Northwest Organization of Nurse Leaders News

NWONL Leaders in Action June 2020 - 10 min read

Leadership Always Present?

We are commonly leading 24x7x365 operations and the subsequent demands on us as leaders are relentless.  It’s no wonder that there is a cultural norm in our profession that leaders must always be present. Technology to conduct work from virtually anywhere has become ubiquitous over the last 10 years. This form of remote work has been proven in many sectors but remains largely relegated to technology workers and some professionals in an individual contributor role (think accounting, law, etc). What about us as Healthcare leaders? Could the always on, always present cultural norm of leading from the front actually be counterproductive? Could it be both harming us as leaders via prolonged stress and our ability to be effective? What are the resulting unintended downstream effects on our organizations and ultimately the patient experience and outcomes?  Courtnay Caufield, Chief Nursing Executive, Kaiser Sunnyside Medical Center in Oregon fielded a program to test these hypotheses. The initial outcomes are of distinct interest. 

AWS: Alternative Work Schedule 

Caufield started the study of remote work (Alternative Work Schedule) and launched the program prior to Covid-19. The timing was ideal. Alternative work schedule is a component of adaptable organizations. Given the recent dilemma we have faced with distancing and rapidly adjusting our operations to accommodate we are looking at a necessity to remain flexible and adaptable as a core competency going forward.
As leaders our downstream impact has a snowball effect and potentially quite powerful, positively or negatively. Beyond the logistics, there is evolving research on the potentially positive impact of helping leaders to avoid burnout and improve their engagement and job satisfaction through empowering them to determine their own, optimal, work environment and schedule. Caufield and peers specifically targeted the program to test leadership effectiveness and the impact on self and organization as it relates to conducting work from alternative locations.  

It won’t work here…

Caufield shared that the general sentiment of the leadership strata initially was that a location agnostic and flexible schedule (AWS) “won’t work here”. This is not an unexpected response. In modern organizational development theory, there is the acknowledgment that prior to change most, if not all, organizations will state or act in a manner that reinforces their current state. This evoked through exclamations such as “it won’t work here”, or “we are different” and “we tried this before…” and manifested through deliberate and subtle behaviors including learned helplessness, group think, passive-aggressive behavior, bullying and lateral violence in an intrinsic bias to maintain the current state. 
Caufield’s program acknowledged these risks and brought them forward. Their trial included a pre-trial perception evaluation for transparency. It’s a qualitative tactic but quite useful in helping to understand the emotional barriers to activation and follow through. It allows for an individual to share their voice and concern while keeping their identity private (Delphi-technique). Most importantly it demonstrates to all leaders that their shared value (or desires) are indeed of value to the group as a whole. Essentially Caufield’s trial started with building the largest foundation possible that all contributors can stand on equally while giving voice to their collective fears, uncertainties and doubts. Their results of the pre-survey likely were not surprising to any of us and included:

Shared Value and Measured Impact

Acknowledging the sentiment of “it won’t work here” and then identifying common interest is one thing. Moving to defining shared value and activate trials is another. Fortunately, healthcare organizations are adept in conducting testing and trials. A3, RIE and PDSA are commonplace. The challenge to organizations is why they should invest (take-a-risk) on paying people to deviate from standard operating behavior (or potentially policy and procedure for those with strict standards of work). A trial that creates a new process or environment is inherently risky. It’s doesn’t initially fit the LEAN mentality of reducing waste as it is fraught with the potential for being messy as it evolves. That “messy-risk” is hard to quantify, as it’s packed with what-ifs and is always a hard-sell. However, that is exactly where shared value shows its potential. By acknowledging the downsides, you can move to enumerating the potential upside benefits and change the trajectory of thought: What if we could increase leader effectiveness, contribution, engagement, health and wellness? What if the improvements drive care team subsequent engagement, job satisfaction, and productivity? What if that improves the patient experience? 

More easily said than done...

A stumbling block is agreement. Disparate interests and variations on how individuals, teams, and department success are measured means getting sponsor-stakeholders to agree on what to measure and what success looks like.  This can be exceeding difficult.  Programs like this often mean something different to each person. Contributing and getting them all to actually agree on shared value and avoid groupthink plus passive-aggressive behaviors is one of the biggest challenges you will face. Plus, the reality is, at some point you have to show productivity and cost benefits, or you simply won’t gain full executive support.

Ground Rules 

To counter divergent interests, Caufield’s program started with ground rules (expectations and requirements) that were ratified from the top down/bottom up to help combat this organizational pull to resist change. They included both technical and socio-cultural “agreements” that all players could rely on from their peers from a behavioral standpoint. It provided parameters for the stakeholders and participants to check their own behaviors. It included hard rules for standardized reporting format, sequence, timing and soft rules for behavior to mitigate anti-bullying and lateral violence, plus promote listening and empathy. 

Tangible Outcomes

Caufield’s trial required agreed upon metrics for evaluation that were qualified in pre and post sentiment surveys, and quantified via measured benefits, for both individual leader participants and the organization as a whole over a span of 4 months. The averaged outcomes included:
Leaders Individual Direct Benefits Organizational Downstream Benefits  Participant’s Post Survey Sentiment


The trial for Caufield’s program was prescribed for four months. Enough to gain traction and objective measurement but likely not enough time for an evidence-based organization to move to systematically change their work policy and cultural behaviors permanently. However, given the results, it’s indicated that more evaluation over longer periods of time are warranted. Additionally, there are other potential, longer term, metrics that may be impacted that a four-month trial does not expose. 
The risk exists that running a trial of this magnitude can really set an organization back on its heels.  Consider the four frames of structure, symbology and culture, politics, and policies that organizations operate in. An organizations current state is the amalgamation of all these frames. They are a force holding the organization together both positively and negatively. Getting them to change can be ridiculously hard even when the people in charge desperately want them to change. The take-away is that the results in Caufield’s program are promising. Given the current state of needing to stay adaptable and flexible as an organization while protecting our most precious assets, our leaders and staff, it’s worth serious consideration and a trial of your own.