Response to PIERRE’S REVIEW ON COMPETENCIES AND PRINCIPLES – POST 8.1

Hello Kamal,

Thank you for your post. Although we work in different health authorities and different settings, best practices seem to be universal. Employees need that personal touch to feel heard and respected.

I would like to provide a brief description of CLeAR for everyone else reading:

CLeAR stands for Call for Less Antipsychotics in Residential Care. The British Columbia Patient Safety & Quality Council (2017) describes CLeAR as

a quality improvement initiative that supports teams from residential care homes in British Columbia to address the behavioural and psychological symptoms of dementia (BPSD) with a focus on reducing inappropriate use of antipsychotics.

Antipsychotics are not the optimal choice for treating BPSD. These drugs are minimally effective, but increase the risk of stroke, unsteady gait, increased disruptive behavior, and death (Banerjee, 2009). The Canadian Academy of Geriatric Psychiatry and the Canadian Psychiatric Association recommend using these drugs only when measures not involving drugs have failed, and only if the behavior would be dangerous to self or others (Choosing Wisely Canada, 2017).

The Canadian Institute for Health Information (2017) says 25.9% of antipsychotics in British Columbia long-term care homes may be used inappropriately. With the minimal benefits and increased risks, many parties, including medical professionals and families, want to reduce the use of antipsychotics.

However, other medical professionals, nurses, families, and care staff resist change. As you said, “why change something that doesn’t need to be changed.” (Badesha, 2018) I agree with you about the need for communication, especially change talk. Perhaps one way of reframing the change is the use of expectancy theory.

Purvis, Zagenczyk, & McCray (2014) explain expectancy theory as “motivation on the degree to which an effort is perceived to lead to performance, performance leads to rewards, and the rewards offered are desirable.” In laymen’s terms, we answer the question, “what’s in it for me?” Why should care staff, nurses, families, and doctors care about this initiative? I have found discussing this question to be helpful with some stakeholders. For care staff and nurses, a decrease in antipsychotics may lead to lfewerside effects and deaths. We need to acknowledge when antipsychotics use is appropriate; CLeAR is fewer antipsychotics, not no antipsychotics.

For families, we can sell the idea of better health for their loved ones. Few families want to see residents with uncontrollable behavior, but these same families also don’t want their relatives to live as soulless zombies. We can convey the hope of managing the behavior while maximizing qthe uality of life.

Finally, for doctors, we can talk to them about potential side effects. Doctors know about the maxim of “start low and go slow” with medications. They are also aware of family sensitivity regarding overmedication. We can sell them on the idea of working together to maintain the highest quality of life.

Let me know what you think!

References:

Badesha, K. (2018). Response to Pierre’s review on competencies and principles – Post 8.1. Retrieved November 25, 2018, from https://create.twu.ca/kamalbadesha/2018/11/24/response-to-pierres-review-on-competencies-and-principles-post-8-1/

Banerjee, S. (2009, October). The use of antipsychotic medication for people with dementia: Time for action Retrieved November 25, 2018, from https://webarchive.nationalarchives.gov.uk/20130104175837/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_108302.pdf

British Columbia Patient Safety & Quality Council. (2017). CLeAR wave 2: Final evaluation report. Retrieved November 25, 2018, from https://bcpsqc.ca/wp-content/uploads/2018/07/2017-CLeAR-Wave-2-Evaluation-Report-Aug-3-2017_FINAL.pdf

Choosing Wisely Canada. (2017). Psychiatry. Retrieved November 25, 2018, from https://choosingwiselycanada.org/psychiatry

Purvis, R. L., Zagenczyk, T. J., & McCray, G. E. (2015). What’s in it for me? Using expectancy theory and climate to explain stakeholder participation, its direction and intensity. International Journal of Project Management, 33(1), 3–14. https://doi.org/10.1016/j.ijproman.2014.03.003

Response to Pierre’s Challenge of “Stella’s Strategic Competencies || Blog 8.1: D’Oh!

Hello Stella,

Thank you for your response post. I now have more understanding of how the education system works (although I’m sure there’s much more to it). I am intrigued by the complexity of education; I was certain teachers were entirely responsible for their classrooms. I also did not know how education for special needs students works. Thank you again for sharing.

I am happy you found the link I shared useful. This type of learning helps all of us learn beyond our local environments and experiences. I agree with your assessment of a team (complex) interdependence within your education system, like parts of the health care system. I guess there’s a reason health and education are together in this class!

I promise I didn’t laugh. I giggled a little bit, but only because I didn’t really understand Galbraith’s purpose at first either. I like your example of “twenty pieces of lego… we can put them together like this” (Peters, 2018). I would love to do what my kids do – take all the legos apart and build whatever I want. I can’t, for now, but I can see the connections and understand how things are put together. Just like you, I had my “eureka” moment; I can look at the current structure and figure out how I can renovate!

Reference:

Peters, S. (2018). Response to Pierre’s challenge of “Stella’s strategic competencies || Blog 8.1: D’Oh!.” Retrieved November 25^th, 2018, from https://create.twu.ca/stellapetersldrs501/2018/11/23/response-to-pierres-challenge-of-stellas-strategic-competencies-blog-8-1-doh/

Stella’s Strategic Competencies || Blog 8.1

Hi Stella,

Thank you for your post, and for sharing your ideas for improving your strategic leadership practice. I applaud you and your organization in achieving a 50% growth rate over two years. That is amazing! I see you recognize the challenges in rapid growth, and I believe you will be able to handle them.

I want to discuss one of your choices for your three least important principles. You used Figure 1.1, types of interdependence, as an example. What are the different teams within your organization? Does each teacher work on his or her own? Do teachers of different subjects work together to determine the learning plans? What does the administration do concerning the teachers? (I apologize if the questions seem very basic; I know very little about the education system).

In health care, the interdisciplinary team has four types of interdependence: pooled, sequential, reciprocal, and team (complex).  Galbraith (2014) defines pooled, sequential, and reciprocal but not team (complex). Cholette, Beasley, Abdiwahab, & Taplin (2017) describe team (complex) interdependence as members mutually interacting and collectively managing the flow of inputs and output between members. They use the example of creating a care plan for a patient with multiple chronic conditions; all the team members need to collaborate to make a comprehensive plan. Would this type of interdependence apply to a student with special circumstances?

I also want to ask you about your evaluation of Galbraith’s book. You say it is “too technically focused on business aspects.” (Peters, 2018) If you could start from scratch, to design an education system based on your ideas, would you find this book more useful? Do you think this thought experiment would help you come up with possible innovation for your current system?

Again, thank you for your post. I look forward to your response and learning more about education!

References:

Chollette, V., Beasley, D. D., Abdiwahab, E., & Taplin, S. (2017). Health information systems approach to managing task interdependence in cancer care teams. Journal of Oncology Practice, 13(3), 154–156. https://doi.org/10.1200/jop.2016.020156

Galbraith, J. R. (2014). Designing organizations: Strategy, structure, and process at the business unit and enterprise levels.

Peters, S. (2018) Stella’s strategic competencies || Blog 8.1. Retrieved November 23, 2018, fromhttps://create.twu.ca/stellapetersldrs501/2018/11/22/stellas-strategic-competencies-blog-8-1/

Sadie’s post is here: https://create.twu.ca/ldrs501/2018/11/22/5724/

Hello Sadie,

Thank you for your post. I agree with the principles you have chosen for your organization, specifically the ones where you catch someone doing something right and creating a supportive environment (Thompson, 2018).

At the end of your post, you discussed cooperation and competition (Thompson, 2018, para. 11). Ungerger, Ungerer, and Herholdt (2016) say “cooperation works better than competition” (p. 382). However, this statement does not mean you cannot have both. The term for a relationship that has both cooperative and competitive aspects is coopetition (Padula & Dagnino, 2007). Coopetition has been used by educational institutions to access resources unavailable to them individually (Dal-Soto & Marlon Monticelli, 2017). Another example of coopetition is seen in the health care industry, when multiple facilities form one bargaining association to deal with unions, while still competing for clients.

In your context, coopetition may work. The cooperative part of your environment could be a reward for all staff should the organization meet specific targets. I am unfamiliar with what a relevant target would be; for my organization, one of our targets is a 50% reduction in falls with injury by 2020. Should all our home reach that target, we get a bonus. In the meantime, the competitive part of this goal is the home achieving the lowest number of falls with injury getting a special prize. This competitive part of the goal does not hamper homes from helping their sister homes, but it drives individual homes to be the best among their peers. Something similar may work for in your context!

References:

Dal-Soto, F. & Marlon Monticelli, J. (2017). Coopetition Strategies in the Brazilian Higher Education. RAE: Revista de Administração de Empresas, 57(1), 65–78. https://doi.org/10.1590/S0034-759020170106

Padula, G. & Dagnino, G. (2007). Untangling the rise of coopetition: The intrusion of competition in a cooperative game structure. International Studies of Management & Organization, (2), 32. Retrieved November 22, 2018, from https://ezproxy.student.twu.ca:2420/10.2753/IMO0020-8825370202

Thompson, S. (2018). Competencies, principles, and me. Retrieved November 22, 2018, from https://create.twu.ca/ldrs501/2018/11/22/5724/

Ungerer, M., Ungerer, G., & Herholdt, J. (2016). Navigate strategic possibilities: strategy formulation and execution practices to flourish. Randburg: KR Publishing. ISBN 978-1-869-22623-7.

Kunal’s original post can be found here: https://create.twu.ca/ldrs501/2018/11/20/strategic-leadership-competencies/

Hello Kunal,

Thank you for your post. I find myself agreeing with you on some points yet wanting to seek clarification on some of your other points.

Samson has provided an excellent response to your point of self-management, located here: https://create.twu.ca/chiefanalyzerofthings/2018/11/22/the-importance-of-building-personal-competency-for-success/, so I will not touch on that point.

I wanted to discuss one of the points you chose as least essential; the “evolve, do not install” point from Galbraith (2014). I am having trouble locating the specific reference in Galbraith; would you be able to provide the relevant section or chapter?

You state, “it is one of the company’s policy to not intrigue in other’s work and especially administration. To focus more on their work” (Singla, 2018, para. 11). Does this mean teams within the organization cannot collaborate? Usually, policies have a purpose or rationale behind them. Was there a history of employees interfering in other people’s work? Now I’m intrigued!

Further, I want to get some clarity regarding the definition of “evolution”. Combined with your statement of “the organization adopts the methods which are best suitable for them and the benefit of the organization without thinking of employees and considering them” (Singla, 2018, para. 10), I wonder how this organization functions. It seems as if the organization is using the old economy value of coercion, holding power over employees instead of collaborating with them (Ungerer, Ungerer, & Herholdt, 2016). It appears your organization would not appreciate innovation generated by front-line staff. Have you found the organization implementing new initiatives to a significant degree of success, or has there been much pushback?

Finally, you state the “organization core committee have trust issues with every employee, and they do not trust anyone’s work” (Singla, 2018, para. 9). I am saddened to hear this. I have trouble understanding how exactly this organization continues to function without rapid turnover and/or severe burnout. I do not mean to offend you or your organization, but I know I would have trouble working there. Reina and Reina (2006; as cited in Hughes, Beatty, & Dinwoodie, 2014) describe three dimensions of trust: contractual, competence, and communication. Your organization does not seem to have competence trust if they do not trust anyone’s work.

I look forward to discussing with you further.

References:

Galbraith, J. R. (2014). Designing organizations: Strategy, structure, and process at the business unit and enterprise levels.

Hughes, R. L., Beatty, K. M., & Dinwoodie, D. (2014). Becoming a Strategic Leader: Your Role in Your Organization’s Enduring Succ. John Wiley & Sons.

Singla, K. (2018). Strategic leadership competencies. Retrieved November 22, 2018, from https://create.twu.ca/ldrs501/2018/11/20/strategic-leadership-competencies/

Ungerer, M., Ungerer, G., & Herholdt, J. (2016). Navigate strategic possibilities: strategy formulation and execution practices to flourish. Randburg: KR Publishing. ISBN 978-1-869-22623-7.

Ungerer, Ungerer, and Herholdt (2016, p.34) cite the story of a Zen master teaching a man about the importance of “emptying the cup” to learn something new. LDRS 501 course materials provide us with new ideas and new ways of implementing strategic leadership. Some of the material has been immediately useful, while other material may be helpful in challenging my way of thinking even if I cannot directly implement the concept.

I believe these three competencies will be the most important to my organization and me moving forward:

1. Building Trust (Hughes, Beatty, & Dinwoodie, 2014, p. 148)

Browning (2013) refers to trust as “the lubricant that enables a leader to bring about transformational change.” Reina and Reina (2006; as cited in Hughes et al., 2014) refer to three dimensions of trust: contractual, competence, and communication. Health care magnifies all three dimensions due to the life-and-death decisions made with clients and their families. Leaders deemed untrustworthy by their employees will result in poor practice and possibly even loss of life.

Conversely, a justified sense of trust between leaders and their employees will likely lead to best practice. I plan to build trust by focusing on these three dimensions. Contractually, I will “let my yes be yes, and my no be no” (Matthew 5:37), not making impossible promises. I will increase my competence by continuing to hone my clinical and leadership skills, and by trusting my frontline staff with their assessments and care plans. Finally, I will continue to have open communication with my employees and our clients, being honest and sincere.

2. Lead the organization by building culture (Ungerer et al., 2016, p. 36)

Hughes et al. (2014) remind us of culture’s ability to eat strategy for breakfast. Health care culture has unfortunate aspects, especially with the idiom of “nurses eating their young” (Gillespie, Grubb, Brown, Boesch, & Ulrich, 2017). Instead of trying to fix problems with the workplace with quick-fix solutions, I would need to help the organization with a culture shift. I can do this by promoting the creation of a “just culture”, one where learning and client safety are of utmost importance (Boysen, 2013). A “just culture” acknowledges errors and analyzes why they happen, looking to solve problems within the system instead of immediately dealing out punishment towards individuals. This type of culture in the workplace seeks quality improvement without sacrificing accountability.

3. Creating a Supportive Environment (Lepsinger, 2010, p. 69)

Lepsinger says a supportive environment makes people comfortable so they can try new things. I have previously described my organization as recovering from an environment of authoritarianism. I have no interest in having frontline employees acting like robots with no initiative. I want employees to exercise their free will and to challenge me when they feel a course of action is inappropriate. I would start creating this environment through many 15-minute unit meetings with all of the staff, encouraging them to express themselves and share their ideas. I believe innovation comes from frontline staff, not from a few “gurus”.

I believe this competency may not be as useful to my organization and me:

1. Act decisively in the face of uncertainty (Hughes et al., 2014)

Health care organizations tend to be risk averse due to the need for stability in all circumstances (ASC Communications, 2016). Because of the nature of the field, health care organizations seek to reduce the amount of risk possible, sometimes to the point of near paralysis. Instead of acting decisively in the face of uncertainty, I would instead implement more PDSA cycles (American Society for Quality, n.d.) to reduce potential negative impact to low levels while still moving toward quality improvement.

I have found the following three principles most helpful to organizational practice:

1. Learning from Addicts / Change Readiness (Lepsinger, 2010)

Some of my clients have substance use issues, while others are addicted to questionable practices. Some have resigned themselves to their addiction, saying they are too old to change, while others fear the withdrawal effects. Some of these withdrawal effects can be dangerous; for example, delirium tremens is a form of alcohol withdrawal which may lead to confusion, hyperactivity, and even death (Burns, 2018).  Other times the withdrawal effects can be merely unpleasant.

I have extended this line of thinking into the practice of my frontline staff. Some of my employees became addicted to the status quo, to the thought of “it’s always been done this way”. Yesterday, I introduced a small trial involving a linen cart and a process flow change with laundry. This change would affect 20 residents and two staff – about 10% of the organization. Immediately one senior staff member objected to the change, saying “this will not work” and “why change something that’s working”, even though the old process was wasting valuable time.

Over the past year, I have seen the effects of withdrawal from my staff to various levels. Some of the staff eagerly embraced the change, as if they were free to fly. Other individuals, like the senior staff member above, furiously clung to the old ways, convinced her world would flip upside-down. A few staff chose to retire (career death) rather than change.

I have made the mistake of wanting to cause rapid, abrupt change in the organization, believing the best way to shake things up is by treating behavior like an old bandage – removing it quickly to the effect of more pain but less time. I have inadvertently caused the organizational equivalent of abstinence syndrome, or “cold turkey” (Ghodse, 2010, p.181). Ghodse also says,

Rather than treating relapse as a failure, any worthwhile period of abstinence should be welcome as a success and the patient’s achievement recognized. A positive approach encourages cooperative rather than confrontational attitudes between patients and staff, and in this atmosphere more patients will be prepared to try again.

I resolve to apply Ghodse’s approach to addiction withdrawal – I will seek to encourage employees on their journey to wellness, instead of berating them when they slip into old habits. I am a fellow addict, at times chained to my current ways of thinking. I resolve to journey with my staff, seeking freedom from mediocrity and traveling with them to greater success.

2. Strategic Thinking (Hughes, Beatty, and Dinwoodie, 2014; Ungerer et al., 2016)

The mind is powerful. Recent research discusses the placebo effect or the improvement of symptoms for a condition with a substance that should not have any physiological effect. Crane (2016) says “the ability of the mind to affect physiology, whether through expectancy., meaning, or context, is increasingly accepted”. Western medicine may see this mind-body connection as new, but Eastern thought held this idea millennia ago. One Middle Eastern source says, “Guard your heart above all else, for it determines the course of your life.” (Proverbs 4:23).

The importance of thinking and the personal mind extends into the organization and its collective mind. Ungerer et al. (2016) ask the question of why seemingly intelligent people act in evil ways. Enron, Lehman Brothers, and Bernie Madoff show the effects of greed as a corporate value. Conversely, Bagozzi, Sekerka, Hill, and Sguera (2013) say strong morals lead to strong intentions, which increase the chance of completing moral acts.

Strategic thinking requires an organization to come together and think about its current state, future state, and its systems (Hughes et al., 2014, p. 70). Ungerer et al. (2016) discuss five interrelated thinking stances that will help an organization succeed, namely “possibility thinking, collaborative thinking, abundance thinking, new economy values thinking and paradox thinking.”  All of these thinking stances challenge our perception of reality, to go from “how things have always been” to “how things are and where they will be.”

3. The New Economy (Ungerer et al., 2016)

This principle has had the most impact on my way of thinking about organizations and systems. When I first started in nursing, a hierarchical structure existed where doctors where in charge and the nurses acted as their handmaidens. I also learned to respect my elders and to refrain from questioning their decisions. This structure was the “old economy” of coercion. When I moved from the Philippines to Canada, I saw more collaboration within the interdisciplinary team, thus leading towards the new economy. However, I do not feel we have reached the last stage of the new economy, which is co-creation. To achieve this stage, I believe I will need to implement servant leadership within the organization and recognize all of my co-workers as partners.

I have found these principles to be less useful to my organization and me:

1. The Reconfigurable Business Organization (Galbraith, 2014)

I am confident this principle may be helpful to our CEO and his vice-presidents, but I do not see as much value with our local leadership. Our local facility must conform to the requirements laid out by the local health authority, including the provision of care, recreation, dietary, and housekeeping services. There may be “informal” teams that could lead individual initiatives, but our organization is static overall.

2. The Business Model Canvas (Ungerer et al., 2016)

Just like the reconfigurable business organization, I can see the value of the canvas for very high-level leadership and those interested in the overall business model of the organization. I do not currently see the value of this principle for my leadership team and my staff, as this specific principle would likely generate any interest within our current employees. Instead, they would be more interested in how best to care for residents. They are not interested in revenue streams, cost structure, or revenue streams.

3. The Value-Adding Conglomerates (Galbraith, 2014)

Similarly, this concept makes sense for the CEO and vice-presidents. My parent organization has multiple arms in retirement, long-term care, and real estate, but front-line employees would not any interest in something that seems very abstract. They would instead focus on information and processes that affect them directly.

And the Winner for Least Useful Resource Is…

Sorry, Mr. Galbraith. I can see some value in designing organizations if my organization was a start-up or if I was not involved in long-term care. I am currently working in a mature field with a low tolerance for organization change, so I don’t currently see any practical application for Designing Organizations. Perhaps when I get further in my career…

References:

ASC Communications (2016, March 29). Hospital boards are often risk-averse. Here’s why they need to embrace it — and how. Retrieved November 18, 2018, from https://www.beckershospitalreview.com/hospital-management-administration/hospital-boards-hate-risk-here-s-why-they-need-to-embrace-it-and-how.html

Bagozzi, R. P., Sekerka, L. E., Hill, V., & Sguera, F. (2013). The role of moral values in instigating morally responsible decisions. Journal of Applied Behavioral Science, 49(1), 69–94. https://ezproxy.student.twu.ca:2420/10.1177/0021886312471194

Boysen, P. (2013). Just culture: a foundation for balanced accountability and patient safety. The Ochsner journal, 13(3), 400-6.

Browning, P. (Ed.). (2013). The currency of trust. Independence, 38(1). Retrieved from https://ezproxy.student.twu.ca/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=edsaed&AN=rmitplus197641&site=eds-live

Crane, G. S. (2016). Harnessing the placebo effect: A new model for mind-body healing mechanisms. The International Journal of Transpersonal Studies, 35(1), 39–51. Retrieved from https://ezproxy.student.twu.ca/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=lsdar&AN=ATLAiFZK160930001397&site=eds-live

Galbraith, J. R. (2014). Designing organizations: Strategy, structure, and process at the business unit and enterprise levels.

Ghodse, H. (2010). Drugs and addictive behaviour: A guide to treatment. Cambridge, UK: Cambridge University Press.

Gillespie, G. L., Grubb, P. L., Brown, K., Boesch, M. C., & Ulrich, D. (2017). “Nurses eat their young”: A novel bullying educational program for student nurses. Journal of nursing education and practice, 7(7), 11-21.

Hughes, R. L., Beatty, K. M., & Dinwoodie, D. (2014). Becoming a Strategic Leader: Your Role in Your Organization’s Enduring Succ. John Wiley & Sons.

Ungerer, M., Ungerer, G., & Herholdt, J. (2016). Navigate strategic possibilities: strategy formulation and execution practices to flourish. Randburg: KR Publishing. ISBN 978-1-869-22623-7.