The Role of Organizations As they were As they are As they might become As they ought to be Dee Hock Authentic leaders are not made nor are they born; they are enabled or disabled by the organizations in which they work. David Leach 4
New CNO Idealized Design Nurse Focus Groups Outcome: Practice, Research, Education Support Creation of Office of Professional Nursing 5
Setting the Stage in 2000... Preplanning & effort to influence outcomes Maximize ability for reasoned & informed judgments Create our preferred future 6
A Culture for New Nurses Predicted dearth of experienced RNs and dependence on advanced beginners 7
Table I. 2000-2010 Initiatives for Nurse Residents Year00-01 01-03 03- 04 04-05 05-0808-0909-1010-11 Orientation Unit Based CentralizedHPSHPS/HRSA UHC/ Receptive Listening Receptive Listening Receptive Recep Listening Preceptor Program Generic DHMC 1-Day RN/VNIP ModelOPN 1-Day OPN 2-Day DH History of Support for Residents 8
Setting the Stage 2003: EB Preceptor Program implemented Designed a NRP with HPS 2004: 3-month NRP with HPS implemented 2005-2008 NRP funded by HRSA
End of HRSA research protocols DH Retention had improved, but the UHC benchmark was 9.5% for 3 years. By June,2009, 35% of the 290 residents hired (7/05-2/08) had left DH. Why were NLRNs leaving 1st jobs & nursing at rates of 13-70% nationally? An Opportunity Existed in 2008 10
Journey to Professional Formation and Authenticity Transition into Practice 11
A developmental trajectory from beginner to expert Practice as a way of knowing in its own right Socially embedded knowledge Skill of involvement Benner,Tanner,Chelsa 2009 Transition into Practice
Open to the vulnerability of our patients and where that will take us in action… This emotional connection motivates advocacy, a key aspect of the expert nurse. Skill of Involvement 13
Design Concerns Integrating a year-long residency into the clinical setting and work schedule Recruiting facilitators Training facilitators before and during the process Supporting facilitators and residents in this process Getting residents off the units to attend
The goal is to respond by reflecting or joining the contact in order to help the individual speak of her resistant behavior. Responding to the Function of the Contact
What is the Contact Function of this log? “I guess I am struggling with feeling the need of these meetings. Maybe in time I will find them more beneficial, but right now I do not feel or see the benefits of them”..
What is the Contact Function of this log? “ Especially since, in the small groups, we are all from different areas of the hospital. 2 from OR whom have one another for support and to talk to, 2 on 4West whom also are friends outside of work (went to nursing school together), so they have each other as a resource and then myself in a totally different environment in XXX”.
Why Joining / Mirroring? It makes us similar. We are like one another. Example: NHR: “I like you. You think just like me” NHR: “The love I have for you is the love I wanted from my father but never got”
Joining That’s right. That’s infuriating. That’s frustrating “You” avoided because we “think alike” about the emotion
Joining (Advanced) R: She left me alone for two hours while she had lunch with her daughter. F: That’s infuriating. F: It’s scary -- joining R: Yes F: What makes it scary? -- OOQ R: He’s going to get angry F: That’s scary -- Joining (Pause) Can it be scary and you still do it? -Reflection
Why Reflecting? Encourages the subject to “say or do more” and/or have new thoughts about a topic.
Examples of Reflecting Say more R:Tell me what to do with her! F:How would knowing what I would do be helpful? Can you not be motivated and still write the paper?
Conclusion Also, when with people who “think like us” we are open to listening, report thoughts in a respectful manner and, most important, gain access to the positive parts of our personalities..
Result Natural mitigation of conflict and a natural increase in cooperation and loyalty to each other and the organization that facilitates an increase in intrinsically motivated self-esteem and creativity.
Expectations of Facilitators Able to express their thoughts and feelings in language in a safe setting. Create the container to “say everything”. Participate in their own monthly group that creates its own meaning. Be genuine, caring, and receptive, with receptive by far the most important attribute. Commitment: 9 months, 4 hour /month; logs 34
Facilitators did create a safe environment for residents to put thoughts and feelings into language. Outcome: An intimate glimpse of the lived experience of advanced beginners at the sharp edge of care What Happened Initially? The Fuure Revealed 35
Recognition of value of NRP,HPS, preceptors, educators and unit support Compassion for patients and their families Teamwork: Intergroup collaboration Rewards of being challenged and supported simultaneously Joy of recognizing the developing expertise of each other Initial Voices of Residents 36
Continuous fear of the responsibility for lives of high acuity, unstable patients Disruptive behavior with experienced RNs & MDs Challenging patients/families Systems issues as interruptions Disappointment/ Disillusionment The Journey was Difficult 37
Anxiety related to performance, fear of making errors, killing patients Developmental and personal changes Leaving work at work Physical and emotional symptoms due to work stress The Journey was Difficult 38
Physical or emotional suffering that is experienced when constraints (internal or external) prevent one from following the course of action that one believes is right. Pendry (2007) Moral Distress 39
Socially emotional climate… foundation of trust, mood,and sense of possibility in the group. 40
DHMC Nursing Vision Creating an environment where patients and family can heal. CNO Personal Vision Creating an environment where nurses can do what is right. DHMC Commitment to Excellence 41
The moral distress incited by competing and conflicting occupational expectations within the workplace is one of the primary factors specified for the exodus of new nursing recruits out of acute care workplaces. Duchscher & Myrick 2008, p.195 ) Impact of Moral Distress 42
Advanced Beginner/Clinical Situations Present as a series of tasks to accomplish Opportunities for learning Secondary ignorance A test of personal capabilities…a period of stark terror in which they recognize they are in over their heads. Benner et al (2009) 43
The Process of Becoming: Stages of New RN Graduate Professional Role Transition Although it is by no means a linear or prescriptive and not always strictly progressive, it was evolutionary and ultimately transformative for all participants. 44
Uncertain who they can trust and driven by a need to belong, these graduates went to great lengths to disguise their emotions from colleagues and worked to conceal any feelings of inadequacy. Duchscher, J. (2008). Process of Becoming:Stage One 45
NLRN Characteristics, Work Attitudes,& Intentions to Work Secondary analysis of 612 surveys of NLRNs, focus on work environment: Theme 1: Colliding Expectations Theme 2: The Need for Speed Theme 3: You Want Too Much Theme 4: How Dare You? Theme 5: Change is on the Horizon Pellico, L., Brewer, C., Kovner, C. (2009). What newly licensed registered nurses have to say about their first experience. 46
Using NLRNs to get work done vs using work to develop NLRNs ? 47
Value= Outcomes(Quality) x Time Cost Outcomes 48
Table II 2003-2010 DH NLRNs Turnover Yr I & Yr II
08-09 NRP YR I 12.6% (4 of12) YR II 20% 09-10 NRP YR I 6.2% 10-11 NRP YR I 5.2% Costs >1 st YR 08-09 (n=12) $970,200 09-10 (n=5) $404,250 10-11 (n=3) $242,550 Cost of Turnover>1 st Year 50
Creating a Safe Environment A Safe Environment “It was a very nurturing experience. Being able to talk and vent and listen to other new nurses experiencing the same thing was great. The fact that we were in a non- judgmental place was key (everywhere else we are being judged)”. Trust “What was said there, stayed there”! 52
Themes of Residents’ Feedback Professional identity Self-understanding Renewal Learning in dialogue Problem-solving Sense of belonging Connected to the organization 53
Examples of themes and enactment of residents’ voices will follow 54
Lessons Learned Confidentiality, the foundation of trust in the group, became a barrier to sharing what we heard across the organization. Facilitators need a group, experiential learning, and continuing education to do this work (BGSP). Unit leadership and fiscal resources are essential to support residents to attend small groups.
Unanticipated Outcomes Early detection of residents’ with problems. Clearer understanding of why they leave. Early interventions to assist in decision to transfer within. Facilitators’ character maturation Residents continue to seek this trusted network of facilitators after the year and across facilitators.
Camere by Dom Helder It is possible to travel alone, but we know that the journey is human life and life needs company. Companion is the one who eats the same bread. The good traveler cares for weary companions, grieves when we lose heart, takes us where he finds us, listens to us. Intelligently, Gently, Above all, lovingly, We encourage each other To go on and recover our joy in the journey. 59
Implications for Experienced RNs What could happen if all nurses could put their thoughts and feelings into language in a safe environment where they were not judged, valued, changed, or helped ? 60
WE SHALL NOT CEASE FOR EXPLORATION AND THE END OF ALL OUR EXPLORING WILL BE TO ARRIVE WHERE WE STARTED AND KNOW THE PLACE FOR THE FIRST TIME T.S.ELIOT Next Steps