Considers social systems. The stakeholders are the designers “In systems thinking design is a creative act that attempts to estimate how alternative sets of behavior patterns would serve specified goals” Design has become the preferred choice for problem solving is systems because of a common belief that the future can be created and that you need to dissolve problems through redesign of the system from patient perspectives. RELATIONAL INQUIRY ● “Relational inquiry requires (1) a thorough and sound knowledge base; (2) sophisticated inquiry and observational and analytical skills; (3)strong clinical skills including clinical judgment, decision-making and clinical competencies; and (4) particular ways of being” (Hartrick Doan & Varcoe, 2015 p. 3-4) ● Two essential components – relational consciousness and inquiry as a form of action - a VERB. RELATIONAL INQUIRY STRATEGIES ● Orienting in living relational experience ● Relating to and with “what is” ● Collaborative knowing/not knowing ● Recognizing and responding to patterns Orientating in the relational experience is orientating toward the relational complexities and interplay occurring in any situation in order to work intentionally and skillfully in response to them. -whose well being are you directing your actions to- patient, nurse, system how are you orientating to the 5 Cs (compassionate, curiosity, commitments, competent, caring)  *how are you orientating to the 5 Ws  how are you orientating at the intrapersonal, interpersonal and contextual levels  are you orientating problems relationally  Relating to and with what is- is about not trying to fix everything     Am I letting be to know what is? Letting be is different than doing nothing Am I discerning the specifics? Focusing broadly and specifically Am I in sync? Mindfullness to calm yourself down so that you can deal with the situation Am I being in the complexity and difficulty- keeping peoples and families at the center of any action Collaborative knowing/not knowing- collaborating. Making space to collaborate with families the patient is the knower      Am I following the lead? We must mindfully look and listen to what is of significance to them assessment as an inquiry process *A I listening to and for? Listening fully as it is both an knowledge generating processes and an intervention Am I looking beyond the surface? To see relations in a situation and seeing patients beyond this one health encounter Am I enlisting multiple forms of knowing? Ie empirical, ethical, aesthetic and sociopolitical knowledge Am I willing to backtrack? Recognize when you have jumped to a conclusion and may have made an assumption Recognizing and responding to patterns. Support the discernment of salient patterns playing out in any situation and respond effectively with targeted action. Pattern recognition. Seeing connections, noticing discrepancies, noticing simplifications   Am I creating opportunities for choice-making/- of patients and families *Am I creating opportunities for enhancing capacities and addressing adversities? Strength based nursing, seeing capacity that people have to manage their own problems COMPARING SYSTEMS THINKING AND RELATIONAL INQUIRY SYSTEMS THINKING ○ Looking broadly at causes or potential causes of problems ○ Root case analysis ○ Patient centered care, focus on client experience RELATIONAL INQUIRY ○ Focus on patients and families ○ Interpersonal, Intrapersonal and contextual factors ○ Looking at people broadly beyond a specific health encounter