Posted: May 1st, 2024

TRANSFORMATIONAL COACHING

At the completion of this chapter, the reader will be able to • Recognize the key elements of coaching within a fast-paced organization in highly charged and changing times. • Translate the characteristics of transformational coaching into the planning and implementation of new skill formation. • Describe the needs of teams in a system and explain the importance of team leadership. • Identify the fundamentals of the learning organization and the dynamics of learning leadership.• Name the steps of revolutionary and innovation coaching and how it applies to the role of the leader.
In the 21st century there is no role that has been more greatly challenged and that requires a whole new frame for expression than that of the leader. Much of the work of leaders is directed toward helping others confront the vagaries of major changes occurring in the work and structure of the workplace. Leaders must exhibit a new set of skills to create the conditions for new accountabilities while ensuring positive outcomes. The mental models and performance expectations of staff require heavy retooling to ensure they can thrive in the new work environment. Leaders will learn some of the elements of leading in this new environment and the steps necessary to get staff engaged and motivated to change and grow in a context demanding a different way of delivering health care.
Leadership is not so much who you are as what you do with who you are. Leadership is not a state of being. It is instead a set of internal tools possessed by a person with the energy and skill to use them well. Much of the work of leadership in this new century consists of transferring new skills to the people who live and work in organizations. Because this is a time of great change, increasing complexity, and fast-moving advances in technology, people are finding it increasingly difficult to meet the new demands that are arising. Social and technological forces are conspiring to create

the conditions that affect how people work, relate, and plan for their own future. The role of the leaders in this process is to live the positive experience of change and master the ability to engage the questions and challenges that accompany change. Staff members are watching closely to see how the leaders embrace and engage the challenges of change, for it is by observing how leaders do this that staff members create a vision for their own adjustment to change. The leaders’ role modeling of adjustment to change encourages them to adapt to change and gives them the necessary techniques.
FROM RESPONSIBILITY TO ACCOUNTABILITY In the coming age, responsibility is no longer the key element of work performance. Historically, a worker’s performance was judged to be acceptable if the worker simply did what he or she was supposed to do. For the performance to be evaluated as excellent, the worker had to do this work and do it exceptionally well. In the 20th-century workplace, the focus on responsibility was prevalent in every aspect of the definition of work and the measurement of performance.
This focus was structured in the workplace in several ways. First, job descriptions were often laundry lists of functions and activities. In other words, they zeroed in on the activities of work rather than their product. Second, performance evaluations reviewed the work someone did— the functions of work and the ability of the person to do the work. The person’s behavior and the ability to get along with others were included in the list of “competencies.” How well the person did the work, not whether the work was worthwhile, determined whether the person was to be specially rewarded for doing it.
Third, the evaluation of work tended to concentrate on the quality of the work processes— how the work wasamount of time the worker expended in delivering a service or product as compared with the average. Slavish attachment to process has been an earmark of the 20th-century workplace. Process improvement, process evaluation, process measurement— these all concern what workers do rather than what they achieve. One reason for this may be that, in health care, the relationship between outcome and process has never been well understood.
In the 21st century, work is starting to be viewed from the perspective of its outcomes. Research has shown that focusing on outcomes alters work processes and the elements of the work. Indeed, it is now clear that all processes gain their meaning from their results or products. In other words, a process is considered valuable to the extent it relates “tightly” to the desired outcome. Much effort is now being expended on investigating the “goodness of fit” between work processes and their intended outcomes and improving the fit where possible.
In short, it is the Age of Accountability, and the major role of leaders is to move people and organizations from responsibility to accountability— from a narrow focus on processes to a perspective that encompasses processes and results . In the Age of Accountability, leaders are expected to ensure that all components of the “fit” between processes and results come together into a complete vision of the work and its products. Among other tasks, they need to define expected outcomes for all actions and activities and to establish aggregate performance measures for evaluating the work performed by teams.
This movement toward the appreciation of outcomes requires a tremendous reorientation of the work and the workers. For the whole of the 20th century, the emphasis was on functions and work processes, whereas now it is on creating sustainability in a time of rapid technological change. Focusing on work processes is no longer a viable strategy because each has such a short life span. The appropriate goal is to define the critical integration between means and ends, products and processes. This must be done with an understanding that sustainability is not resident in the work or even the incremental product of a given process or time. It instead results from a continuum of efforts that, when connected together, indicate the journey to be taken to improve the conditions or quality of life.

Responsibility versus Accountability Responsibility (20th Century) Accountability (21st Century) • Process • Product • Action • Result • Work • Outcome • Do • Accomplish • Task • Difference • Function • Fit • Job • Role • Incremental • Sustainable • Externally generated • Internally generated
Accountability is always internally generated. It rests first and foremost within. Specifically, accountability is the result of a person’s commitment to advancing, improving, growing, adapting, and enhancing his or her own life experience. For that person, accountability is generated out of the energy that the person brings to the exercise of living, whether at work or in other realms of life. In addition, accountability depends on individuals’ having complete ownership of what they are and what they do and on their making a commitment to take their talents, energies, and skills and apply them in ways that make the circumstances of life better for themselves and for others. In an organization, in particular, accountability depends on the members’ joining in a concerted collective effort to achieve the organization’s ends. If each person brings his or her energy, gifts, skills, and knowledge to bear fully on the work to be done, the outcomes of that work are ensured. Everyone in the workplace has a right to expect a commitment from all to apply themselves and use their skills and talents to the fullest. Furthermore, everyone has a right to expect that each team member (or employee in a group work context) will have a positive relationship with the other members and exhibit the same level of energy and commitment to the work and the products.
Key Point In an organization, the leader has the responsibility of creating a sustainable structure for work and ensuring a good fit between the organization’s goals and processes. Congruence here guarantees that the system functions as it should.
Leaders have the obligation to make certain that the processes and structures needed to support ownership of the work are fully present. Each of the three main components— structure, relationship, and process— should be directed toward facilitating ownership so that the organization’s work can be sustained and advanced. If the energy and desire of the worker cannot be maintained, it is impossible to sustain and advance the work of the organization.
The principles of human action and interaction must be clearly understood and applied. Human beings are dynamic and complex beings. When the commitment and motivation of colleagues are at high levels, conflicts and other challenges arise. The work processes in place must be designed with the understanding that such challenges are normal and to be expected. They should also be designed to anticipate these challenges and address them in a way that increases the probability of good outcomes and sustains the work and the relationship between the employees.
The recognition that the vagaries of human behavior and relationship are normal is critical to the role of leadership in an accountability-based organization. The leaders of such an organization must be aware of the whole spectrum of human dynamics and be capable of managing the vagaries of these dynamics. They must have tools and techniques to maintain the energy and focus of the workplace and its members in a way that advances the work and the achievement of desirable outcomes.
One of these techniques is to establish the expectation that principles are consistently applied and that accountability is maintained. If this expectation is made clear to all members of the organization, along with a commitment to not permit behavior inconsistent with this expectation, the members will try to live up to the expectation and act appropriately. In accountability-based work processes, the range of acceptable practices and behaviors is enumerated and articulated by the members, and processes for creating consistency are available to help members address those issues outside the agreed framework. Membership in a workgroup, like membership in any other collaborative enterprise, requires that the expressed expectations for the members are fulfilled; otherwise, the goals of the group are threatened or only partially achieved.
In regard to accountability, there are patterns of behavior that reflects negative characteristics that ultimately impede personal expression and team interaction in the workplace (Lencioni, 2008). Which ones fall below the line and which above depends on the particular culture and context of the workplace. The two sets of behaviors must be clearly outlined by the members to form a framework for the principles that determine the rules of engagement in the work relationship. The structure and process of leading and managing must be designed to ensure that the above-the-line behaviors are sustained. When the below-the-line behaviors emerge, the processes and methodologies in place must “click in” so that these behaviors can be addressed quickly and effectively. Quick response to behavioral variances is essential to prevent subsequent and sometimes irresolvable problems.
Point to Ponder Typically, about 90 percent of the leadership role is devoted to managing relationships. If a leader determines that managing relationships takes up a much smaller percentage of work time than that, the leader may need to reassess her or his priorities.
It must be remembered that accountability really means something. So often in the past few years accountability has lost its central meaning and its impact on organizations and people. The scandals of the 1990s and the early 2000s pointed out just how little understanding of accountability really exists. Accountability assumes that the leader accepts the full responsibility of that which occurs under the auspices of his of her leadership. It doesn’t matter whether someone else “did the deed”; it only matters that the leader bears accountability for the actions ofthose for whom he or she holds leadership responsibility.
Accountability has three major elements that indicate its presence: the right to decide and act, the power to decide and act, and the competence to decide and act. Productive accountability requires all three to be present in the role of the leader to be expressed. Failure in the exercise of any of these three elements always results in a failure of accountability. Personal and organizational conflict always result when any one of these elements is missing from the expression of accountability. Persons and organizations always suffer when there is a failure to integrate or appropriately express these components of accountability in the best interest of persons and of organizations.
The dynamics of relationship and work are highly complex and variable. It might seem good if the framework for human behavior in the workplace were permanent and unchanging, but a permanent framework, besides being impractical, would also be boring. It is within the course of relationships and interpersonal demands that the vagaries of life always have an impact. Personal patterns of behavior and changing patterns of interaction challenge the best work environment.
GROUP DISCUSSION Responsibility and accountability often are used interchangeably, but they actually have different meanings. Based on the analysis of accountability in this chapter, compare how to change behavior in an accountability-based organization and how to change it in a responsibility-based organization.
Leaders are always trying to read work situations. They assess the demands and the dynamics of intersecting and interacting variables and make judgments about how they affect the work being done and the relationships between the workers. They know that these variables create challenges for work relationships and functions— challenges that they are required to address. Research in the area of accountable behavior and organizational considerations is a work in progress. Thus leaders need to continually review this research to gain up-to-date information on how to ensure that work processes result in desired outcomes.
TRANSFORMING WORK AND THE TRANSFORMING WORKER During the current era, the major leadership task is to change the mental model of and framework for work. In all segments of society, work and the workplace are changing too fast for most people to keep up. It is up to the leaders, therefore, not only to guide the transformation of work (see Chapter 1) but also to help people make the adjustments that the transformation requires.
For transformation to occur, there must be a fundamental change in thinking. Workers, for example, must completely reconceptualize their roles. Most people are satisfied with establishing an accustomed pattern of work and a set of rituals. Eventually, they become so accustomed to the pattern and rituals they see them as essential to the work. Indeed, they begin to see the work from within these and ultimately become suspicious of anything that threatens what has become normal for them. Despite the fact that their adherence to patterns and rituals may impede necessary changes, leaders who are agents of change should not criticize them. Leaders who are trying to bring about certain changes often become so unhappy with people’s attachment to rituals that the rituals themselves become the visible representation of people’s unwillingness to change. After all, people’s attachment to the routines of work does ensure that the work not only gets done but also meets certain standards of performance. Their attachment may obstruct improvements in quality, but it does virtually guarantee the performance of the activities necessary for the work to be accomplished in some fashion. In fact, even in transformation leaders are looking to establish new patterns of work, even if the patterns soon need to be revised because of further rapidly changing circumstances. In addition, leaders often want workers to establish the same kind of attachment to a new pattern even though they complained when the workers were attached to the old patterns.
There are also organizational dangers to transformative thinking. This type of thinking is characterized by a willingness to seriously question all current processes and can threaten organizational stability. During transformation, leaders engage the staff and other stakeholders in a dialogue and hear things that would not normally be expressed. In fact, to make the transformation succeed, the leaders must be open to new ideas and be willing to listen to all kinds of responses from the full range of stakeholders. Even the thinking that underpins the changes must be subject to question and exploration if their implementation is to be appropriately rigorous and thorough. The environment necessary to support this kind of thinking creates a level of challenge and instability that even the leaders may not be comfortable with.

Key Point There is a whole body of research demonstrating that an open, inclusive, and accountable structure for work creates extra opportunities for creativity and innovation.
The process of transformation requires an environment in which creativity and change are embraced. In other words, discourse, deliberation, dialogue, consensus building, and experimentation must be viewed as safe and appropriate strategies. Leaders must create this environment before they can expect to see innovation and engagement with change become routine in their units or services. If the staff members do not feel safe in the presence of change, they certainly will not feel comfortable making change.
Transition from 20th-Century Work to 21st-Century Work. The transition involves moving through the stages of change from predominantly vertical organizations to more horizontal systems.
Causes of Transformation • Destabilized environment • Noise • Culture of change • Loss • Emerging reality • New financial realities • Demand for new behaviors • Work process changes • Shifting technology
Living in an environment of horizontal relationships and accountability-based controls rather than of management-driven decision making and vertical controls is a different experience for all parties. The former type of environment, however, is essential for transformative thinking and acting. No research suggests that rigid vertical control structures lead naturally to change and innovation. On the other hand, a whole body of research indicates that an open, inclusive, and accountable work structure creates numerous opportunities for creativity and innovation. Biology has lessons for organizational survival. Biological research shows that growth and adaptation are required for life to continue. If the environment changes noticeably because of some cataclysmic event or the accumulation of small alterations, plants and animals either adapt or cease to exist. Indeed, past changes form the foundation for future changes, and adaptation to earlier changes determines the level of adjustment to future changes.
The same is true of organizations and other forms of social life. Even minor changes can upset the delicate balance that allows certain kinds of organizations to thrive and can turn the environment into a threatening place for them. For organizations to survive in this world, many of the processes and behaviors, rituals and routines that have their foundation in the 20th century must be replaced by new processes and behaviors. The transition requires true leadership and a transformational format for radically altering everything that workers know and do.
GROUP DISCUSSION In the emerging world of health care, the major leadership task is to transform people’s attitudes and insights regarding the changes that are required of them. On a flip chart, list changes that affect what healthcare providers do and also list attitudes toward the demand for change. Order the attitudes based on their potential influence and discuss how a healthcare leader could go about altering two of the most important to smooth the transition to new ways of working.
EVOLUTION AND REVOLUTION The only difference between evolution and revolution is the rate of the change process— the amount of time it takes for the changes to occur. Certainly, technology, because of its high rate of innovation, can be said to be undergoing a revolution, but the resulting changes in society are occurring at more of an evolutionary pace. It takes much longer to incorporate social and behavioral changes than to implement technological advances. Yet both types of change must be accommodated, and people need to adjust at both a fast rate and a more studied rate. The challenge is to know which is which and to attach the right rate of accommodation to the right process.
Leaders in an organization need to recognize the demand for change in enough time to respond correctly— at the right time and in the right format. Of course, not all changes are known far enough in advance to allow an appropriate and timely response. Nonetheless, the chance of responding correctly is increased if the leaders assess the probability of any reasonably likely change and consider its expected effects. By anticipating the kind of changes that will occur, developing an understanding of their conditions and circumstances, and passing this understanding on to the staff, leaders ensure that the staff can react appropriately. In short, leaders must be signpost readers and articulate trends clearly enough to create a picture of their impact. Leaders must also be transformational agents. In coaching staff members to embrace necessary changes, leaders must show the same tone, enthusiasm, and skill in adaptation they expect from others. Seeing the signposts is simply the first step in transferring the information to the staff in a way that puts accountability for response into their hands.
Leaders must be able to see systemness and complexity as normal conditions of change and adaptation. Through expressing their accountability for witnessing and previewing the potential for change, the leaders prepare the staff to deal with the right change at the right time and in the right circumstances.
Transformational coaching requires leaders to engage in an array of activities that move employees through the process of responding to essential changes in a way that embraces the changes and achieves desired outcomes. In fact, leaders are responsible for creating a system of response to essential changes and then creating a structure and process for these changes to occur as lived or operational experience. Transformational coaching is more of a system than a process, and in applying the components of this system leaders can ensure a dynamic, ongoing framework for adaptation and engagement.
THE LEARNING ORGANIZATION An organization’s ability to adapt to change depends on how open and responsive the social and organizational context is to change and to the dynamic processes of learning. If the organization values change and learning, the vagaries of change will be less traumatic and incidentally dynamic. Research, however, has shown rules of engagement even in creating a true learning context.
Chris Argyris (2006), in his review of the research, indicated some basic criteria for success at any level of organizational learning and change. The focus must first be on behaviors and attitudes. Identifying the fundamentals of behavior and the factors that influence specific behaviors is critical for creating a context and process for change. Once these behaviors and attitudes are identified, the focus switches to the vagaries that affect particular behaviors or recurrent patterns of behavior and through them affect the way work is done or the way it is adapted to new realities.
The system developed for addressing behaviors must include a mechanism for reducing the number of continuing counterproductive activities and self-fulfilling patterns of behavior that keep the participants from fully engaging with the changes they must make. Behaviors that are inconsistent with both norms and expectations find room to exist if not addressed quickly and efficiently. They even stand a chance of becoming the norm and in any case can compromise the environment and participants in a way that obstructs adaptation to the necessary changes. The noise that results creates a further impediment to the participants’ ability to engage with the changes and thrive. Focusing on the behavior of participants gives leaders an image of the mental and emotional “maps” in operation. These maps can then be used as a beginning point for the process of making meaningful and sustainable change. Leaders need to look critically at the participants’ mental maps to determine from them the pattern of response they have helped to create. In fact, this pattern of response— the participants’ theory-in-use— has a more dramatic impact on the participants’ engagement with essential change than do the behaviors themselves.
When leaders approach participants to discuss their mental maps, they do need to be cautious. These maps form the contextual framework out of which behavior flows. The theory-in-use is simply the conceptual constant that the person draws on to explain, justify, and retain sufficient commitment or energy to a particular course of action. In this highly individual context, the person seeks to provide a solid values or belief foundation that can give meaning to a position or a specific action. Often, the theory-in-use is identified as the rationale or justification the person uses for his or her actions. This theory-in-use has only an inferential relationship to the truth. It relates more to the individual’s sense of truth or interpretation or application of truth than to anything that may actually be true. Regardless, it is vitally important to the person. It is the theory-in-use out of which that person acts, and it gives a reason for the action. In this issue, leaders find that much of a theory-in-use cannot be discussed, for it concerns who the participants perceive themselves to be, even to the point of being perceived as a part of their identity. A person’s role and sense of self in the role and the person’s relationships with others and the organization create a foundation for the person’s pattern of behaviors. However, because every person’s theory-in-use is expressed in his or her pattern of behaviors, the patterns of all participants must be directly addressed if the behaviors necessary to learning, adaptation, and meaningful change are ever to be evidenced in the organization. This awareness of a person’s theory-in-use helps the leader understand and address particular behaviors and gives a clearer context to an individual’s personal struggle with change. Almost every organization fails to maintain adaptability over time,
The main reason is that organizations, although they might change what people do, usually fall short of changing how they think. Because the conditions of change are now so prevalent, not to change the thinking of people has ceased to be an option. Nurses, for example, must learn to practice in a world where long lengths of stay and long-term patient relationships no longer define nursing practice. Nurses who complain of a lack of time for patient care have failed to realize that their grievances reflect an outmoded mental model of nursing. Hospital lengths of stay will continue to shorten, the aged will be cared for in ways that do not require their institutionalization, new pharmaceuticals will radically alter how patients get treated, and so on. In this instance, the role of leaders is to assail the old mental model and create a fluid enough foundation for nurses’ expectations that they give up their old expectations and acquire new ones.
Point to Ponder Failure to thrive is not uncommon in times of great change. The main reason is that organizations, although they might change what people do, usually fall short of changing how they think.
Physicians also need to be aware that the circumstances that brought them into medicine no longer exist. The unilateral, responsible, but nonaccountable practice modalities that once defined medicine are disappearing, to be replaced by accountability-based, outcome-oriented, rational, complex, and multifocal modalities. The healthcare system is rife with the dissatisfactions of physicians who say they can no longer practice the medicine they know. What they have failed to recognize is that the 20th-century manual and mechanical model of medicine has died. The one that is emerging, driven by all the improvements and enhancements in therapy and treatment, has altered forever what medicine is and how it will be practiced. For physicians and others to enthusiastically and energetically engage with the changes affecting medical practices, their mental models must be confronted directly and in a manner that allows them to identify the discrepancies between what they believe and the current reality.
Effective adaptability means also developing a level of predictability or prediction of those things that are going to change before they actually change. This predictive skill is now as much a part of the skill set of the leader as any other recognized leadership skill. Predictive capacity calls the leader to synthesize data and information about the convergence of forces or occurrences and to define the resulting conditions or circumstances. Such skills are becoming less optional for leaders as the pace of change quickens and the significance of each change increases the impact on people and groups. The scope of global changes and the broad landscape of change events now call leaders to visualize the groundswell of particular events and to link them to other elements or occurrences to create a mosaic of substantial change that prepares others for their onset or impact, far in advance of experiencing it.
Over the past 35 years, shared governance has enumerated the structural components and context necessary to create the scaffolding for sustainable change and full participation (Porter-O’Grady, 2007, 2009). Now we are joining a host of contemporary leaders in declaring the importance of empowerment, shared decision making, self-direction, and shared governance and are urging the replacement of traditional organizational and management constructs with currently relevant models of workplace organization. To gain a fuller understanding of how to adapt to the changes that are occurring, leaders must create an environment that fosters learning. In doing this, they should keep the following in mind: • Learning must be oriented to the actual experience of the learners in their
own environment. • The purpose of learning is to ensure growth, improvement, and adaptability. • People need to be empowered to take charge of the design of their own learning and to alter their roles and behaviors in response to what they discover. • The organization must be willing to allow experimentation and risk taking so that innovation becomes a constant. • Learning requires time, and the organization must therefore allow staff the time it needs to pursue new knowledge. • Learning should not be accidental or incremental; an infrastructure for learning should be developed to ensure that innovation and new learning are considered an ongoing part of the way of doing business in any environment. • People need to feel they are growing and improving. Therefore, learning should always be directed toward giving people new skills that are relevant to their job activities.
Learning can be single-loop or double-loop. In single-loop learning, the learning process is implemented as designed and the outcome is achieved as anticipated. Single-loop learning deals with the apparent, the visible, and the symptomatic. In double-loop learning, the governing variables, the driving forces, the root causes, or the foundations for action are understood and applied to the process. In addition, the participants are familiar with the process of learning and incorporate it into their own learning activities as an ongoing part of delivering health services. Double-loop learning is essential to addressing sustainable solution seeking and achieving enduring results. For learning to occur, especially double-loop learning, participants must understand their own theory-in-use (or automatic reasoning processes). Most people bring their own reasoning processes and preexisting notions to any learning situation and even look for things that validate their preexisting notions. The mother of one of the authors is a smoker of many years. When confronted with the fact that long-term smoking leads inevitably to illness and death, she invariably identifies those rare creatures that are long-lived, lifelong smokers. When reminded that she can name these people because so few are still alive, the logic escapes her. Her theory-in-use forces her to identify the circumstances in which her premises and beliefs can be confirmed and reinforced, giving her, in her own mind, no reason to change her pattern of behavior.
Key Point Being open to the dynamic processes of learning and change is a requisite of adaptability. The leader is always testing the system to see how much the staff engage with the demands of change and how quickly their roles adjust to new performance expectations and to the chaos and vagaries of changing the way work is done.
All people have preexisting notions and a propensity to try to validate them. Leaders (or anyone else acting as a coach) must recognize the importance of identifying and describing these notions sufficiently clearly to address them and even use them as vehicles for personal learning and change. The goal of coaching is to help people acquire new ideas that validate the experience of change and more accurately reflect the prevailing reality, ensuring they have a place in it.
GROUP DISCUSSION How many of us really know why we believe what we do or act as we doThe members of the group should each identify a statement about their professional work that they believe and two reasons for believing it. What is the theory-in-use in the application of this belief Do others understand the statement in the same way Is it really rational to believe the statement Helping others change means knowing your own rituals and routines and the rational basis for acting on them.
Newer concepts of triple-loop learning now encourage a system that supports the questioning of premises, the clarification of beliefs, and the foundation of new learning. The infrastructure of the organization and the configuration of leadership expectations must now be aligned to ensure that past or current notions or concepts of the work do not become an impediment to questioning the prevailing beliefs, practices, rituals, and routines. This becomes necessary to ensure the organization does not become irrelevant or so inculcated in its own story and practices that it fails to see a different world and role ahead.
Point to Ponder Adults learn most easily when they can apply what they have learned. The best approach is to teach them on the job so that they can apply their new knowledge then and there. Likewise, they accept changes most easily when they can act on the changes immediately.
The final step in the learning process is to generalize what has been learned and reinforce it through applied action. Using new knowledge is the best way to incorporate it into the foundation on which the processes of work are built. Furthermore, integrating the new knowledge into the foundation leads to additional new learning and to another revision of the foundation, allowing the workers to achieve higher levels of performance and personal satisfaction. Leaders need to understand that for double-and triple-loop learning to occur, they must create a culture that promotes the necessary processes and risk taking. This means that every role at every level of the organization— from the very highest levels of authority to the point of service— must be involved to some degree in the learning process and make use of available learning tools. In other words, the organization must live the learning process in everything it does. When an organization fails to embrace learning, the reason often is that a genuine culture of learning and adaptation was not designed and structured into the life of the organization. Dynamic adaptation and learning are simply unsustainable in any organization that does not have a vibrant learning culture.
Action Learning Tools • Computerized scenarios • Case studies • Comparative modeling • Video presentations • PowerPoint presentations • Storyboards • Clinical exemplars • Virtual classrooms • Satellite interactive sessions • Group practice sessions
All learning is essentially individual. It begins at the personal level before it can become organization-wide. Therefore, each member of an organization must be expected to engage in learning activities, and the structure of the organization should even make it impossible for members to survive without pursuing new knowledge. The need for all members to become more knowledgeable is especially great now because of the reconfiguration of systems and enterprises that is occurring. Leaders, through coaching, can help staff change the language in use and find the right questions to ask— those that reflect the current reality, for it is in this reality that the answers lie.
People are so strongly socialized by their past relationships and experiences that it is difficult to alter behaviors resulting from their socialization. When people come to work, their socialized behaviors come with them and are acted out. Leaders must recognize that socialization is a critical factor with regard to change and make sure it is incorporated into the structure and dynamic of learning. By engaging employees in a discussion of the effects of socialization on their behaviors and incorporating that discussion into the learning equation, leaders are more likely to get the personal changes necessary to generate the shifts in work processes and outcomes.
ORGANIZING FOR TRANSFORMATION Leaders know that behaviors do not change accidentally or on request. The context or culture of the organization or unit plays a major role in determining what behaviors occur and how they become modified. The leader of a unit, for instance, must have in place a uniformly applied set of expectations to ensure that the patterns of behavior are consistent. Further, the expectations and associated patterns of behavior must be congruent with the environmental demands that drive the work of the unit to ensure that responses to the demands are quick and that the prevailing operational processes reflect it and can use this intersection as a way of advancing organizational effectiveness. Another essential leadership task is to establish, together with the unit’s members, some basic foundations underlying the unit’s functions. To do this, the leader must continuously assess the patterns of relationship, interaction, and personal and professional behavior within the context of the expectations defined for them. In the culture of adaptation, there are clearly understood and consistently applied processes that assure each participant that the agreed parameters are up front and continuously applied.
The leader should be aware that the purpose of these processes and structures is not to keep people happy. In many organizations, the goal of keeping people happy actually has become an impediment to making them happy. In fact, the knowledge that the leader expects employees to be happy can create conditions that ensure they are not. Happiness is not something that can be achieved through organizational means; it is instead a personal matter. What is within the leader’s purview are those things that keep the employees motivated, invested, involved, and satisfied with what they are doing. The leader’s best chance of creating an environment in which employees are all of these things is to set expectations that are high but not so high as to prevent the employees from consistently meeting them and even surpassing them. These expectations and the structures and processes developed to ensure they can be met form the framework for advancing the organization’s goals and those of the people who make it up. The leader also has the responsibility to ensure that certain basic requirements for learning and adaptation are in place: • The members of the unit must be informed of the prevailing rules for personal behavior, personal interaction, and problem identification.
• Innovation must be an expectation of the workplace and of organizational learning to ensure that workers understand that contributing to their own change and that of the system is an expectation of work. • There must be a mechanism for calling the parties to the table when a problem occurs or an issue arises. This mechanism must become the unit’s normal means for first responding to problems and issues. • There must be a routine mechanism for discussing and critically reviewing each issue that affects the staff. The purpose of this mechanism is to give the relevant parties an opportunity to play an active part in the deliberations and decision making intended to resolve the issue. • Shared decision-making models should be used for empowering staff members and giving them a role in dealing with issues for which they are accountable. • There must be a forum and a method of resolution for conflicts between members, concepts, plans, or processes. These conflicts should be addressed as quickly as possible. In the case of conflicts between individuals, the goal is to return the parties to a productive and active relationship with each other. If a good working relationship cannot be established, there must be a mechanism for separating the parties. • Staff should be involved in the strategic and tactical activities of leadership. In particular, they should participate in decisions that define their future, thereby gaining ownership of their work.
“Key Point When gathering people together, the first step is to clarify the rules of engagement. Although this can be tiresome, people must be reminded of the expectations regarding interaction and communication. Deliberations break down most often because the parameters for dialogue were not reinforced and followed.”
Besides building appropriate processes and structures, the leader has the responsibility of stimulating the members of the unit to achieve high levels of performance. This can be done through building a shared vision and helping the members see that their work is a significant part of a great enterprise. The leader must realize that everyone wants to be a part of something important and to make a meaningful and sustainable difference. The leader keeps the members as focused on the purpose of their work as on its processes. The members should not become so fixed on the work itself that they lose sight of why they are doing it. Structure is a critical element in the creation of a meaningful and motivating work environment because it provides the context for behavior and sets the parameters determining how the processes of work unfold. A good structure enhances personal interaction, problem solving, learning, and adaptation and keeps alive the human dynamics that energize and give meaning to the work. In the absence of such a structure, none of this can be ensured.
DEALING WITH THE LACK OF TIME “Not enough time” is perhaps the most widely heard mantra in the workplace today. In the past few years, it seems as if work has expanded and time has been compressed. Although time has not literally shrunk, dramatic changes during this period have affected people’s perception of both time and work.
First, work generally has become more complex. Although the purpose of a job may be the same, what it takes to do it has changed radically. There is simply more to the job than there used to be. In health care, for example, managing the continuum of care so that the proper services are provided in a timely fashion requires communication and interaction with a whole host of professionals and use of numerous resources that are new on the scene. The need to do work speedily and effectively has also increased the intensity of the work and made time even more of a concern.
Leaders and staff need to look at the issue of time differently. For many years, work was looked at as a process that had no beginning or end. As a result, it became an end in itself, and the usual goal was simply to be efficient and do what had to be done on time. The issues are now more profound and require a different mental model for their resolution. Rather than looking for more resources or time, leaders are confronted with the questions about who should be used and how they should be used— questions about being different in a world that is changing before our very eyes. The fact is that resources, human and other, are not available in the same numbers and format they once were. The questions are no longer about more of anything. Looking for more resources, people, or time is not likely to help get more of any. The issue is no longer about doing more with less; there are instead questions about doing and being different in a changing world.
Point to Ponder Leaders can have a big impact on problem solving merely by eliminating the word more from the dialogue. As long as people believe that more resources— more money, time, people, capital, equipment, and so on— will solve their problems, they will not put enough imagination and creativity into the mix to discover sustainable solutions.
In other words, leaders need to challenge the prevailing framework. For instance, besides realizing themselves that resources are finite and not as readily available as before, leaders must repeatedly point out to the staff that the value of work is embedded in outcomes, not processes. They must also recognize that nurses and physicians are challenged with having to validate their treatment decisions by providing evidence that their choices were either less costly and less resource-intensive than comparably effective treatments or had better results than other possible treatments. For most of their years in practice, health professionals never had to prove a functional relationship between what they did and what occurred. Today, there is no future for healthcare treatments for which such a relationship cannot be demonstrated.
Work in this new era requires more flexibility and fluidity than previously. The old notion that work should have fixed time and function parameters is no longer realistic. With wireless technology, a healthcare provider can be anywhere and still be reached for advice or follow-up. When does a provider’s job really begin, and when does it really end It is now the responsibility of the individual to determine his or her workload and availability and the extent of the work period. In the past people went to a workplace, did their jobs, and went home. Today, jobs go with the jobholders wherever they go, and there are no parameters defining the jobs more narrowly.
Leaders must now begin to apply tools to staffing that allow the planning and utilization of staff to be more flexible. They must also consider job candidates with an eye to their skill sets and personality characteristics to ensure they increase the organization’s adaptability. The notion of “goodness of fit” applies to people just as it does to roles. Scheduling around workload is now a critical method of staffing. So is contracting for workload— bringing staff members on board based on an agreed workload and paying them for the workload rather than for time and function. These methods give staff members more control over their work life and over their life outside work.
The revolution in communications gives staff members more documentation and information-gathering options, not to mention unprecedented access to each other. The hands-free earpiece or headset allows providers to connect with others at a wide variety of times rather than just during a few set periods (e.g., rounds). Finding someone, reading the chart, and documenting information have become easier with the new telephone and personal digital assistant devices now common in the workplace. Because of the increase in specialization, health professionals have become more interdependent. No one can be an expert in everything, and the members of a healthcare team must identify and make use of each other’s expertise, fashioning a strong clinical network in the process. The leader of the team helps the other members become both more self-reliant, where appropriate, and also more interdependent. Rather than being a manager in the traditional sense, the leader is instead a colleague who creates the possibilities and conditions for real advancement and learning. Time and resource problems do not always have easy solutions and what might work in one part of an organization might fail outright in another. The organization’s leader should realize that all problem solving is ultimately local and that those individuals who own a problem must be the ones to discover and implement its solution. Therefore, the leader needs to push staff members to find their own solutions and to identify processes that work for them and can be sustained in their environment. The key here is ownership. Those at the top of the organization do not know how to resolve all the difficulties that arise at the point of work. It is rather the staff members who know how to handle problems there, and the leader’s job is to make them understand that they are expected to own the problems that arise, apply the appropriate methods and tools to solve them, and then use the necessary means to evaluate the outcomes and sustain whatever benefits they have achieved. The leader, of course, keeps his or her eye on the results, knowing that outcomes drive all processes and that all processes are disciplined by sustainable outcomes. Leaders are often required to play the role of coach, and they bring to this role not only insight and skill but passion as well. In fact, by exhibiting energy and drive, they encourage others to stay invested in their own activities and commitments. They act as living examples of the excitement that result from engagement with the challenges of the times.

“Key Point Staff members must be allowed to find the solutions to their own problems. The role of the leader is not to solve problems but to make certain that staff members have the insights and skills necessary to solve them. The one absolute unforgivable is to take care of other people’s problems for them. “
Coaches, including leaders acting as guides or counselors to staff members, find their greatest reward in helping others develop and move in the direction they need to go. They become invested in the achievements of those they are helping to learn and experience the learners’ gains as gains of their own. Issues that arise in coaching and that leaders acting as coaches in a team situation need to keep in mind are as follows:
• Having a genuine interest in people means supporting their growth. Every team leader therefore needs to make sure other members know and feel the obligation to advance themselves and become full participants in the process of learning and adapting. The individual team members are accountable for thriving, and the leader must always keep this truth in front of the team members’ eyes.
• Coaching team members is not the same as raising children. The team members are always fully accountable for their own development. The leader provides assistance in the form of tools and support but does not take on the burden of accountability for the other members’ growth and advancement. The leader’s role is to remind the team members of relevant expectations and parameters for action and to support them in meeting those expectations.
• When acting as coach to the other members of a team, the leader does not acquire possession of their work. Also, the leader does not own the staff’s relationships and interactions or the outcomes of their efforts. The leader is on the alert for staff attempts to transfer possession of these to ensure that the ownership remains where it belongs. The leader is like a circuit rider, moving continuously around the periphery of the team, observing, interacting, assessing, and identifying. When issues, deficits, or concerns arise, the leader is ready to transfer skills, insights, and tools to the team members in a clear way to ensure they have what they need to deal with their problems and advance their own work.
• The team leader is not in control of the lives of the other team members or of the circumstances in which they do their work. The leader is their colleague rather than their manager, and the coaching role is one of partnership. The team leader’s job is to keep the other members connected, invested, and aware and to help them develop to the point where they can operate with little outside intervention. In a transformational time, the leader is always pushing at the edges, helping the other members recognize the changes that are occurring, the issues that are arising, and the best methods for resolving them. The leader is in back, pushing the team into its reality, not in front, pulling it into his or her reality.
• The leader is the chief learner on the team. By modeling her or his commitment to the “way of learning” as a way of living, the leader helps create a learning culture and shows others how to embark on their own journey. The leader is always curious, searching, reading signposts, transferring information, raising issues, and pushing the parameters. The leader sees learning as a dynamic, as an essential constituent of living and relating, and becomes for the team a visual representation of learning in action.
Because the work of transforming organizations is so critical in these times, leaders in their role as coaches must exhibit the attitudes and behaviors of change and adaptation. In living the process of change, they perhaps do more to further the ability of others to handle change than they do by their explicit instruction. People need to see leaders dealing with change so that they have someone rather than something to identify with. They look to leaders to humanize the experience of change by growing and adapting themselves, for by seeing others who are successfully adjusting to change, they become more comfortable carrying out their own personal journey of transformation.
THE LEADER AS REVOLUTIONARY
As mentioned repeatedly, the healthcare system is at a critical moment. New thinking, different models and processes, and whole new technologies are pushing the system toward a huge transformation. Yet there is so much in the way— a long history of now outmoded patterns, rituals, routines, and infrastructure. To help carry out the transformation, each leader must become a revolutionary in residence.
The skills of revolution are different from those of evolution, because, in a revolutionary context, time is compressed, it is already too late, the options to thrive are significantly threatened, and leaders and personnel are almost paralyzed by their circumstances. The leader of an organization in this case has the job of initiating a number of processes so that the organization as a whole can engage with the radical changes occurring and implement adaptations in a timely fashion. Of course, the leader cannot do it alone. A coalition of like-minded revolutionaries is necessary for substantive change to occur. Indeed, the leader, acting as a transformational revolutionary, seeks to widen the circle of “conspirators” until the whole organization is conspiring to transform itself and its processes to meet current demands. This section describes several steps a revolutionary leader goes through to ensure that adaptation becomes the modus operandi of the system.
CREATE AN ARGUMENT FOR REVOLUTION The organizational leader must create a vision of the transformation because what the transformation is and does are critical to getting people mobilized. The leader thus gathers together like-minded leaders within the organization to make a statement about the efforts entailed by the transformation— essentially a vision statement. The forces at play, the impact of events, the changing circumstances, the altered financial configurations— all these jointly determine how the current mental model should be revised and what needs to be done. The organizational leader then collects data to validate and refine the vision statement. The statement must show a clear connection between the conditions and the response and indicate why the conditions are so compelling as to make nonresponding a nonchoice. It must not only describe the conditions but also explain the response, citing the critical factors that influence the organization’s position in the future.
GROUP DISCUSSION As a group, identify one major change that needs to occur in the healthcare system. Make sure that the change is significant and radical. Using a flip chart and pasting the pages on the wall, create a plan for revolution around the identified change. Identify the various constituencies and conspiracies that are necessary for building momentum. Evaluate whether the plan is revolutionary enough and how and where to start its implementation.
DEVELOP A CHARTER FOR THE FUTURE
After clarifying the conditions demanding transformation, the leader and his or her coconspirators must develop an agenda for the future. This can be likened to a map of the territory through which the system must now travel. The goal at this stage is not to devise a detailed program for change but to articulate the themes and signposts indicating the organization’s proper direction. The “charter” should consist of a simple and clear point-by-point enumeration of the factors and themes of becoming. It should contain engaging terminology so that key words and phrases like “creating a sustainable partnership” or “building the health journey” can be pulled out and used to generate energy and enterprise throughout the organization. It should also indicate obstacles that are in the way of achieving the goals of the charter and that the conspirators need all of their commitment to overcome.
BUILD THE CONSPIRACY The transformation process has no meaning and will die an ignoble death if the conspiracy does not continuously expand. The charter starts to gain life when the organization embraces it as its work. The role of the leader is to make sure that commitment to the transformation moves outward into the far reaches of the organization. All the key players, informal and formal, at all places in the organization must embrace the charter, take ownership of it, and move it to the next levels of application. No formal mechanism of generation is required. Those who “get it” are brought on board when they are ready, and then they do their part to find and lead others who can “get it” as well. As might be guessed, the various organizational committees, from medical staff committees to management councils, are great vehicles for publicizing the vision and expanding the conspiracy. This kind of revolution cannot be secretive. Everyone eventually must be on board to help in the creation of a preferred future. The work of the conspiracy is merely to stimulate this journey for all members of the organization, from those at the point of service to those in the boardroom. Joining the conspiracy to operational processes already under way is a good mechanism for getting the charter on the table of those who most need to engage with it.
BE STRATEGIC AND PATIENT There are no enemies in this revolution— only those not yet part of it. The conspirators must understand which stakeholders they need to bring on board to give the charter both life and legs. They must also understand when to approach these individuals and groups or include the charter in their work. Further, they should know the local politics of communication and action and identify what strategies are best for addressing specific challenges and circumstances. Getting specific individuals to perform certain required actions (because of their relationships, positions, or skills) is a part of the strategic process of managing the charter and guiding it through the political landscape. Indeed, one-on-one interactions with key players are as important as group meetings. In approaching key players, the conspirators need to translate the charter into their language to obtain their acceptance and advocacy. Key players have to be able to see how the process benefits them and advances their own opportunities and circumstances— that is part of the political process.
SEEK OUT SIGNIFICANT CHAMPIONS As the conspiracy grows, it must incorporate champions able to take the charter farther on its journey. The transformation process is like a relay race: different runners with different skills are required at different points in the process. The organizational leader must anticipate the new focus, person, or skill necessary for getting to the next stage and must ensure that each is applied in the right format and at the right time to move the process along. As in most conspiracies, movement toward the goal is not along a straight line. Backward or horizontal steps are occasionally required to refresh or expand the process. In addition, as progress occurs, the kind of champions needed often can be found at new locations. That is as it should be. The conspirators must celebrate any support that moves the transformation along to the next stage and increases its chance of success.
ENSURE SMALL SUCCESSES OCCUR EARLY AND OFTEN Successes must take place along the way to maintain momentum. Creating a plan for substantive change and getting the whole organization to embrace it are long, gradual processes, and people will remain unmotivated if they perceive their efforts as unlikely to make a difference. Even small accomplishments show that movement has occurred, and without some “deliverables” the organization is sure to lose interest before it gets very far. The accomplishments give the transformation process “legs” and ensure that the process’s champions can overcome objections and opposition in a manner that allows them to incorporate new ideas into the process and convert possible opponents into supporters.
MAKE THE TRANSFORMATION THE MAINSTREAM ACTIVITY The goal is to enable the whole organization to thrive well into the future. The conspiracy is simply a means of ensuring the organization’s survival at a time when the organization appears to be missing an opportunity to prosper. Thus the conspirators must always keep in mind that the purpose of their efforts is to benefit the organization, not themselves. They also must avoid becoming so committed to the conspiracy that their attention is diverted from the real end and their energies wind up misdirected. Once the conspirators have attained their objective— to make the transformation the central activity of the organization— the nature of their endeavors shifts toward initiating work processes related to the new reality. The conspirators must now fully embrace the character, context, and content of the new reality, which means redefining the work, retooling the workplace, and focusing on the conditions that allow the organization to thrive. In a sense, the conspiracy has now become the new reality. Of course, the talk, in this section, of a conspiracy is merely a way of highlighting the focused commitment to fundamental change that leaders in an organization must have when options are limited or opportunities are being missed. It pinpoints the sense of urgency the leaders must impart to the entire organization to get everyone to make the kind of effort needed to ensure the organization’s ability to thrive in a highly charged and changing set of circumstances. The leaders, acting as change agents, must stimulate the staff and other stakeholders to raise their own levels of energy and refocus their efforts. The conspiracy enlists them in an effort that is greater than they are as individuals, giving them a sense of meaning and purpose and generating the energy, emotion, insight, spirit, and commitment they need to adapt and grow. Focused commitment and strong motivation, along with appropriate processes, methodologies, and techniques, round out the requisites of revolutionary transformation.
INNOVATION COACHING A team leader has the responsibility to create the right conditions for the team and its members to learn and grow. In fact, the main purpose of team leadership is to ensure the team members can develop and become what they must to thrive in shifting circumstances. The achievement of this goal, of course, requires the team leader to overcome existing obstacles to effective coaching .
To become successful in the new age, leaders and staff members must relate to the processes of transformation so that they see them as the essence of their work and not as mere responses to a demand to do things differently. Adaptability is as much an attitude as it is a way of doing business, and the goal of leaders should be to help everyone be different, not just perform new job activities. After all, in this era of revolution, it is not just the work that is changing, it is the very workplace itself— the conditions, elements, and technologies of work. Because the working conditions are being substantially altered, leaders must ensure that the differences do not escape the attention of those who do the work. They need to help the workers revise their mental model of work and turn every one of them into a revolutionary. In other words, they need to publicize the fact that innovation is now a way of life and help the workers develop the skills and attributes they require to live that way of life and become part of the transformation of the workplace.
Impediments to Effective Coaching Use of power Knowledge • Inadequate power • Undeveloped knowledge • Autocratic application of power • Learning needs • Lack of empowerment • Inexperience • Nonstrategic use of power • Lack of personal technique Self-image Problem solving • Poor self-esteem • Inadequate worldview • Unclear role • Intolerance of diversity • Psychological flaws • No clear process • Situational solutions

To convert work into innovative effort, leaders need to follow several rules, discussed subsequently. They should also keep in mind that the workers not only must figure out the emerging context for their work and relationships, but they must also create the structures and content for the journey itself.
SET THE BAR HIGH Leaders need to convince workers that expectations for their performance are high but not so high they cannot be met. The challenge is to set expectations that the workers from falling back on old behaviors and practices but that also do not discourage them. The expectations should stimulate the workers to engage in different thinking and to change the very nature of the work. Another way of saying this is that the transformation of work requires new models for thinking, a new context for work, and goals that demand new ways of working. The goals should not be so easily attainable that the workers can retain their old ways of doing things.
BE CLEAR ABOUT WHO YOU ARE In the new world of work, people need to redefine who they are and their definition of success. For example, hospitals, which were originally defined as places where the sick were cared for, have been redefined as places where healthcare services are delivered. The range of services that fall under the rubric health care differs from the range that falls under the rubric caring for the sick. Because of alterations in the health services landscape, healthcare leaders must highlight the changes in the context of work and the implications for its performance, including the new demands that have arisen. They must then revise the structures and processes of work to meet the new demands and to assist staff in adjusting their insights, attitudes, and behaviors appropriately. Staff members must live the image of the organization in all they are and do. Making sure that staff members see the shift and can live the new perspective in their work and relationships is a critical element in the journey into the future.
Inovative as a Way of Life. The leader focuses on the central components of personal transformation to ensure that each person can embrace change.
TREAT TRANSFORMATION AS A MISSION, NOT A JOB The staff of an organization must not simply change the way they do their work but also change the way they live their work. Therefore, the organizational leader, acting as a coach, must be able to explain how to live and work differently using the broadest and clearest language possible. Transcending simple notions of labor, the leader creates an image of healthcare delivery as having a purpose beyond its immediate effects. By showing how work efforts can influence the world of health care, the leader transforms the performance of work by an individual into the pursuit of a mission. People want to support good and noble causes that take them outside of themselves and also want to view their efforts as having a profound value. The leader can help them take this leap from the mundane to the honorable and incorporate a sense of mission into the very fabric of their work activities.
EXPOSE STAFF TO DIFFERENT MESSAGES AND DIFFERENT MESSENGERS To motivate staff members, the leader must give them encouraging messages that differ from those they have heard all along. The leader must also communicate new expectations and provide opportunities for staff members to learn what they need to know to meet these expectations. The encouragement and the expectations communicated must be consistent with the transformation on which the organization has embarked. The goal is to stimulate staff members to think about how to do their work more effectively.
“Key Point The leader must be so consumed by the organization’s mission that transformation becomes second nature. In addition, by being committed to this mission, the leader presents a visible example of transformation in action that has the power to inspire others to transform themselves and their job activities.”
New voices should also be heard. Young workers, workers who are quiet and reserved, and workers from outside the particular workgroup should be included in the collective dialogue. The leader should do as much as possible to “push the walls” to move people out of their comfort zones and stretch into new ways of thinking and doing.
CREATE AN EGALITARIAN ORGANIZATIONAL STRUCTURE Hierarchy should be minimized in times of great change. In fact, in the new age hierarchy has little value. Horizontal relationships, defined not by position but by role, are the cornerstone of accountability. The leader of an organization must therefore facilitate relationships with those he or she depends on for planning and performing the organization’s work. In other words, the leader must value the work and the worker equally. Each worker has a contribution to make, and the leader’s job is to get each to offer innovative ideas on how to improve methods and processes, for the workers are the ones who know best what produces results and what does not. The leader therefore needs to make it safe and easy for workers to become part of the collective dialogue and put forth suggestions. Barriers to interaction, sharing, and challenging simply cannot exist if the spontaneous communication of ideas is to become the organization’s modus operandi. Ideas are an important form of capital for any enterprise and can come from any place. For them to be released, the organization’s culture must make it not only possible but routine.
PUT MONEY WHERE THE IDEAS ARE For an idea to be implemented, some level of financing is required. Although not every idea is worth supporting, funding for good ideas must be available because staff members need to know that their ideas have the potential to go somewhere and make a difference. If their ideas are ignored for lack of funding, they will eventually go back to old routines and refuse to contribute. If their ideas, on the other hand, are taken seriously and investigated, they will continue to make suggestions.
The funding or budgeting process must make it possible to explore ideas and innovations to an extent commensurate with their likely utility. Out of 1,000 ideas perhaps only 10 will ever be used, but those 10 could not have emerged unaccompanied by the rest. In short, the exploration of all ideas is critical to the discovery and application of the few that do become part of the organization’s practice.
LET THE TALENTED EXPERIMENT It is impossible to apply new thinking by rote or through using a “straight line” approach. Talented people must be gathered together and supported. This means, among other things, allowing them to take risks. The outcomes of ideas are often unpredictable, and thus a certain amount of trial and error is necessary. Ideas must be tried and possibly modified before their worth can be known. If an idea is not shown to be beneficial after a trial period, it should be discarded. Nothing should be set in cement. Strategies should be implemented and then modified as necessary. Structures and permanent processes should be avoided because they create barriers to necessary revisions. In addition, there must be enough creative people in the organization to ensure that innovative thinking occurs. Constant attention to bringing in and keeping such people is critical for sustaining the transformation. The leader must be comfortable with those who are bright and creative and come up with ideas that challenge the leader to think and act differently.
ALLOW PEOPLE TO SHARE IN THE FRUITS OF THEIR CREATIVITY This is perhaps the most challenging notion for healthcare leaders. For some unfathomable reason, the practice of rewarding people for their contribution has not become common practice within the healthcare arena. However, people own their creativity and ideas and lose interest and move on if their ownership is not honored. Keeping creative people means investing in them, and investing in them means rewarding them for their innovations.
Point to Ponder Experimentation is critical to innovation and adaptability. An organization not willing to experiment is doomed to failure.
Creative people often do not seek to be compensated financially. For them, seeing their originality have an impact can be reward enough. Nonetheless, the leader should acknowledge contributions in a meaningful way. Although a bonus is the most recognized and established kind of reward and should be seriously considered, there is a host of other kinds, including public acknowledgment (celebrations and events), publishing the work inside or outside the institution, gain sharing (sharing the rewards), and shared ownership. Whatever rewards are defined by the organization, the reward granted to an individual for a given contribution should fit the needs of the person and the kind of contribution. Remember, highly creative people are looking not for long-term, permanent positions but for opportunities to express their gifts and talents. Keeping them on as employees depends on whether the organization’s culture provides them with an ability to create, grow, and advance.
The leader is always attentive to the need to keep the organization moving and to respond to current demands. Creating the environment, structure, and processes necessary to ensure the organization’s adaptability is the leader’s single most important task. Because inventive people are essential to the organization’s ability to respond to new demands, the leader is forever looking for, challenging, and rewarding such people in an effort to maintain a pool of creative talent.

GROUP DISCUSSION A common topic of discussion today is the nature of true integration. As a group, brainstorm the basic elements of integration. Identify areas where group members disagree. Break into two debating teams of two or three members each and have each team take a position and argue for it. The remainder of the group will critique the debate and evaluate the arguments. After the debate, the group members should discuss how their view of integration has been altered or reinforced. Finally, identify three or four common elements of integration that can be used as criteria to determine whether integration has been achieved.
MAKING INTEGRATION WORK Because of the systems-oriented dynamics of health care, making things fit together is very important. The leader of a healthcare organization must evaluate the fit between elements and improve it wherever possible. When a merger or alliance occurs, however, creating proper fit can be a great problem. People bring to the new entity their past ideas, commitments, cultures, and notions of how the work is to be done, and they resist or find it difficult to create the level of integration that is required. Much of the energy of the leader is devoted to making the new arrangements not just workable but productive.
Perhaps the greatest concern is the speed with which things seem to happen today. Although time itself has not accelerated, the extra complexity of work has made it difficult to accomplish tasks at the pace once expected. Because staff members find they no longer have enough time to do what they used to do, the leader must help them replace their focus on doing lots of things with a focus on doing the right things.
Elements of Integration • Goodness of fit • Role congruence • Alignment • Integrity • Focus on the whole • Interdependence • Accountability • Orientation toward outcomes
Porter-O’Grady, Tim; Malloch, Kathy (2010-10-25). Quantum Leadership (Kindle Locations 12469-12477). Jones and Bartlett ebooks. Kindle Edition.
In the old days, healthcare providers did a lot of things for patients. In fact, this reality drove the definition of caring. Today, although caring is still central to health care, it is expressed differently. The independence and accountability of the users of health services are now as important as the services delivered by care providers. People must acknowledge their responsibility for their own health and be empowered to act in the right way at the right time to ensure their well-being. Providers consequently are faced with a different mix of activities and priorities and must recognize that doing everything for patients is not the best way to render needed assistance. To many health professionals, the idea that patients are responsible for their health borders on heresy. At the very least, it goes against a long tradition. Nonetheless, in this age of consumer control and accountability, the complexity of health care and the added demands on the providers’ time require many of the tasks to be placed in the hands of patients. This transfer of responsibility, of course, changes the character of the provider– patient relationship.
The leader must ensure not only that the transfer of responsibility is carried out but also that providers and patients change their attitudes, beliefs, and practices accordingly. Replacing the expectation of “doing for” with the expectation of “doing with” is an arduous task, not just for staff but for patients as well. Patients, too, have grown up with a certain image of health care and certain expectations of what they should obtain from the healthcare system, and they can feel disappointed when these expectations are not fully met. They, too, operate with a dependency model according to which they surrender responsibility, accountability, and control to healthcare providers in return for being tended. In fact, their surrender of these things sometimes facilitates their descent into conditions and lifestyles that contribute to the illnesses for which they seek treatment.
Today, part of the healthcare provider’s role is to alter patient expectations of “being taken care of.” Part of the healthcare leader’s role is to work with providers in creating a new model of health care and revising the patient– provider relationship. The ultimate goal is to help providers use their time more effectively and appropriately in delivering care and providing services to those in need. In particular, providers must focus on teaching and otherwise empowering patients to see more and do more in their own interest. They must also involve family members or significant others in the delivery of services and in counseling, supporting, and caring for loved ones in need of assistance. For these changes to occur, healthcare leaders need to focus on four important responsibilities, described subsequently.
SPEEDING UP PROCESSES Time is of the essence. Providers have less and less time to talk with patients about their healthcare needs and provide appropriate services, and therefore providers and patients must make better use of their time together. For example, follow-up now means making sure patients can gain access to the resources they need (i.e., connecting them to a network of resources, including sources of information that can guide their actions when they are no longer within the healthcare system).
Key Point The healthcare system is changing in fundamental ways, so providers and patients need to act differently and “expect differently.” The providers, in particular, need to change their own behaviors and expectations and educate the patients to change theirs.
As noted, the locus of control is in the hands of the patients (where it really belongs), and the providers must make sure that it never shifts away from there and that the patients have what they need to do the right things for their health. Healthcare leaders have the task of helping staff become comfortable with this reality and guiding them into practices that allow patients to make the best decisions and carry out those decisions. For the transition to the new patient– provider relationship to occur, both staff and patients must develop new skills or skill sets.
ORCHESTRATING THE DYNAMICS OF CHANGE Making the shift to new ways and new roles is difficult for everyone. Complicating the situation is the fact that new rituals and routines must replace those that reinforce behaviors suitable for the older model of service. Staff members, having lived for so long with the more traditional dependent practices, now need approaches, tools, and skills to help them initiate and sustain new behaviors. Leaders must ensure that they develop and use these in ways that fit their culture and experience with change. By exchanging best practices with other settings, staff members can connect with others who are busy creating and constructing methods and models for improving services and changing their relationships with those they serve.
BUILDING RELATIONSHIPS Everything is built on good and sustainable relationships. The most important leadership task is to ensure that everyone is “singing off the same song sheet.” Keeping an organization’s staff on target and focused on its mission is difficult yet critical work. The leader continually tests, challenges, and extends personal and collective relationships with stakeholders throughout the process of changing behavior. When things get tough or stuck, the leader’s only resource may be the personal relationships he or she has developed during this process. Identifying with the difficulties and vagaries that staff members are undergoing and supporting them through the changes they encounter are critical to sustaining their efforts. Testing, stretching, evaluating, renewing, supporting, and challenging are steps in the normal cycle of action, relationship, and response that every leader needs to know how to do.
PUTTING NECESSARY STRUCTURE IN PLACENew behaviors are not sustainable without accompanying structural supports. We learned from the chemical dependency movement that addressing an addict’s behavior is not enough— the environment also must be changed. Creating a context for behavior means building an environment that leads to desired behaviors. Having the workers themselves fully participate in the creation of their environment increases the chance that they will take ownership of the appropriate behaviors and achieve the desired outcomes.
Cycle of Transformational Learning Leaders often fail to pay close attention to the structural realities, allowing staff to fall back into old patterns of behavior. Creating structures that limit old patterns and foster preferred patterns, along with rewarding the performance of desired behaviors, can make the difference between an effective workplace and one that is unproductive and problematic. As an impetus for positive change, structure is at least the equal of behavior itself.
HITTING PROBLEMS HEAD ON People who do not approach problems proactively acquire a “firefighting” mindset. Unfortunately, because of the large number of problems and issues that confront leaders daily, they often end up spending more time on daily skirmishes than on substantive issues. Their firefighting, by leaving their real responsibilities unattended, simply begets more fires to fight.
Point to Ponder Behavior changes cannot be sustained without structural supports in place, and leaders must pay as much attention to these as to the changes themselves.
Some ways of dealing with problems allow leaders to do their transformational work. Indeed, problem solving can be a source of growth and can support a leader’s transformational work. The trick is not to look at problems situationally and attempt to resolve them within the context of the situation but instead to investigate the circumstances in which they occur. Rather than filling holes in the staffing schedule on the spur of the moment, for example, a leader should identify and address the underlying causes, for otherwise the problem will occur again, often in a form more difficult to resolve.
HITTING PROBLEMS HEAD ON People who do not approach problems proactively acquire a “firefighting” mindset. Unfortunately, because of the large number of problems and issues that confront leaders daily, they often end up spending more time on daily skirmishes than on substantive issues. Their firefighting, by leaving their real responsibilities unattended, simply begets more fires to fight.

SOLVE PROBLEMS SELECTIVELY It is unbelievable how many leaders take on, all at once, the full range of problems affecting their organization. Not all problems can be or need to be solved immediately. Leaders must approach problem solving like any other deliberative process. In particular, they must develop strategies for prioritizing problems and bringing order and focus to the effort of addressing problems critically. Because problems are omnipresent and affect everything that people do, leaders must look at the relationship between problems, explore the way in which they interact, and then decide the order in which the problems are addressed. Not every problem has the same weight or the same ability to obstruct work and the achievement of desired outcomes. Setting up a list of problems to be dealt with first is a necessary step in the problem-solving process.
WORK ON THE FUNDAMENTAL PROBLEMS FIRST Many leaders believe they should work on the most urgent problems of the day. Yet problems that seem small and unessential can be the source of these seemingly more critical problems. If the root problems are not resolved, all others caused by them also do not get resolved. In addition, problems that appear to be critical to people in the midst of a crisis usually turn out to be mere symptoms of more fundamental problems. Thus an important goal in problem solving is to determine which problem is a root cause and which is an effect.
INCLUDE PEOPLE WITH THE NECESSARY SKILLS AND POWER IN THE RESOLUTION OF PROBLEMS Although it is best for people to assert ownership of the problems that concern them, it is not always possible for everyone affected by a problem to be part of the problem-solving effort. What is more important is that the right people be involved— those who have the skills to resolve the problem and the power to make the resolution permanent. In most cases, finding and implementing a solution to a problem requires the engagement of a broad range of players and stakeholders.
BE ACCOUNTABLE FOR ENSURING PROBLEMS ARE SOLVED Although leaders are obligated to see that problems are solved, they are not obligated to solve problems they do not own. The important consideration in determining who should deal with a problem is who owns it and who is best placed to resolve it (i.e., usually one and the same person or group). The role of the leader, in most cases, is merely to provide the proper people with everything they need. As a result, the leader’s focus is not so much on the problem as on the process. If the owners of a problem turf it outside of their locus of control, the problem is unlikely to remain fixed for long. Therefore, leaders must make sure that problem-solving skills and processes are embedded in the organizational culture and that those who are attempting to deal with a problem have the wherewithal to take care of it.
Counterproductive beliefs and practices are significant barriers to the permanent resolution of problems. For example, despite what many leaders believe, being committed to resolving problems is not nearly as important as being committed to using good problem-solving techniques and processes. These techniques and processes create the insights and skills necessary to deal with problems effectively and quickly enough to avoid long-term trauma.
ELIMINATING FIREFIGHTING ALTOGETHER The best thing the leader of an organization can do is replace firefighting activities with much more productive behaviors. The research and work of Roger Bohm have been important in codifying what is wrong with most problem solving and in publicizing better methods (Savitch, 2008). To make problem solving truly effective, the leader needs to use tactical methods and strategic approaches and to alter the organization’s culture (Schabracq, 2007). Point to Ponder Firefighting is not a good problem-solving approach because it keeps the focus off the root issues and on the symptoms. In fact, the more firefighting a leader does, the more firefighting the leader has to do.
TACTICAL METHODS The advantage of tactical methods of problem solving is that they can be put into place quickly to deal with problems in the short term while the infrastructure for the more lasting approaches is constructed. Tactics simply mean making a change applicable and practical so that it can be successfully implemented. Tactics provide a means that is useful and can be replicated, evaluated, and changed when required. They are not cast in stone and can be readily adapted to new realities or necessary changes. The dynamic nature of tactics allows the leader to bring flexibility to bear
Getting Help from Outside the Circle It is often wise to have someone from outside the service or unit help with the response to problems inside. A person from outside will have a fresh view of the issues and will not be invested in the issues or the solutions under consideration. Leaders often refrain from using outside resources because they are uncomfortable with others knowing their problems or simply because they have not attempted this maneuver in the past. Yet the more insight that can be obtained from those who do not own the issues, the more objective and effective the solutions are likely to be. In the new age, one of the expectations should be that leaders will call on each other as outside consultants in dealing with the deeper and more complex problems and issues that undoubtedly arise.
Trying Something New People have a tendency to do the same things while expecting different outcomes. They become attached to rituals and routines that are inherently problematic and refuse to face the challenge of learning new practices. Most problems in organizations occur because the members hold on to old practices that have become barriers to smooth functioning and effective performance. The leader of an organization, acting as a change agent, must begin at the fundamental level— by creating a good fit between form and function and establishing a culture that supports changes in behavior. Here again, it is by creating the right context for change and creativity to occur that leaders can most help reduce the impact of habit and make it possible for people to let go of past practices.
Triaging Problems Problems are always occurring. The goal is to solve them as soon as possible so that they do not incubate greater problems. It therefore makes sense to sort through current problems quickly to determine which are normal or trivial and which are pivotal and likely to cause other problems. A conflict between two practitioners, for example, might create a bottleneck in the flow of work, especially if they sabotage each other’s efforts. Resolving their conflict would therefore prevent a range of difficulties down the road, and so the conflict would appear high on the list of problems to be tackled immediately.
STRATEGIC APPROACHES Strategic approaches, because they are embedded in an organization’s way of working and doing business, take longer to plan and implement than tactical methods.
Prioritizing Problems Problems should be viewed as a normal part of organizational operations and their solution as a normal part of the leader’s work. As much as possible, the leader should help the staff see problems as normal and develop categories for classifying problems according to their potential impact. Problems that affect staffing and the availability of clinical support resources, for example, would be treated as more urgent than office supply problems, and conflicts between departments would rank higher than conflicts between individuals on a given unit. Prioritizing problems is not intended to diminish the importance of any problem; it simply ranks them so that more critical issues are not left hanging.
Using Learning Scenarios The leader of an organization is crippled if she or he is the only one to take on the responsibility of solving problems. The “mamma” syndrome, in which problems are seen as exclusively within the leader’s jurisdiction, prevents the building of problem-solving processes into the system. Everyone needs to develop problem-assessment and problem-solving skills and the independence to take care of problems at the right time. There is no way to avoid or eliminate all problems, and indeed problems are a sign of life in the universe. Once staff members understand this, the leader can use present or past problems as vehicles for teaching problem-solving skills. Through this kind of “scenario learning,” the leader can help staff memebrs alter their attitudes toward problems and can change the locus of control for solving them. The staff can embrace problems as tools and develop the skills necessary to manage them to the organization’s benefit.
Building a Problem-Solving Tool Chest The solution of each problem should build the skill sets necessary to solve subsequent problems more quickly and easily. In a sense, each solution serves as a database for future problems. Codifying and recording approaches to specific kinds of problems increases the likelihood that recurrences will be solved in a similar fashion. Better still, it increases the likelihood that recurrences can be dealt with early enough to prevent a negative impact. In addition, banding together the strategies for dealing with particular types of problems creates a good framework for handling problems effectively.
CULTURAL CHANGES An organization’s attitude toward its own problems is as critical to their permanent resolution as any other single factor. If the organization refuses to see its own problems, nothing it does will ensure its ability to thrive in the long term. Rejecting Patching as a Problem-Solving Approach Focusing on situations instead of issues— or being sucked into situations and seeing the issues only from the inside— is sure to lead to failure. The best policy is to help the staff develop problem-solving skills so that they see clearly the problems that arise as part of their work and act as independent troubleshooters. Everyone who faces a problem wants the associated pain taken away. However, the pain is merely a symptom, and focusing solely on it ensures that the underlying issues never hit the table. In other words, the patching approach to problems must be challenged and eliminated from the set of permissible approaches.
Making Problem-Solving Deadlines Irrelevant It is true that problems cannot be allowed to go on forever. Rather than set deadlines for solving problems, however, the leader should embed a problem-solving methodology into the work itself. If the methodology is effective and problem solving is fostered by the organization’s culture, deadlines become moot. The problems that arise will not be avoided or treated as belonging to “the other guy,” but instead will be looked at as opportunities for growth.
Refusing to Reward Firefighting In health care, a premium tends to be placed on those who can make critical decisions quickly and correctly. Health professionals with this ability are treated as heroes by every medical soap opera and documentary. Heroes make poor citizens, however, and require a great deal of ego feeding. In fact, they are not necessarily good models except in war and can cause more problems than they are credited with solving.
It is better to implement good problem-solving methods and mechanisms than to have staff use individualistic approaches. It is better to build an organization committed to problem solving than to reward good firefighters. Waiting for problems to manifest means being a day late and a dollar short— by the time the problems are addressed, most of the damage has been done. The preferred strategy is to anticipate problems and incorporate their resolution into the life and work of every member of the organization.
CONCLUSION
For a leader, transformation can be a way of life. It is a journey consisting of logical stages made up of specific actions and processes. At its best, the journey is rational, progressive, and purposeful . Leaders who accept the role of transformational coach must embrace and cope with the vagaries of these changing times. Through their role modeling and commitment to self-direction and growth, they create a context for new expectations and new behaviors. Through living the reality of change, they ensure that others can embrace their own changes and respond appropriately. In all their actions, they fulfill the aims of transformational coaching by remaining fully engaged with the staff and guiding them on the way to a productive future.
References
Argyris, C. (2006). Reason and rationalizations: Capital limits to organizational knowledge. New York, NY: Oxford University Press USA. Lencioni, P. (2008). The five disfunctions of a team. New York, NY: Wiley. Porter-O’Grady, T. (2007). Implementing shared governance. Atlanta, GA: Tim Porter-O’Grady Associates. Porter-O’Grady, T. (2009). Interdisciplinary shared governance: Integrating practice, transforming healthcare. Sudbury, MA: Jones and Bartlett. Savitch, W. (2008). Problem-solving. New York, NY: Addison Wesley. Schabracq, M. (2007). Changing organizational culture: The change agent’s guidebook. New York, NY: Wiley.
CHAPTER THIRTEEN THE LEADER’S COURAGE TO BE WILLING
BUILDING A CONTEXT FOR HOPE Something unforeseen and magnificent is happening. Health care, having in our time entered its dark night of the soul, shows signs of emerging, transformed. —Barbara Dossey and Larry Dossey
CHAPTER OBJECTIVES At the completion of this chapter, the reader will be able to • Review the sources of healthcare professional disenfranchisement. • Describe the behavioral concept of willingness as it relates to the role of the leader. • Describe a process for identifying and evaluating dogma in the healthcare system. • Define the five essential qualities of will. • Identify specific situations in which leaders can positively affect practice using the five essential qualities of will.
This chapter explores the concept of willingness and related concepts (e.g., will, the will, and willpower), the personal and organizational context in which willingness unfolds, and the factors that may erode its expression. It explains how the will of a person generally operates, how leaders can maximize their will, the evolutionary stages that a person’s will goes through, and the purposes toward which a person’s will can be directed. It also describes the five essential qualities of will (or willpower): courage, passion, energy, discipline, and trust. Finally, it presents eight strategies for facilitating willingness and associated assessment questions for leaders.
Why are healthcare workers, especially nurses, so discouraged Where has all the hope gone Job-related stress, emotional exhaustion, and feelings of depression, helplessness, hopelessness, and entrapment continue to fuel dissatisfaction and discouragement among all health professionals, even physicians and healthcare administrators. The combined assault of staffing shortages, excessive regulation, and reduced reimbursement has left a pall of apathy over the healthcare profession.
First, severe staffing shortages are challenging leaders to find quick solutions— a nearly impossible task. Second, state and federal regulations require healthcare leaders and workers to perform numerous procedural tasks to document compliance, with associated high costs in time and money. A recent article identified more than 30 regulatory bodies at the national level and a number of state licensing agencies (eight or more per state) that have jurisdiction over healthcare organizations. The complex laws and regulations generated by these agencies are often conflicting, and their benefit to the public is generally unknown. The fact is that the regulation of health care would almost certainly be less extensive if health professionals were consistent in their practice and used value-based interventions exclusively. After all, it is not clear whether regulations passed to govern procedures are working as intended. Yet, despite the problems in the nursing profession, the public has more regard for nurses than for any other type of health professional. Nurses have a powerful voice in their communities— perhaps even more powerful than they know. Consumers and politicians want to know what nurses think about prescription issues, ensuring access to care, and changing the health system to meet the needs of patients and their families.
Why are some leaders more successful than others in leading an organization through transformational change necessary to address staff shortages, reimbursement, consumer needs, and regulations Why do some leaders fail to sustain their commitment to a change, letting it slowly subside or disappear altogether Why can some people create an environment of hope and calm despite desperate or difficult circumstances The answer can be found in the notions of will and personal willingness. Willing leaders are the co-creators of change. They recognize that no one person or situation can take away their personal peace, joy, and sense of competence, and they transmit these feelings to others.
Due to feelings of desperation, personal investment in the status quo, or a need for psychological preservation, some very knowledgeable leaders lose their willingness to take the initiative in making changes. Instead, they replace their willingness with an organizational mask, becoming what they believe the organization or a powerful other wants them to be. Such leaders may be incapable of seeing the whole and acting on their vision of it. Willing leaders not only see the whole but also claim responsibility for creating their personal experience of transformational change.
A CONTEXT FOR HOPE Leaders of quantum organizations can move only in one direction— toward building and sustaining the context for healthcare services and reinforcing expectations for a better future. These leaders behave in new and bold ways and see things from an optimistic and futurist perspective. Further, they are willing to do the work that needs to be done to meet patient needs, adhere to professional standards, and stay within the limits of available reimbursement. By their commitment to creating a hopeful context, they ensure that healthcare workers are better able to do the work of healing and health promotion. The degree of a leader’s willingness to lead can be explained by the extent to which he or she possesses courage, passion, energy, discipline, and trust. By possessing these qualities in abundance, the leader can engender in others not only hopefulness but a greater willingness to provide service.

WILL Will (or willpower) has been defined as an inner power— a power over nature and over the self (i.e., self-control). Only the development of this inner power can offset the risk of our losing control of the tremendous forces at our disposal and becoming victims of our own achievements. The terms will and willpower are typically used to refer to this inner power in the abstract, apart from the consideration of any individual person. The term the will is used when discussing willpower as evidenced by an individual person. In this usage, a person is said to have a will, and this will, typically viewed as the center of the person’s self, is what exhibits willpower (or lack of willpower). Because the development of each person’s will depends on the person’s culture and the current circumstances, including political and economic factors, a person’s will can be very powerful, very weak, or some degree in between these two extremes.

Key Point Will is the self-directing capacity of human beings— the internal body of personal power. In coaching others, leaders should recognize that developed willpower has an enormous potential for creating and adapting to change. Once leaders gain an appreciation for how the qualities of willpower are expressed, they can comprehend the dynamics of those whose will is less strong and understand their rationale for pulling away. Reframing the work of leadership in terms of willpower can serve to create or rebuild hope and to redirect others toward greater achievement and satisfaction.
DISCOVERY OF WILL This section explores the view that a quantum leader’s will is critical to his or her leadership success. The leader needs to discover the essence of his or her will and to create the conditions for others in the organization to discover and honor their own will.
For each person, the discovery of his or her will encompasses the following five phases: 1. Recognizing that willpower exists. 2. Realizing that one has a will. 3. Living one’s personal will. 4. Recognizing one’s soulfulness (an awakening of the self resulting from insight and self-exploration). 5. Recognizing that awakening the will can be risky and can even threaten paralysis.
The simplest and most frequent way in which a person discovers his or her will is through determined action and struggle. When a person makes a physical or mental effort or actively wrestles with some obstacle or opposing force, the person feels a power, or inner energy, rise up inside.
Self-exploration, particularly investigation of one’s will, does not appear to be widely embraced by those in leadership positions. Overworked and sometimes taken for granted, leaders must struggle with a number of issues before they can embark on an examination of their will. These issues include the following: • Leaders often have a Victorian conception of will, according to which it is associated with stern control over others. • Most people are reluctant to change, particularly if it involves personal examination. Also, change requires time and patience— two commodities that are in short supply. It is easier to sit back and let others carry the ball. • Leaders often do not want to pay the price for becoming more involved in change (or becoming less involved). • Leaders are hesitant to discuss willpower and its characteristics with the executive team for fear of job loss.
Not surprisingly, the organization’s culture strongly influences whether an exploration of willpower does in fact occur. The values, practices, and longevity of employees can facilitate or obstruct meaningful changes that foster a readiness to investigate the nature of willpower. Initially, a person’s will has a regulatory and directive function. Take the case of a rehabilitation patient. He knows what his legs are supposed to do and in which direction he is supposed to move, but in addition to the normal power he uses to propel his legs, he needs the encouragement of the physical therapist, giving him the willpower to act. Without this encouragement, the patient’s willpower would be weak or sporadic and might disappear altogether.
When individuals discover that willpower exists within themselves and realize that the will and the self are intimately connected, they become more oriented toward the self and concomitantly less oriented toward others and the world. Recognizing that the power to make changes is located primarily in the self and not in others, they are now free to use their willpower to choose, relate, and bring about changes in themselves and others. They feel a new sense of unlimited potential for action, whether this involves altering themselves or acting on the outside world. Consider the prevalence of noise in patient care areas. It is well known that noise prevents patients from relaxing and resting, yet little is done to keep down the noise level. Care providers know they should be less noisy and also remind others of the importance of quiet, but only rarely does an individual with a high degree of courage speak up about the need for a restful environment. In other words, the will to act is usually missing or is not sufficient for action. Although solving the problem of noise would seem to be simple, the fact is that noise in patient care areas continues to be one of the most common causes of patient complaints. Another example concerns the resistance of workers to changes in their work routines. They may believe that the current work routines are the best way to achieve the desired goals, but often they are merely fearful of what will happen to them after the changes are implemented. Thus their fear, rather than their will, is driving their behavior. Overcoming resistance to change is a consistent theme in management literature, and efforts to guide leaders in developing the skills needed to foster change and innovation are well documented.
Given that any complex adaptive system exhibits self-organization, unpredictable interactions, and interdependencies, leaders need to learn to work with the natural energy of the system. They can learn this and overcome resistance to change more effectively by developing an understanding of will and willingness. It is helpful to note that will, despite the Victorian conception of it, is not about sternness but rather about the multidimensional directive and regulatory balances used by an individual.
It is not difficult to let the easygoing side of one’s nature take control and to allow internal or external influences to dominate change when negative pressures exist. Such behaviors reinforce apathy and discouragement. Leaders need to take the trouble to oppose negative behaviors. They should not expect training of the will to be accomplished without the expenditure of energy and persistence required for the successful development of any other quality, physical or mental. Effort lies at the base of any worthwhile leadership activity and is a requisite for success.
NATURE OF WILL Because will is embedded in the self, self-exploration and the astute observation of colleagues are starting points for gaining an appreciation of the significance of will for leadership. Self-exploration can help a leader • Control his or her own will • Identify areas that need to be developed • Assess the application of willpower by others • Intervene in cases of inappropriate use Awakening of the self requires insight, self-absorption, and struggle. In the journey through transformational change, leaders discover the power to make choices, relate to others, and bring about changes in themselves and others. As a result of the new insights they gain during this journey, leaders could withdraw their support for certain projects or change priorities. Both positive and negative actions can be conscious or unconscious, depending on the degree of self-examination. When self-examination is a conscious process, the effect on the individual can be profound, as the self shifts its orientation inward.
Key Point Are you willing to want what you get when it comes or to force yourself to get what you want How strong is your will
Unfortunately, there are obstacles to and dangers in self-exploration of the will. All too often, leaders work to become who they believe the organization wants them to be, preventing themselves from becoming who they really are. When this happens, they struggle and perceive themselves stuck in a persona that is not authentic, with the result that they feel impotent, apathetic, and insincere. The questions that leaders, not to mention other individuals, need to ask themselves are these: Are you willing to say yes— to act, think, and feel as you really are Can you picture what this would be like Would it not be joyful to do things because they reflect your will and are authentic rather than solely because the organization expects such behaviors By developing their will, leaders are better able to make decisions intuitively and rationally. By integrating their personal heart and objective mind, they become more authentic individuals and increase their willingness to act. Alternatively, if they act solely for reasons and values outside of themselves, they will continue to suffer and be disinclined to participate in the changing environment.
Further, denying one’s personal will is a way of avoiding personal accountability. Assuming accountability, on the other hand, means never experiencing anything that is not a product of one’s vision, mental model, or emotions. The self, not the external world, is the source of experiences. It follows that nothing can take away one’s peace, joy, or sense of adequacy— each of these must be given up voluntarily.
TYPES OF WILL Characterizing the types of will that people have can help clarify what will is. For example, it is relatively common to hear people described as having a strong will, a skillful will, or a good will. A brief account of each type follows. To say that someone has a strong will is to say that that person has significant power or determination. A typical mistake is to believe that strength of will is the essence of the whole will— that having a will means always attempting to get one’s
own way. Someone who possesses a skillful will is able to achieve desired results with the least amount of energy. People who have this type of will must understand their own habits, goals, and desires, and the relationships among these, to use them skillfully. A person with a good will is benevolent, has a high degree of integrity, and does not use his or her will to overpower or corrupt the will of others.
ESSENTIAL QUALITIES The notion that a person’s will consists only of strength or weakness, or goodness or badness, is incorrect and can lead someone engaged in self-exploration in the wrong direction. Instead, for a person to exhibit will or willpower, he or she must possess a certain set of qualities, namely, courage, passion, energy, self-discipline, and trust . Leaders who are interested in increasing their expertise should use this set of qualities as a paradigm of will during periods of self-examination or when evaluating the behavior of others.
Courage Courage is that quality of mind or spirit that enables individuals to face difficulty, danger, and pain without fear and to act in accordance with their beliefs. Courage is required to stay the course during the shaking and shuddering of the chaotic stage of change and to manage resistance to change to reach new levels of knowledge and performance. It is also required to tolerate paradox— to function while holding two competing forces inside. Courageous individuals also tend to be creative, daring, and trusting of their intuition, whereas individuals who lack courage are cautious, to put it politely . Courage often does not emerge until the pain of not doing something exceeds the fear of doing it. The fear that we feel when we encounter an unfamiliar pathway and must enlarge our thinking is a signal that we are on the brink of learning. It is like traveling in a foreign country and being seized by a vague fear and the instinctive desire to go back home. Similarly, during periods of change we experience an instinctive desire for the protection of old habits. At that moment, we are tense but also porous to learning.
Numerous explanations for the lack of courage exist. Most point to fear of the unknown or discomfort with what is happening. Fear is paralyzing and brings out the worst in people— their most basic instincts, those for self-protection and survival. Yet healthy fear— the kind of fear that enhances the acquisition of new knowledge— needs to be valued, reinforced, and fostered. To create a more hopeful culture, leaders need to assist others in finding the courage to deal with the type of fear that causes imperviousness to learning and shuts down the capacity for connectedness. Believing in others and remaining patient while they endure and experience the process further supports their personal growth and accountability.
The Nike slogan “Just do it” calls individuals to jump out of the comfort zone and into the fringe of the unknown. Leaders need the same “just do it” attitude. This does not mean acting impulsively and without a plan, but instead doing the best that one can given what one knows and expects at that particular time.
As an example, although the perceived conflict between financial viability and professional standards will probably continue forever, decisions still need to be made. Leaders must often “just do it”— make a decision that balances standards and reimbursement. To develop the courage to make such decisions, you must let go of what others believe you should be and boldly show the world who you are. Courageous leaders • Face their fears • Explore their vulnerability • Lean toward risk

GROUP DISCUSSION After reading the following case study, identify the presence (or absence) of courage, energy, trust, passion, and discipline in the behavior of the nurse. A staff nurse admitted a terminally ill patient and reported to her supervisor that she believed she really had made a difference in the care of the patient and in the final outcome. She also stated that she had required a total of two hours for the admission process— an hour in excess of the allocated time. The supervisor, in response, showed concern about the extra time used in the admission process and the additional expense for this type of care.
The staff nurse then explained the situation more fully. A female patient with terminal cancer, accompanied by her husband, was admitted for pain management and relief of abdominal ascites. She was scheduled for a fluoroscopy-guided paracentesis to relieve the fluid and to receive IV pain medication. The patient was exhausted and wanted relief from her discomfort. Also, in the course of the admission, the patient informed the nurse that she was ready to die, that she had fought hard and long enough and knew nothing could be done to extend her life. Her husband agreed.
The nurse asked the patient if she knew that draining the fluids from her abdomen would relieve the pressure temporarily but would leave more space for the fluids to collect again. The patient was told that she could be kept comfortable without the paracentesis and could be assisted to die as comfortably as possible. This approach was discussed with the physician, who gave it his approval. The patient and husband chose to have pain management only. The patient died peacefully two days later.
In discussing the case with her supervisor, the nurse argued that use of two hours for the admission process resulted not only in a desirable outcome but in an economic savings. True, the admission cost the organization an additional hour of RN time, but eliminating a fluoroscopy-guided paracentesis avoided the addition of approximately $ 2,500 in charges to a DRG bill. The organization was saved this entire amount, as the reimbursement for the patient was fixed. Thus, the nurse maximized the quality of the care while minimizing the organization’s costs.
• Celebrate failures • Never give up
Passion Creating a sense of passion and willingness in employees requires leaders to institute employee incentives based on patient satisfaction and to empower employees to do what is right for the patients. The goal is to create an organizational culture that turns employees and patients into thunderous evangelists for the organization. This type of culture is very different from the traditional organizational culture, in which
• The employees are expected to manipulate patients into using a select group of providers in a particular geographical region. • Employee productivity is closely monitored. • Policies are strictly enforced.
Energy Energetic individuals are vigorous and active, with a capacity for serious effort. Such individuals also have an intensity of will capable of overcoming opposing forces, like an athlete in competition. This intensity of will is a form of power and needs to be recognized and used positively. The energy required for optimal willingness is never limitless; rather, energetic individuals learn to temper and manage their energy expenditure, balancing high-energy times with quiet times. In contrast, low-energy individuals are apathetic, uninterested, or burned out. Some are fearful of getting involved or becoming too hopeful because of past
disappointments. For these individuals, the lack of a clear defined sense of self is often at the root of their inaction. If they see themselves as disempowered, which many of them do, their stagnation is reinforced. What low-energy individuals need is assistance in reentering the unfolding processes of life. In particular, they need to assess their goals, focus on the future and on what is positive and working, and accept that human beings are inherently imperfect.
Self-Discipline Self-discipline is personal willingness to adhere to standards and meet responsibilities. It is the ability to check impulsive actions while persisting in selected activities. Self-discipline is regulation of one’s own behavior, not that of others. Without self-discipline, a leader with a strong will acts impulsively and unpredictably, negating the positive spirit of leadership willingness. When leaders develop self-discipline, they are better able to focus their attention and minimize impulsive and scattered activities. Their inner concentration grows, allowing them the steady control and clarity of action and thought they need to gain the support of colleagues.
Trust Developing trust between colleagues requires congruence of values, nonpossessive warmth, effective communication, and empathy (i.e., the ability to understand the perceptions and feelings of others). It also requires knowledge that the shared values are ethically sound and that the work of the care providers is truly intended to further the public’s interest. The trust that has been built up between colleagues is reinforced when everyone consistently behaves in accordance with accepted patient care standards and uses resources wisely, shares information appropriately, and discusses new ideas openly. A leader with a fully developed will, characterized by courage, passion, energy, self-discipline, and trust, creates a positive and encouraging context in which employees are expected to practice within professional standards and values. This type of leader also instills a sense of hopefulness in all members of the organization, increasing the chance that together they will bring about a better and more meaningful healthcare future.
Hope: Hope is the feeling that what is wanted can be had or that events will turn out well. People find it difficult to be hopeful if they do not believe things are going satisfactorily. They become less inclined to get involved and less willing to do the right thing because it does not seem to matter. When the qualities of will— courage, passion, energy, self-discipline, and trust— are present, a beacon of hope emerges to begin a positive cycle of behaviors. Discouraged and disenfranchised workers start to see new opportunities and develop a new willingness to focus on the present and future, leaving the past behind.
STRATEGIES TO FACILITATE WILLINGNESS Once leaders understand the nature of will, they are in a position to facilitate willingness as a means of achieving their goals. Following is a discussion of strategies that incorporate the qualities of courage, passion, energy, discipline, and trust. Note that these do not exhaust the strategies for increasing the willingness of employees, but constitute a beginning on which to build. focus on patient care. Willingness to be a co-creator of change rather than a defender of the past. • Embrace diverse perspectives. Willingness to look at multiple reasonable alternatives while giving up the role of patient advocate. Willingness to acknowledge that some situations may not be acceptable but are a major part of one’s work life and must be handled patiently. • Focus on value. Willingness to educate others to understand evidence-based approaches as the new context for providing healthcare services. • Awareness of the larger system. Willingness to move between micro and macro views of issues— from the patient to the team to the department to the organization to the community to the state to the world and back.
REMOVING THE DOGMA BRICK WALL So much health care is done routinely and automatically, with little thought to its rationale. As science advances, new technologies and practices emerge and become popular. These and the older technologies and practices should be examined to ensure that the highest quality care is being provided at the lowest cost. Examining technologies and practices demands significant courage, for it can involve challenging the system and its players. It also requires openness to new ideas and the recognition that change is (i.e., change is inevitable and should not be avoided).
In surveying health care for the purpose of making improvements, leaders should not look first to see what additional products, services, and providers are needed in the future, but rather review the current situation to identify non-value-adding services for elimination. This approach, besides helping to create excess capacity for future needs, revalidates what is important in health care. All too often, practices become integrated into the system and continue to be used long after their rationale is lost or forgotten. “We have always done it this way” is not a good reason to keep on using a nonbeneficial practice. For one thing, we have not always done it this way. At one time, only physicians were allowed to take blood pressures, insert nasogastric tubes, administer IV bolus medications, and write prescriptions. Now aides, technicians, and nurses perform these same tasks. The fact is that health professionals,
especially physicians, often hesitate to relinquish technical tasks that the state practice act does not really require them to perform. This is cause to wonder, for example, how and when the task of taking and recording blood pressure came within the purview of nursing assistants— or, better still, the responsibility of the patient! An individual somewhere, someplace was willing to question whether it was really appropriate for physicians to own this chore. Courage is needed to examine current practices, give up what is not appropriate, and retain what is. Further, this type of examination needs to be done with passion for the essence of the profession, not for personal recognition or benefit.
Unquestioning adherence to authority and tradition is a well-known barrier to the development of knowledge. Although authority and tradition provide a seemingly stable foundation, in fact blind faith is problematic and can be detrimental to survival. Continuing progress in nursing and other areas of health care thus warrants an examination of all dogmas and a release from those that are without foundation.
There are dogmas that pertain to professional roles as well as procedures and practices. Efforts to delineate the boundaries of each profession need to be ongoing. Those responsible for delineating the domains of the various health professions must look at the received wisdom (conventional beliefs) within each profession, the profession’s knowledge base (science), and the profession’s application of that knowledge (art). The practices of any professional healthcare worker go beyond science as traditionally conceived to include, for instance, the use of intuition and the therapeutic use of the self. Likewise, the emerging principles that pertain to building relationships and partnerships beg for inclusion into the healthcare disciplines.
The real work of quantum leaders is to deconstruct the dogmas of traditional Newtonian science and transform current organizational underpinnings to reflect the essence of complexity science. The realities of current organizations— the great number of connections and relationships between the many elements and the inherent capacity for change or adaptation— demand a better explanation than can be delivered by the linear thinking characteristic of Newtonian science. Unlike the mechanistic Newtonian paradigm, complexity science affirms that no leader is an island. In other words, the achievement of desired outcomes in a system is beyond the talents of any one individual. Instead, outcomes result from the relationships between individuals. Although the abilities of a single individual are important, they are not completely useful until the individual establishes relationships and works together with other individuals. Thus the attention of leaders shifts from individual performance to appropriate patterns of interrelationship. Strategies for minimizing dogma include these: • Examine and assess the value of at least three current practices each month. Retain or eliminate each practice depending on its value.
• Believe in the value of process so strongly that at least three employees gain the same appreciation each month. • Approach difficult situations in which there is personal impact with the same enthusiasm as situations that do not affect you personally. • No matter how long current practices have been used, be willing to examine others. • Review prevalent dogmas in a patterned way. Commit to making no change impulsively. Instead, first talk with colleagues to ensure that every proposed change makes good sense. • Know that colleagues share concerns about long-held practices and believe there are better ways as well but may not be quite ready to address the issues. Patience is needed.
CONTINUOUS LEARNING High-quality healthcare services can be delivered only by educated, compassionate, and skilled care providers. Further, such providers need to maintain or increase their competence levels through continuing education. Following through on a commitment to professional growth, however, can be incredibly difficult in an organization steeped in reorganization. Everyone’s energy is channeled into the redesign and maintenance of the new context, making continuing education hard to pursue. The quantum leader must therefore support the acquisition of new knowledge and skills by employees, while at the same time sustaining the reorganization efforts. Following are some ways for a leader to ensure that continuous learning becomes part of the organization: • Create and maintain a culture that fosters continuous learning. • Recognize that new knowledge is essential for all to survive. • Participate enthusiastically in continuing education and share the knowledge you gain with colleagues. • Support continuous learning consistently, namely, through every budget cycle and challenge throughout the year. • Identify and trend performance measures that support the value of continuing education.
MINIMIZING PROFESSIONAL ANTAGONISM In hierarchical departmental organizations, the workgroups tend to become competitive and adversarial. In healthcare organizations, for example, nursing and non-nursing departments continually battle for resources and position.
In addition, nurses have been reported to “eat their young.” A recent panel of student nurses working in a particular healthcare organization identified the nurses who coached and mentored them in a positive way and those who reinforced their novice status in the presence of others. One student freely shared why she would not select that organization for employment: she had been assigned a preceptor who was a nationally recognized nurse expert but who was avoided by students because of her intimidating behaviors and perceived intolerance.
Antagonism exists between new employees often because of poor interpersonal skills of supervisors, preceptors, and colleagues. In nursing, the nurses (the staff and the nurse manager) have the greatest impact on nurse stress, not non-nurse coworkers. Thus, in this regard, nurses truly are their own worst enemies— and consequently the solution may lie within nursing rather than outside the healthcare system. Nurses need to care for each other— just as they do for their patients. They need to be their brothers’ and sisters’ keepers. The leader’s role in reducing professional antagonism is to do the following: • Bring issues into the open for discussion and minimize behind-the-scenes dialogue.
• Realize that relationships truly can be therapeutic. Expecting collaboration is the only way to develop the culture and context for high-quality, low-cost patient care services. • Address issues as they arise. • Stay focused and remain objective.
MEETING THE NEEDS OF EMPLOYEES There are two categories of employees: those who have jobs and those who have careers. Those with jobs report to work, perform their duties as well as possible, and go home at the end of their tour of duty to get on with their lives. In contrast, those with careers not only do the necessary work but plan where they are going in their chosen profession and participate in professional activities outside of the workplace. Not every person is seeking a career. Some individuals are satisfied with a job that is meaningful and fairly compensated. Expecting to motivate all employees to commit to a career is unrealistic. It is especially ill-advised to dangle cash before professionals as a way of inducing desired behaviors and changes. This strategy is based on the assumption that people are motivated only by material gain and is likely to lead to a healthcare workforce that is indeed petty and greedy. It is also based on the assumption that individuals act independently of their social institutions and that social systems are nothing more than the sum of individual actions. This is a shallow notion of human decision making and ignores the way our values and actions are conditioned and constrained by social relations.
The world of work today is very different from what it was in the past. Workers stayed with one company or organization for a lifetime, whereas now workers may have several career pathways, and mobility rather than promotion is the symbol of advancement. The notion of loyalty needs to be redefined to reflect the marketplace of the 21st century. Loyalty to an organization may have been appropriate at one time, but now loyalty to one’s core values is more suited to the way work is organized.
Leaders need the courage to recognize this phenomenon and ensure that both types of employees— job holders and career seekers— are valued and treated fairly. The organization must meet not only the needs of the customers, but also those of the individuals it employs. The presence of employees from different generations and with different values requires leaders to use multiple strategies: • Create a compensation system that recognizes the multiplicity of employee values and needs. In addition, the system should support retention and guide employees to new opportunities when the organization’s needs change, the required job skills change, or the employees’ desires change. Become a partner with employees in managing their work and planning for the next position. • Be vigilant and persistent when implementing and maintaining an appropriate compensation system and recognition and reward program.
• Stay focused and committed despite resistance from those who would like the current compensation system and recognition and reward program to remain unchanged.
PROVIDING VALUE-BASED SERVICES What one does and what difference it makes are the key issues for all providers. If an organization provides 1,000 services and only 25 make a difference, then the other 975 services must be considered for elimination— even if the 975 services have billing codes that render them reimbursable. Provider accountability for contributions to patient care outcomes is a missing piece of health care. All professional care providers must focus their actions on achieving desired outcomes and implement only interventions that have a basis in science or a realistic chance of benefiting patients.
The measurement of health care outcomes is gradually becoming more meaningful and reflective of patient needs. Unfortunately, indicators are often looked at in an order that fails to take into account the basic goal of health care– health improvement. For example, productivity measures are typically examined before clinical outcomes. If productivity targets are exceeded, increases in productivity are mandated without consideration of their potential impact on care provision.
Nonetheless, consumers of healthcare services expect that the services received are based on logic and scientific knowledge and that the intended outcomes are likely to occur. Further, they view the primary goal of healthcare organizations as providing effective clinical services, not making a profit. The problem for these organizations is how to provide value-based, high-quality care that is affordable and at the same time makes money (this is different from making as much money as possible). Given the constraints caused by balanced budget initiatives, leaders are often

caught in a cost-quality balancing act and are not always sure how to achieve value-based care. No clear solutions are on the horizon for the ailing healthcare system— certainly no financial relief of any significance. This raises the question whether we can afford to spend money on quality initiatives. Ethically, the answer is a resounding YES! And that is the public’s expectation as well.
Perhaps it would be helpful to reframe the quality question as a value question. Value is determined by the three elements of cost, quality, and service (Malloch & Porter-O’Grady, 1999). Cost is driven by the available resources, which are currently very limited. Quality is partly determined by the outcomes of care. Service is a matter of the time and type of care provided. Thus, the question becomes: Are healthcare leaders obligated to provide value-based services to patients and family members The issue of spending money on quality is now linked to both cost and service.
Achieving value-based health care faces an additional challenge: drawing conclusions about quality initiatives and return on investment when there are multiple factors involved. A further complication is the extensive use of a type of cost-benefit analysis that is not sensitive to healthcare objectives. If the benefits of a program can be priced in dollars, then a cost-benefit analysis can identify the alternative with the largest benefit-to-cost ratio. However, many decisions involve benefits that are not easily quantifiable in monetary terms or otherwise, such as psychological benefits and environmental benefits (clean air and water).
Healthcare leaders and providers are now required to examine services using the value equation and to make decisions accordingly. If resources are limited, leaders must ask whether every patient sign and symptom requires intervention, particularly if minimal or no improvement in the patient’s clinical condition is the likely outcome. Paying close attention to the health improvement value of healthcare services is an incredibly difficult challenge for providers and leaders schooled in the doctrine that increasing access to health care and growth in the healthcare system were absolute goods. Unfortunately, accountability and control were absent from the cost-based payment system, and the results are well known— exhaustion of resources. Health professionals are currently challenged to move from “rich” care to “wise” care.
Another value-related issue of interest is productivity. Because business still operates under questionable assumptions regarding productivity— that the more hours employees work, the more productive they are; that the faster employees work, the more they accomplish; and that the more employees are paid, the more motivated they are to be productive— leaders are challenged to better understand the reality of employee productivity. Health professionals in this country are working more hours than ever before and getting less done. In fact, Americans have the dubious distinction of being first in the number of hours worked each year. The U.S. Department of Labor, Bureau of Labor Statistics, noted only a slight increase in productivity from 1960 to 1990, and the productivity increase in the last 10 years is attributed to technological advances, particularly the development of the Internet.
Myths and Truths About Employee Productivity Accepted Notions • If employees work more hours, they will be more productive. • If employees work faster, they will be more productive. • If employees are paid more, they will be motivated to work harder and produce more. The Reality • Employees perform optimally for 6 to 7 hours and may be able to work longer in a burst of energy or inspiration, but then they must rest.
• Employees need balance; they need a life outside of work. • Slower, intuitive thinking is often more effective in solving problems than mental agility. • Studies show that, in Germany, where individual performance is not rewarded with pay increases, productivity is often higher than in the United States. • Employees are most productive when their employers pay them equitably and then do everything possible to help the employees put money out of their minds.
Source: Data from Johnson, C. B. (2000). When working harder is not smarter, The Inner Edge, 3( 2), 18– 21.
Healthcare employees are burning out faster than the replacements are coming in, yet they are still being pushed to become more productive. They are working 12-hour days, are commuting up to two hours a day, and are held by an electronic leash to the office. Their opportunity to relax is almost nonexistent.
Contrary to popular belief, we need to learn how to slow down our thinking, not speed it up. Time for reflection and contemplation of ideas and issues is sorely missing in health care. The never-ending checklist is always present and demanding attention. Further, experts report that pay is not the chief motivator for productivity. In general, employees desire to do meaningful work most of all, next they desire opportunities for collaboration through group decision making, and then they want equitable pay.
What drives people to work at their best How can healthcare leaders revitalize the lost passion of employees What retention strategies support the rebuilding of a hopeful culture Interestingly, the answer is simple. When employees believe their work is meaningful— productive in the sense of producing beneficial results— they are motivated to work harder and experience a renewal of passion and hopefulness. Productivity is not only about quantity; it is also about quality
Optimizing Performance: Productivity or Fruitfulness Productivity • Productivity is mechanistic. • In a productivity-driven organization, employees are treated like machines and judged on the quantity of their output. • The predominant concern is getting more “bang for the buck.” • Efforts to increase employee motivation are dependent on external sources, pay, benefits, etc. Fruitfulness • Fruitfulness is humanistic. • Fruitfulness involves a respectful, holistic view of each person that recognizes values, beliefs, and expectations. • Fruitfulness honors the inner need of each person to express his or her uniqueness and talents and to develop and expand. • Fruitfulness engages the inner selves of employees and causes them to grow and be sustained naturally and enduringly. Source: Data from Johnson, C. B. (2000). When working harder is not smarter, The Inner Edge, 3( 2), 18– 21. Optimizing employee performance takes on a whole new meaning in this context. All human beings have a need to express their uniqueness and their talents in the work they do and be recognized for their contributions . Therefore, employees are typically motivated by jobs that develop their skills and expand their minds, demand individual initiative, involve working on teams, benefit others, and spark a desire to make a difference in the world. Jobs that have these characteristics possess what Cedric Johnson (2000) called fruitfulness— work flows from one person to another in a way that is both respectful and valued. To ensure that healthcare work possesses fruitfulness, leaders need to do the following: • Continually examine services, measures, and systems to assess their impact on patient outcomes. Retain those that improve patient outcomes, and eliminate those that have no effect or a negative effect. • Believe that hope can be restored to care providers through restoring value to the work they do. • Believe intensely that individuals give their best when treated like adults. • Be committed to doing what is best for patients. • Consistently expect only value-adding services to be delivered to patients. Publicly recognize individuals who focus on value, and guide those who require assistance in eliminating unnecessary and non-value-adding work. • Believe that all healthcare providers intuitively know that restoring value to work is the right path but have not been able to translate their perceptions into practice. Believe that most, but not all, will eventually make the transition. Believe that the healthcare system will not only support but will require increases in the value of healthcare services. Know that colleagues support caring, healing work that makes a difference.
BECOMING MENTALLY FIT Some care providers appear to be tougher than others. In fact, their “toughness” might be a kind of mental fitness resulting from their sense of commitment, perception of control, and ability to view change as a challenge. Mental fitness involves taking responsibility for one’s reactions to adversity. Through this kind of fitness, individuals can prevent emotional exhaustion and turn stressful events into meaningful challenges. Mental fitness is helpful for handling role modifications and reductions in the workforce. Employees who lack mental fitness often develop an attitude of learned helplessness. For example, if they are laid off, they react with anger, believe getting laid off is beyond their control, blame themselves, and generally feel helpless. Their helplessness triggers a downward spiral of self-defeat in which they see themselves as increasingly unable to get ahead. Goal setting, mental imagery, emotional mastery, and positive thinking are all part of the mental conditioning that is necessary to overcome this helplessness and survive substantial changes. The mentally fit alter the perception of stress and mobilize effective coping techniques, lessening the trauma of stressful events. In fact, they transform these events into opportunities for increased meaning in life. Leaders who are mentally fit learn to manage the context of the work as well as the specific content of their discipline
. Mental fitness among leaders is associated with leadership resilience and leadership agility. As leaders become more mentally fit, they also become more resilient, decreasing the probability that they will experience burnout. Many leaders, particularly those at the vice-presidential level, work persistently to support and guide the chief executive in clinical matters in addition to meeting their own responsibilities. The relationship between the head of the nursing department, for example, and the chief executive is not only intense but typically requires more from the nurse, who is likely to be continually providing feedback about the impact of decisions on patient outcomes and care provider satisfaction. Not surprisingly, the nurse leader, if lacking in mental fitness, will be prone to burnout.
Leaders who are downsized experience a much greater emotional and psychological impact than typically has been acknowledged, and their ability to deal with such trauma is minimal at best. For one thing, the skills needed to handle disappointment are seldom taught in educational programs. Therefore, downsized leaders spend considerable time second guessing past decisions and become reluctant to make decisions for fear of further emotional insult. If they get follow-up counseling, it is directed toward helping them cope with their behaviors, rather than preparing them for future disappointments. Becoming mentally fit, on the other hand, is a matter of learning to expect, anticipate, and plan for job-related disappointments and defeats and taking a proactive approach to managing one’s personal destiny.
Leadership agility is the ability to respond quickly and appropriately to input from employees and colleagues, the actions of competitors, and developing crises. Leaders with this ability are better able to manage the stress of situations and to calculate the odds of success or failure. Once they acquire agility, along with resilience and mental fitness, leaders are in a good position to handle their responsibilities without becoming exhausted and incapable of experiencing the pleasures of their work. They are also in a good position to appreciate the virtues of mental fitness and to understand its importance for the organization as a whole. To ensure that the organization’s entire workforce is mentally fit, leaders should do the following: • Create a culture that recognizes that good and not-so-good events occur, understand that employees need support when things do not go well, and provide the necessary support to those who require it. • Develop a personal commitment to help others acquire mental fitness, resilience, and agility. • Continually strive to increase their own mental fitness and create the culture that requires others to do the same. • Extract hope and energy from the mission of health care. • Establish a program of self-examination and self-renewal.
• Recognize that no individual is an island and that each person needs relationships, support, and feedback. Planning for Position Elimination • Recognize that no position is forever, nor should it be if the work of the organization is changing to meet the needs of the marketplace. • Consider other roles that might be of interest in the future and begin to develop skills in the relevant areas. • Homework help – Discuss your interests with your immediate supervisor, request assistance in continuing to meet current expectations, but also be prepared for changes. (Note: Although it may be difficult to discuss role changes, open and honest communication is always the best approach.) • Retain control of your career— avoid letting other factors control you.
BALANCING THE USE OF TIME The transition into the Information Age has left many people with far too many activities on the to-do list and too little time to accomplish them. Leaders must therefore guide employees toward looking at time use in a different way. No individual ever has enough time for all the things he or she would like to do. Time management strategies may assist employees in eliminating nonproductive or nonessential tasks, but the employees still need to find a good balance between the things that are truly important to them. More specifically, they need to achieve an equilibrium between the activities of work and personal activities so that they can find joy and pleasure in both.
Some progress has been made in creating more balance between work and personal life, but more needs to be done to minimize the burnout and keep employees from feeling discouraged and disenfranchised. When organizations identify balancing work and personal life as a goal, they tend to focus on the time at work. An organization might develop initiatives to help employees have flexibility in work hours, for example, but at the same time it might leave vacancies unfilled and ask employees to do more with less. It does not matter that the employees have flexible hours if they also have to work 5 or 10 more hours each week. Because they are not much better off as a result of the initiative, the employees view the message as ambiguous. In addition, management might then perceive the employees as ungrateful, causing the employees to feel that the executives just do not get it.
Achieving a balance between work and personal life is a never-ending process for both leaders and employees. Employees need tools to do their jobs well and to help them feel successful, and they need recognition and reward systems that measure and acknowledge their accomplishments. Leaders need to build a culture of respect for employees and their accomplishments. When people feel successful, leaving the workplace at the end of the day is easier both physically and mentally because the shadow of work is not hanging over their heads.
Leaders also should help employees feel successful in other aspects of their lives. Sometimes the support needed might seem like it falls outside the leader’s jurisdiction. However, quantum leaders recognize that no individual ever enters the door of the organization and leaves all personal issues behind. They understand that personal issues have an impact on any employee’s ability to work effectively and that assisting the employee might be critical to the team’s success. Employees have a wide variety of needs that change as their lives change. Few have the personal skills to achieve and maintain balance. A strong mentoring program not only produces better employees but also can teach the skills needed to balance work and personal life.
Once employees feel supported and successful in the workplace, they are better able to reduce or eliminate time-wasting activities and behaviors, such as gossiping. Certain attitudes and emotional states can act as hidden consumers of time. These include defensiveness, selflessness, and boredom. Defensiveness is a common problem. Reacting to criticism by uttering sharp remarks or lashing out in defense of one’s actions creates an atmosphere of irritability and anger and can affect everyone in the environment for some time to come. Time spent in angry rumination is wasteful at best.
Selflessness, not selfishness, can be a time waster as well. Saying yes to every request is not realistic. Learning to say no on occasion lets the individual take back some of the time he or she has been losing. The hardest part, of course, is getting beyond the guilt. Boredom is another time waster that is not often recognized. Boring tasks often cause individuals to waste time procrastinating. If a task is extremely boring to an individual, it most likely could or should have been delegated. The following strategies should be used by leaders to help themselves and employees balance their work and their personal life and avoid activities, behaviors, and emotions that consume time to no good purpose: • Recognize that everyone has the capacity to balance his or her use of time better. • Focus on balancing time use as an opportunity for increasing meaningfulness and not as an opportunity for increasing control and regimentation. • Share the reality that time is short, desires are many, and every person engages in a never-ending struggle to close the gap. • Be persistent in examining personal activities for balance and avoid the tendency to shift back to being task focused. • Be persistent in coaching others in how to balance work and personal life. • Believe that colleagues know that a good balance between work and personal life results in higher productivity and greater job satisfaction.
INCREASING THE FOCUS ON PATIENTS It is no secret that the locus of control for healthcare services should be the patient, not the provider. Yet in spite of all the efforts to create patient-focused care delivery systems, few patients would agree that they are in fact the focus of services or in control of anything. In explanation, they could cite facts such as these: • Providers continue to prescribe treatments without discussion with the patients. • Visiting hours are still in effect. • Appointment times for services are based on Monday through Friday schedules. • Patient procedures and their scheduled times are determined by providers without input from patients or families. Leaders have plenty left to do to transform the healthcare system into one that is truly based on the will of the patient. A good place to begin is the Internet, which should be pushed as a proactive means of assisting consumers in interpreting healthcare information. Other strategies leaders should use to increase the patient focus of health care include these: • Find the courage to continue the journey to creating a better system. Avoid the tendency to believe that the system is as consumer focused as it can be. • Recognize that personal experiences as a patient can be invaluable for learning the truth about healthcare service delivery. • Remain committed and focused when complaints override positive feedback. Resist the temptation to retire from health care. • Never stop asking patients to share their experience of the healthcare system. Learn from them and share the information gained with other health professionals to improve the system. • Believe that every health professional possesses courage, passion, energy, and self-discipline but may need reassurance and encouragement to exhibit them fully.
BECOMING POLITICALLY COMPETENT Political competence encompasses the ability to accurately assess the impact of public policies on one’s domain of responsibility and the ability to influence public policymaking at both the state and the federal levels (Longest, 1998). Politically competent leaders are aware of relevant regulations, laws, proposed acts, and certification procedures and are able to remove or mitigate outside barriers to the delivery of services. They also work within the organization to define issues affecting the delivery of patient care services and identify internal policies or procedures that should be altered.
However, these are only the first steps. The leaders need to ensure that all members of the organization have a degree of political competence, can address concerns in a timely manner, and can suggest possible solutions. The point-of-service staff members experience the real concerns and successes that occur at the delivery of services, know when things do not go well, and can offer recommendations for change. Their input is needed not only in the executive suite but, in many cases, in the legislative arena as well. Strategies for increasing the political competence of the organization as a whole include the following: • Develop the ability of all employees to share information about system effectiveness. Be aware that the empowerment of employees, if not guided, can result in chaos. • Recognize that empowerment can light a fire throughout the organization. When a person’s personal contributions are valued, the fire in that person’s heart is fueled. • Patiently guide employees to communicate and share information. Never give up trying to ensure that the information necessary for identifying and implementing improvements is available to the members of the organization. • Pay close attention to the desired outcomes of care as well as to the processes used to achieve them. On the other hand, never circumvent necessary processes for the sake of efficiency.
Although the preceding quotation was written more than 20 years ago, it is still applicable today, partly because of the cyclical nature of health care and the recurring need to create healthcare services that are congruent with the demands and resources of the marketplace. We have much to learn about the healthcare system’s cycle, but the basic needs are always the same— to meet current challenges, to learn from the past, and to continue to create new and better methods to integrate technology, information, and the wisdom of providers and leaders.
The words of Florence Nightingale offer hope and gentle reminders for all healthcare workers. Her perceptions are consistent with the public and political consciousness of today, namely, that public health and human caring are supremely important. Further, as in her time, many are now calling for reform of basic social and healthcare practices. In our era, for example, there are many critics of our society’s response to the needs of the homeless, the medically indigent, those who are HIV positive, those who are living with AIDS or another incurable or chronic illness, and those who are relatively powerless or neglected, including pregnant women, children, and older adults. Consider these themes from Nightingale’s writings: • Basic caring and healing practices must be restored. • The moral, the spiritual, and the metaphysical must be reintegrated. • The knowledge and values of women— the sacred feminine healing spirit— must be allowed to play an essential role in health care. • Healing professionals must recapture their sense of “calling.” • The public’s requirement of personal and professional caring competencies and commitments must be honored. • The wisdom of connected oneness and wholeness— the interrelationship between person, nature, environment, and health— must also be honored. Aren’t these same themes relevant today Is there any doubt that the transformative journey we are on dates back at least to the 19th century As Watson (1999) noted, our work should be about relighting the lamp and helping our colleagues to reintegrate and reconnect to restore the professional wholeness that was wounded during the recent modern era.

CONCLUSION
The Age of Complexity encompasses exponential increases in information, technology, and interaction between diverse people and cultures, confirming that our world is truly global. In addition, despite the fear that many people feel today, the complexity of this new age can be a source of hope. The speed of change, the blurring of work and home life, and the new global relationships enrich each one of us directly or indirectly.
In this next era, leadership thinking will be more humanistic and more sensitive to the complex interrelationships in the world. Hope in the future and willingness to transform bureaucracies into self-renewing organizations is another aspect of the journey of leaders into and beyond the millennium. To accomplish their goals, leaders require courage to do the right thing, passion for the work of healing, energy to stay the course, self-discipline to remain focused, and trust that others are partners in the process. Finally, they must be steeped in the belief that the future will indeed be better because it is they who have designed it.
References
Buckley, C. D., & Walker, D. (1989). Harmony: Professional renewal for nurses. Chicago, IL: American Hospital Publishing. Johnson, C. B. (2000). When working harder is not smarter. The Inner Edge, 3( 2), 18– 21. Longest, B. (1998). Managerial competence at senior levels of integrated delivery systems. Journal of Healthcare Management, 43, 115– 135. Malloch, K., & Porter-O’Grady, T. (1999). Partnership economics: Nursing’s challenge in the quantum age. Nursing Economics, 17, 299– 307. Palmer, P. J. (1998). The courage to teach: Exploring the inner landscape of a teacher’s life. San Francisco, CA: Jossey-Bass. Watson, J. (1999). Postmodern nursing and beyond. New York, NY: Churchill Livingstone.

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