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Original Articles

Complexity Leadership in the Nursing Context

Uhl-Bien, Mary PhD; Meyer, Danika MSN; Smith, Justin MD

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Nursing Administration Quarterly: April/June 2020 - Volume 44 - Issue 2 - p 109-116
doi: 10.1097/NAQ.0000000000000407
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  • Continuing the Conversation

Abstract

Health care is ever evolving, but many organizations struggle with how to stay ahead of the changes. Promoting an environment where creativity and innovation are embedded in a culture requires taking a certain amount of risk. Yet many times I find myself in situations where risk is identified as an option that must be avoided at all costs. I decided to pursue leadership because of my desire to not only protect but improve the environments we work in. Making changes that support these values can sometimes be near impossible because you are forced to navigate the “red tape”—from having to achieve multiple levels of approval to increasing financial restrictions. Doing this day in and day out can leave nurse leaders feeling defeated, uninspired and burnt out.

—Amy, Nurse Executive

THE CHALLENGES FACING nurses and nurse leaders are immense. Not only are nurse leaders handling clinical situations that threaten the life or well-being of patients and caregivers, they are also being held accountable to financial and operational components of health care. This is occurring as health care consolidation, through mergers and acquisitions, continues to unfold in response to the disruptive forces of complexity. The goal of consolidation is to buffer health care organizations against turbulent and uncertain environments to increase their chances of survival. Yet, while consolidation is improving the overall fitness and viability of health care systems, it is having the opposite effect on health professionals working within them. For these individuals, consolidation is being experienced as an added burden from the business and regulatory side on top of their already overwhelming clinical demands. In this “do more with less” environment, many nurse leaders have to sacrifice their personal lives to meet the demands, and this “martyrdom” model is being increasingly rewarded in nurse leadership roles. Is it any wonder that burnout is a primary topic of discussion in health care circles these days?

One response to the burnout problem is a focus on resilience training. The idea is that increasing resilience will help nurses and nurse leaders better cope with workplace demands.1 Individual resilience training alone will not solve the problem, however. The underlying causes of the problem must also be addressed. As described by Rosemary Taylor, resilience is a complex and contextual concept, and “any intervention to promote resilience in healthcare workers must recognize and address the structural and organizational factors.”2(p10) The question is, what does this mean in nursing contexts? The answer is, we need to enhance both individual and organizational adaptability.

At its core, resilience is about adaptability: those who are more resilient are able to cope with and adapt to adversity.3 This applies not only at the individual level but also at the organizational level. The quest for resilience is what is driving health care organizations to consolidate in the first place—they are trying to increase their adaptability in the face of complexity. The good news is that health care organizations are doing it the right way by building complex network structures. What they are not getting right is recognizing that when you change the structure you also need to change the leadership. Rather than overburdening existing leaders through added bureaucracy, leaders need to be freed up to suggest and enable changes that made the system run better. Doing this requires moving from classic hierarchical leadership models to emerging models of complexity leadership.

COMPLEXITY LEADERSHIP: WHAT NEEDS TO HAPPEN

Complexity leadership is a framework for understanding how to enable people and organizations for adaptability.4 It draws from complex adaptive systems (CAS) theory in complexity science to show how systems can be more adaptive in the face of complexity. Examples of CAS are neural networks in the brain, the immune system, and the developing embryo. All of these function by enabling information from across networked interactions to flow into an “operating system” that can capture the information, make sense of it, and apply it into the system for adaptability.

In complexity leadership theory, this is depicted as the complexity leadership model (Figure 1).5 The model shows how networked interactions enable new ideas generated by entrepreneurial leaders to flow through adaptive space and into the operational system, where they are captured by operational leaders to generate beneficial new order (ie, adaptability). This new order can range from increased efficiencies, such as cutting costs, to beneficial innovations such as improved health outcomes.

Figure 1.
Figure 1.:
The complexity leadership model. Used with permission.

The uniqueness of the complexity approach is that it does not view leadership as only a management function occurring in formal leadership roles and hierarchical structures. Instead, leadership is a collective process flowing through networked interactions. This requires radical new ways of thinking about leadership. Rather than leaders being just managerial implementers of top-down directives, they are seen as collaborators who work together to enhance the overall adaptability and fitness of the system. From a complexity leadership perspective, the role of nurse leaders should be not only to help the system run but also to help it run better by increasing organizational adaptability. They do this by enabling the adaptive process.

The adaptive process

The adaptive process is the mechanism through which CAS maintain adaptability. At the core of the process is the tension dynamic—the injection of tension in a system that motivates it to change.6 Tension creates dissonance, a feeling of discomfort that leads one to want to reduce the discomfort and restore balance. Systems (and people) that restore balance by engaging the tension to generate beneficial new order are adaptive. Systems (and people) that restore balance by getting rid of the tension and staying in equilibrium are largely maladaptive—they can get away with this for a little while, but if they continue to not adapt to a changing environment they will eventually fall out of fit. This is why health care organizations have been going through such massive change. The environment is changing, and the leaders of these organizations know that if they do not adapt to it, the organizations will “die.”

Moving to network structures is the appropriate adaptive response for health care. Complexity is fundamentally about networked interactions—it takes complexity (a network) to beat complexity (a network).7 But when the structure changes, leadership must change with it. General Stanley McChrystal8 lays this out in his book Team of Teams, in which he describes how the leadership style he and the Joint Special Operations Command force used had to evolve to a networked approach in the face of the loosely networked structure of Al Qaeda in Iraq. Essentially, what he was describing was the adaptive process of complexity leadership. In the adaptive process, complexity pressures come in from the environment and the system must change. Those within the system experience a tension between those who desire to do things the same way, that is, the “order” response, and those who recognize the need to do things differently, that is, the “adaptive” response. The role of complexity leaders is to keep the system from staying in order by viewing their roles not as bureaucrats or administrators who are keepers of order, but as enabling leaders who are enablers of adaptive responses.

Enabling leaders

Enabling leaders foster adaptive responses by creating conditions for the adaptive process to occur (Figure 2). The first condition is engaging the adaptive tension of conflicting. Conflicting is the natural process that begins when agents in a system begin to ideate around novel solutions in the face of complexity pressures. This ideation process is the entrepreneurial leadership described earlier—the push for novelty sparked by the need to innovate. The need to innovate brings tension into the system by advocating for doing things differently. This creates conflict by running up against a bureaucratic system designed for stability, not adaptability. The predominant response to conflict is to shut it down. Nurse leaders do this when they do not act on adaptive ideas advanced by entrepreneurial leaders, or when they reduce adaptive tension by stepping in or stopping conflict among those trying to ideate and innovate. This is not necessarily the nurse leaders' fault. It is what they are taught or told to do.9 Most nurse leaders understand their role to be managers or administrators of the hierarchical system and not leaders or enablers of adaptive change.

Figure 2.
Figure 2.:
Enabling the adaptive process. Used with permission.

The second condition of the adaptive process is connecting in the face of conflicting. Connecting is finding ways to bridge differences to create adaptive solutions, or linking up agents (ideas, information, resources, technology) in ways that lead to beneficial new order. Conflicting without connecting is not beneficial; it simply leads to divides. For adaptive responses to be generated, connecting must occur. In many ways, this is the harder part of the adaptive process. It requires skill and creativity to see how to bring people together amidst the differences of conflicting. Connecting is not only a facilitation skill but also a networking role.10 Nurse leaders can enable connecting at the system level by bridging across differences and brokering connections that bring people together.

BUREAUCRATIC LEADERSHIP: WHAT NEED TO STOP HAPPENING

In most health care systems, the process just described is not what is actually happening. Instead, consolidation is leading to increased bureaucracy. This is experienced by nurse leaders as a piling on of responsibilities. The increasing administrative and operational demands are not met by decreased clinical responsibilities. On top of staffing deficiencies, overwhelming clinical work and the need to deal with the shift to consumerism in health care, nurse leaders are expected to meet a growing number of metrics coming from regulatory bodies and health care systems. The result is overwhelming workloads that reduce, rather than support, nurse leaders' ability to enable adaptive change. They are so bogged down in meeting the basic needs that enabling change can feel like a luxury rather than a requirement. To compound the problem, the removal of nurse leaders from where practice actually occurs leads to the perception on the floor of “out-of-touch” nurse leaders.

This happens in all organizations that try to respond to complexity with traditional bureaucratic leadership approaches. The idea is not to do complexity leadership on top of traditional leadership—that overburdens the leaders. It is to replace bureaucratic leadership with the networked approach of complexity leadership. This requires a mind-set shift along with accompanying administrative and operational changes that advocate for and support entrepreneurial and enabling leadership. The focus of leadership should not be do more with less but to “do things better.” Complexity leadership proposes a multipronged approach for accomplishing this:

  • Enabling leadership by nurse leaders who continually ask questions such as: How can I foster and support entrepreneurial leaders who have good ideas that can lead to better outcomes? When nurses bring problems to me, do these problems represent an opportunity for something we can fix to make things better? What are the biggest tensions nurses in my unit are facing, and how can we use these tensions to identify ways to do things better?
  • Entrepreneurial leadership among nurses who understand the strategic initiatives and mission of the health care system and take on informal leadership roles by identifying and advocating for changes that can lead to improved operational efficiency and better adaptive outcomes.
  • Operational leadership that is held accountable not only for results but also for adaptability. Operational leaders need to partner with and support entrepreneurial and enabling leaders who are advocating for system-wide adaptive change.
  • A chief nursing officer who is an effective advocate for complexity leadership and a sponsor for adaptive initiatives involving nursing.
  • A reduction in non–value-added bureaucratic processes and meetings that pull resources away from the real work of the organization.
  • A dedicated information technology (IT) staff and chief information officer fully bought into engaging in the adaptive process (conflicting and connecting) with nurse leaders (both formal and informal).
  • A clearly laid out strategy that helps nurses and nurse leaders know where they fit in the strategic mission and how they can advance adaptive initiatives that align with the strategic plan.

As an example, imagine this scenario: A nurse identifies a technology or product that helps with timely documentation of intravenous line assessments on an hourly basis, or an idea for a new method of communicating product and practice changes that could affect timely delivery of certain therapies on a mobile platform. She takes the idea to her nurse leader. In hierarchical leadership, the nurse leader will likely not have time to address her innovation or will feel that the bureaucratic structures are so overwhelming that it is pointless to try to advocate for the idea. She sees her job as meeting the goals set by the nurse manager above her and keeping things running in an efficient and effective way on her unit. In this environment, it will not take long for her nurses to stop bringing her ideas and for the adaptive process to shut down.

In complexity leadership, in contrast, the system is aligned around helping nurses and nurse leaders advocate for adaptive outcomes and continuous improvement. When the nurse brings an idea for change to the nurse leader, the leader connects the idea to a person on the operational side who is willing to put a “business case” around it. This person is rewarded for increasing operational efficiency and adaptability, so he or she is motivated to try to find a way to make the idea work. The operational partner helps work through “conflicting” and “connecting” by trying to remove obstacles and roadblocks to getting the idea implemented. If the idea truly will not work because the timing is bad, it is not financially feasible, or it will not work currently with the IT system, the operational partner educates the nurse and the nurse leader so they understand why it will not work. This keeps all of them motivated to continue to partner and collaborate in finding ideas that will lead to adaptive outcomes.

A simple way to think about complexity leadership is that the goal should be to promote and protect adaptive space. Adaptive space opens up naturally when complexity pressures enter into a system and create the need for change. Despite this, people and organizations are very good at resisting these pressures and keeping the system in equilibrium. Enabling leaders counteract the pull to equilibrium by creating adaptive space to foster the conflicting/connecting adaptive process. They do this by promoting adaptive space through dialogue that encourages conflicting agents (ideas, information, people, technology) to come together and find ways to connect. They also encourage entrepreneurial leaders to develop and advance ideas and then enable these ideas to link up in ways that feed and fuel emergence of new, adaptive order.

In our work at Cook Children's, we see multiple examples of adaptive space designed to foster and promote adaptive change. One such space is Cook's Professional Development Program, which was created to provide support and acknowledgment for nurses who want to champion change throughout the medical center. The program encourages informal leadership and promotes the role of the nurse as a contributing professional on top of their clinical responsibilities. Nurses are required to create a portfolio and a case for their engagement in operational activities in pursuit of entrepreneurial ideas. Mentors are provided to help them through this process. Another developing adaptive space is the newly forming Cook Children's Innovation Department. Nurses (and others) can submit ideas that are vetted by leadership and, if adopted, can result in financial and administrative support as well as financial benefit through intellectual property agreements. In addition, there are ongoing nurse-driven research projects that receive support from the Director of Nursing Research who “flanks” frontline nurses interested in research or evidence-based practice. The Director of Nursing Research supports these nurses with practical knowledge and encourages a spirit of inquiry through real implementation of projects they are personally interested in. These initiatives provide a unique opportunity for nurses to develop new ideas to scale.

CHALLENGES AND OPPORTUNITIES

While complexity leadership offers many ways to ease the burden currently being placed on health care leaders due to overwhelming workloads and rising bureaucracy, implementing it can present challenges. Perhaps, the biggest challenge we see is the lack of understanding of organizational leadership among health care providers. This plays out in frustration and confusion over the disruptive forces of complexity, as well as the lack of training and preparedness to be leaders in organizational contexts. Health care organizations recognize the ongoing need for physician and nurse leadership, but health care providers are trained in medicine, not in business or leadership. Expecting them to be able to automatically step into leadership roles is like asking businesspeople to practice medicine when they have no training. When health care providers are placed in leadership roles they are often overwhelmed with learning the organizational system on top of their ongoing clinical demands.

This is where health care leadership programs can really help. These programs are growing around the country and playing increasingly important roles. They can be formal degree programs, such as the growing trend toward health care MBAs at universities, or more informal continuing education programs delivered through custom executive education. At Cook Children's, for example, the Advancing Healthcare Leadership Program is a continuing education certificate program conducted in partnership with the Neeley Center for Executive Education at Texas Christian University. The program is delivered to a different cohort every year and provides training in business and management concepts centered around complexity leadership. Coursework focuses on enabling adaptability, as well as teamwork, communication, negotiation, strategy, and finance.

The program is intentionally designed to create adaptive space. Cohorts are structured to bring people from clinical and operational sides together in one room, and executive sponsors are present to foster network connections. Speakers address issues regarding complexity trends in the environment, challenges in health care, and the Cook promise (strategic vision and values). Teams are assigned to work on projects to enable adaptive change on the most pressing leadership challenges at Cook.

Health care leadership programs can also help in the bridging and brokering connecting function of the adaptive process. A common mistake in many health care systems' attempts to implement leadership change is trying to bureaucratize the ideation process of nurses. Requiring nurses to submit ideas—or compiling ideas and passing them up to hierarchical leaders—is not the way the adaptive process works. Instead, ideas need to be developed in the local context, when complexity pressures arise, by entrepreneurial nurses who have both expertise and an understanding of the health care system issues. These nurses are best positioned to ideate, iterate, and socialize the idea to operational leaders. When these entrepreneurial nurses try to advance their ideas, they will likely run into obstacles because they do not know how the organizational system works. This is where enabling leadership is needed to make the connections and link up the appropriate people from the clinical and operational sides. Health care leadership programs help train these enabling and entrepreneurial leaders by educating them on the business and administrative sides of the health care system, increasing their ability to bridge and broker across the system to drive adaptive change.

A natural enabling leadership role that has emerged to do exactly this is the Doctor of Nursing Practice, or DNP. The DNP is an adaptive outcome that emerged from complexity pressures in health care around the need for more practice-based leadership and research in nursing. The DNP generates nurse leaders who are professionally trained in collaboration and advanced practice implementation as a complement to the skill set of those trained in the Doctor of Philosophy in Nursing. Although there are challenges in understanding how to effectively position this new role in the organizational system, the promise of the DNP is an enabling leadership role. DNPs can work in partnership with other health care leaders and the more research-based Doctor of Philosophy in Nursing to drive adaptive change. Their education prepares them by developing expertise in quality improvement, evidence-based practice, and systems leadership that can be used for enabling leaders on both the practice side and the administrative side.

CONCLUSION

Complexity leadership shows that the burnout problem in health care is being fueled by inappropriate leadership demands being placed in the face of complexity. Rather than trying to layer complexity on top of more traditional hierarchical bureaucratic leadership, leadership structures and culture need to embed complexity leadership thinking. This means a mind-set shift away from “do more with less” to aligning the health care system around adaptive change. Resilience is not only an individual-level issue but also one that requires system-wide leadership and culture change. The focus should be on improving patient outcomes and operational efficiency, as well as quality of work life.

When done right, complexity leadership should make nurses and nurse leaders feel energized and empowered. They need to be given the skill sets required to lead this kind of change. This is already happening with the introduction of the DNP, which is preparing nurse leaders for enabling leadership roles. It is also happening through the training of young doctors and nurses who are coming out of education programs with new ideas about how to work together and lead in different ways. It is not just up to the clinical side, however. The administrative and operational sides must also be on board with vision and executive leadership that fosters and promotes complexity leadership, and a performance management system that rewards adaptability as a key organizational outcome.

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Keywords:

burnout; complexity leadership; health services administration; nursing management; organizational adaptability; resilience

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