Clancy, Thomas R. MBA, PhD, RN
As systems evolve over time, their natural tendency is to become increasingly more complex. Studies in the field of complex systems have generated new perspectives on management in social organizations such as hospitals. Much of this research seems a natural extension of the cross-disciplinary field of systems theory. This series of articles applies complex systems science to the traditional management concepts of planning, organizing, directing, coordinating, and controlling. In this article, I discuss how the dynamics of distance running can help nurse leaders solve complex health system problems.
All my life, I have been a runner. For as long as I can remember, I could run long distances at an effortless clip while my peers struggled to keep up. It was as if I was built to run. My natural talent for long-distance running resulted in a very successful high school and college track and cross-country career. During my senior year in college, an athletic trainer evaluated my running form and told me that I overpronated. Pronation of the foot occurs when the heel bone angles inward and the arch tends to collapse. Overpronation can lead to foot pain, as well as a host of injuries such as knee pain, shin splints, Achilles tendinitis, and plantar fasciitis. To prevent injury, the trainer suggested that I start running in a shoe designed to reduce overpronation. Back then, shoes were simple, offering slightly more protection than just running barefoot. This line of new, "high-tech" shoes was sweeping the country and promoted as the wave of the future for serious runners. I took my trainer's suggestion and started running in these new "super" shoes. Immediately, I noticed a difference in my running. It was as though I was running in shock absorbers, and I was able to progressively increase my daily mileage without injury. I concluded that these shoes were marvelous… or so I thought.
About 6 weeks after I started training again, I noticed a dull pain in my knee. This dull pain gradually increased over the next week to the point where I was referred to an orthopedist that specialized in sports injuries. After examining my knee, the orthopedist concluded that although my new shoes were great for my feet, they were hurting my knees. Apparently, the shoes changed my "natural stride," and this placed additional stress on my knees. In other words, in my attempt to prevent one problem, I created a new one. Does this sounds familiar?
Distance Running and Organizations
Although this experience occurred more than 30 years ago, it has helped form my understanding today of how complex systems work. The human body, like any system, seeks stability and balance, what I referred to in my running analogy as its natural stride. Running represents enormous complexity. The coordinated actions needed to run require the musculoskeletal, cardiovascular, and pulmonary system to operate in perfect harmony. However, natural does not mean perfect. Natural is unconscious, instinctive, and effortless. A natural stride is innate and is genetically inherited; you are born with it, and it is nearly impossible to change. And although 2 runners may have a similar stride, there are no 2 strides that are exactly the same. One's natural stride is balance in motion. It emerges as the result of multiple factors interacting simultaneously: muscle size, height, weight, bone length, posture, flexibility, foot size, and so forth. Each factor adapting to offset vulnerabilities in others.
Do organizations such as hospitals also have a natural stride? Is there a unique rhythm in the everyday workflow of nurses on different units? I think there is, and like the human body, it results from factors such as the physical layout of the floor, the number and competency of the staff, the types of patients, and so forth. In the human body, even as we age, our stride remains the same. The same can be true of social organizations. Even as nurses come and go, over time, the unit workflow remains the same. This is what makes complexity so interesting. Although there are multiple, seemingly disparate factors contributing to nurse's workflow, there is an underlying rhythm that permeates over time. However, the combined effect of all these factors is so complex that it is virtually impossible to understand why.
I started running again this year. During the last 30 years, I have tried numerous different shoes to prevent injuries. I have seen podiatrists, physical therapists, exercise physiologists, and orthopedic surgeons. I have experimented with various types of orthotics and arch supports. I have even had surgery on my foot. But in the end, I generally suffer some form of injury within a few months of running. So after a while, I just gave up. Then 6 months ago, my son gave me a book entitled Born to Run: A Hidden Tribe, Superathletes, and the Greatest Race the World Has Never Seen,1 which purports the notion of running barefoot. At first, the idea seemed absurd, but the more I read, the more it made sense. If one measures the existence of man on a yard stick, less than the last inch would represent the time he has worn shoes. Humans evolved shoeless, and our body is built to run long distances. Starting at a very young age, shoes change our natural stride and actually weaken our feet. So I started running barefoot.
I wish I could say that my experiment was a smashing success from the start, but it was not. At first, my feet throbbed at night and my lower calves ached all the time. But I stuck with it, and during a 6-month period, my body adapted and I am now running injury-free and farther than I have in years. I have found my natural stride again.
Finding Your Organizations Natural Stride
As nurse leaders, 1 of our hardest challenges is finding and maintaining our organizations natural stride. Change, whether it is a new facility design, technology, or practice, disrupts the natural rhythm of a nurse's environment. And more often than not, our attempts to prevent a single problem simply create new ones. Here are a few of my more recent observations related to workflow in hospitals:
1. Although provider order entry systems have reduced medication errors in many areas, they have proliferated a host of new errors related to human computer interaction (HCI).
2. Although the aim of evidence-based practices is to decrease variation in quality (including cost), the burden borne by individual hospitals of developing and updating them may exceed the financial benefits of implementing them.
3. Although the movement by hospitals to a single-bed environment improves patient satisfaction and privacy, it decreases nurses' efficiency by increasing the distance they must travel between patient rooms.
As nurse administrators, I am sure you could name many, many more examples. What is more disturbing, though, is how frequently we make the problem worse. For instance, to eliminate medication errors resulting from HCIs, I recently witnessed a policy that required all nurses to complete an online checklist before administering a certain chemotherapy agent. Not only did this not decrease errors (because the nurses ignored it), but it also doubled the time it took nurses to complete the documentation. This is the paradox of leading change in complex systems. Solving problems in one area often creates new issues in others.
So what is the solution? I keep going back to my running experience for the answer. By trying to prevent overpronation through new shoes, I changed my natural stride and placed additional stress on my knee. Although pronation can lead to injuries, in this case, it was actually preventing one. In was an adaptive mechanism in the complex web of musculoskeletal relationships inherent in my natural stride. Although painful at first, by running barefoot, I reestablished the unique balance in my natural stride and am running again.
The same analogy can be used in solving problems in complex healthcare systems. Recently, a hospital I consulted with investigated whether medication transcription errors resulted from providers having to reenter patient information in a patient's paper chart multiple times during admission. Their solution was to have the admission nurse enter the data once in an electronic medical record. This would allow other providers to simply review the information and eliminate the need for asking a patient the same question multiple times. Medication errors actually increased after implementing this tactic. Apparently, the act of having multiple providers ask a patient the same questions was an adaptive mechanism that actually caught transcription errors! The solution was to have the admission nurse enter the data once but to have the other providers validate key medication questions during their assessments. The natural workflow (stride) was to validate patient information by multiple providers, and once this process was eliminated, errors increased.
The lesson here is that solutions to complex systems can be counterintuitive. We often think that we are preventing a problem when, in fact, we are creating a new one. If quality indicators on your nursing unit are performing well, then you are probably hitting your natural stride. If they are not, then something is likely out of balance. The problem, though, is that we tend to investigate systems only when they are underperforming. Just as important is to understand what factors are working when they are performing well. I searched for solutions to my running problem for 30 years. If I simply looked at what I was doing before I switched shoes, I probably would have solved my problem years ago. Make sure you know what your unit looks and feels like when it is hitting its natural stride. If you lose it, it may take a long time to find it again.
© 2011 Lippincott Williams & Wilkins, Inc.