“Yesterday I was clever, so I wanted to change the world.
Today I am wise, so I am changing myself.”
—Rumi (Poet, Scholar, Theologian)
DESPITE the widely accepted concept that health care is an industry primarily aimed at caring for people, there remains incongruence between the linear methods of the industry and the complexity of human beings. The middlemen here are leaders being held accountable to methods that have been successful in widget-type industries, such as reduction in variability, Lean management, and outcomes-focused work as the sole keys to quality patient care and reduced cost. The mind and the spirit are challenged by this current paradigm of linear thinking, in light of the complexity of the human customer. While both reducing variability in how care is delivered and how patients perceive their care are solid goals, how do leaders and those at the point of care mitigate the unexpected? Do patients, who are complex beings in their own right, always respond according to a linear algorithm, “if I do A and B every time, C will happen?”
What if health care leaders dared to consider a different way to approach an industry that deals with the unexpected every hour of every day; a way that dares to challenge leader-centricity, linear thinking, and poor readiness for innovation?1 While many health care leaders continue to believe in a linear method to reduce cost and improve quality, what if leaders chose to emulate the truthful child in the well-known tale, “The Emperor's New Clothes,” and had the courage to go against popular opinion? What if leaders were offered a model that generates change from the center outward? What if leaders had a choice to lead in a different way, as Connectors, Awakeners, and Upholders who are open and ready for the unexpected? What if they were allowed to start by changing themselves? What if leaders were acknowledged as the people who not only lead the people but also care for the people? If all of those things became the expected norm for health care leadership, would patients (the humans entrusted in our care) be more likely to heal, trust, and feel cared for? In the current state of the health care world, from the unit to the hospital to the new reality of mega systems, there is a need to recognize the reason all of those microsystems and macrosystems exist: the people being cared for. Human-Centered Leadership is a model and idea that's time has come.
CURRENT STATE OF HEALTH CARE LEADERSHIP VERSUS HUMAN-CENTERED LEADERSHIP: POINT AND COUNTERPOINT
Traditional leadership is typically understood to be “top-down” linear leadership. The leader is at the top of the structure and the followers or workers are employed to accomplish the goals set forth by the leader. Porter-O'Grady and Malloch,2 however, explain that a sustainable and successful change rarely comes from the top of any system. Instead, change begins at the center of the system and moves to all other parts, influencing everything in the system. Crowell3 describes the structure in a complex adaptive system (CAS) as one that self-organizes as a result of the independency and transforming feedback loops between the different parts of the system. No one part determines the change in the whole system. Because of this self-organizing process, outcomes are predictably unpredictable in a CAS.
In the industrial age, health care was seen as a business like most others; value was given to the quantity of work produced. Porter-O'Grady and Malloch2 state that the processes associated with the work were seen as almost more important than the purpose of the work, and there was a sense that activity was in itself valuable. In the current environment, the purpose of a health care network is uniquely positioned to address the health needs of the local community, both the individual members and the community as a whole. Each element of the system must empower those at the point of service so that they can care for the individuals served.2 Quantity is simply not a differentiator for value.
Linear thinking was embraced during the industrial age. Porter-O'Grady and Malloch2 describe linear thinking as vertically oriented, hierarchical, mechanistic, reductionistic, compartmental, and controlling. “Linear models assume that the input to a system will yield a proportional output.”1(p269) Collateral thinking, which is consistent with CAS and followed in the information/knowledge age, is multidirectional, horizontal, whole-oriented, integrative, intuitive, and relational.2 Linear elements of leadership are still needed around rules, policy, and procedures. These keep an organization running smoothly to meet required regulations and quality standards.3 Leaders who embrace complexity methods effectively value and embrace both types of leadership. “The natural tension between the two (actions) facilitates innovation and change in the organization.”3(p41)
A traditional leader would expect outcomes to result from the leader or manager's authority or influence over the workers at the point of service. If we shift the paradigm to consider CAS, those at the point of service are the influential leaders who should be empowered to make decisions pertinent to the care provided. The point of service workers are the influencers who have the knowledge, information, and practice to inform their decisions.2 Crowell3 explains that the complex systems approach requires the leader to balance tight planning with an openness to new possibilities, realizing that most changes or outcomes cannot be predicted.
While the traditional leader's role was to create a vision, plan, and control, the current leader must create an environment that supports the empowered worker to become a part of the visioning and to be accountable for practice and results.4 The perspective of a leader, positioned outside or above the system, will be very different from one who is embedded within the system and recognizes the point of service employees for their expertise and capability. The vision must emerge from the organization itself through collaboration and intersection of relationships at all levels.2 Innovation readiness is the differentiator and must be embraced by both the leader and the other stakeholders of the organization.1
CONNECTION TO COMPLEXITY THEORY AND COMPLEX HEALTH CARE SYSTEMS
Human-Centered Leader as Awakener: Cultivating a Culture of Excellence
“Effective change generally moves from the center of a system to all other parts, influencing everything in the system.”2(p82) The Human-Centered Leader, who is at the center of the leadership model, leads change through the professional development of each employee, recognizing that the impact of each individual's growth within a complex system will ultimately result in change and adaption of the interconnected whole organization. In health care settings, the leader motivates, inspires, mentors, and coaches the professional nursing staff to advance professionally, through completing BSN and MSN programs, obtaining specialty certifications, attending conferences and continuing education offerings, learning best practices, and integrating the latest evidence into practice. As the individual grows, so does the professional team, which, in turn, impacts the entire organization.
The Human-Centered Leader becomes the Awakener of the people through a collaborative relationship and “cultivates” them as they own their individual growth plans for development. Individual ownership of the growth plan results in individual accountability for results. The leader is not the “mama” who raises the employees. Instead, the Human-Centered Leader's role is to ensure certain processes and structures are in place to support the staff members in their growth process. The leader must ensure that a vibrant learning culture is in place and each member must be expected to engage in learning activities such that it is impossible for employees to survive without pursuing new knowledge.2
Nurses, growing as individuals, must work together in Nursing Professional Governance (NPG) councils to integrate new knowledge, best practices, and latest evidence into their practice. This process will require the availability of information resources for nurses to link evidence-based practice interventions to patient and organizational outcomes. The leader must ensure that the resources are available, and staff members are educated on information retrieval and evaluation skills.5 The leader must also ensure that processes and structures are in place for the (1) relational connections between the team members to develop, (2) knowledge and insights to be shared, and (3) innovation to emerge from the diverse perspectives and collective wisdom of the team. The leader must ensure that there is room for errors and experimentation in order for the staff to be comfortable with this risk-taking process.
As professionally prepared staff members incorporate evidence-based practice, new knowledge, and innovative ideas into their daily practice through work in professional governance structures, the foundation is laid for the staff to become accountable for practice, quality, competence, and knowledge.6 The leader must continue to be in the work, supporting the decisions made by those at the point of care, following and communicating results of performance indicators, and celebrating positive outcomes. If energy and desire of the workers cannot be maintained, it is impossible to sustain and advance the work of the organization.2 In the Human-Centered Leadership model (as illustrated in the Figure), staff members own their individual and collaborative practice, implement innovative solutions based on new knowledge, and own the quality outcomes. This culture, which begins with the leader as the Awakener, is worthy of being called a culture of excellence (Table 1).
Table 1. -
Attributes of the Awakener in Human-Centered Leadership
||Establishes a learning culture with high expectations for ongoing learning
||Provides honest feedback, address behaviors inconsistent with learning culture
||Advises on member accountability for individual growth plans
||Designs structures/processes so innovation can emerge
||Ensures resources are available to research and adopt EBP
||Allows room for errors and experimentation
|Engaged team member
||Recognizes problems and decisions from the perspective of those at the point of care
|Vulnerable lifelong learner
||Allows own growth experience to be visible to others
Abbreviation: EBP, evidence-based practice.
Who is an Awakener?
As with complexity leaders, Awakeners require a level of self-knowledge and vulnerability that makes their growth experience visible to others.2 The Awakener models the consistent push toward growth that is communicated as the expectation for all. When dealing with staff members, an Awakener does not prod or coax. The Awakener is not responsible for individuals' happiness or success. Instead, the Awakener motivates individuals to be their best in order to maintain their vital role in the changing environment and add value to those impacted by their practice. The leader underpins each staff member's plan for growth and should set the bar for expectations high, but not so high that they cannot be met.2 The leader gives honest feedback and quickly addresses behaviors inconsistent with the norms and expectations of a learning culture.2
Human-Centered Leader as Connector: Building a Culture of Trust
According to the French philosopher, Emmanuel Lévinas, the ethic of belonging and valuing the connectedness of all beings within a system can be designated as the first principle of science.7,8 The science of complex systems postulates that energy emanates from the center outward, influencing independent agents within the system to self-organize, distribute leadership equitably, and cross the edge of chaos to create new order and innovation1–3,9 Just as complexity science recognizes the connectedness of each part or being in relation to the whole, the Human-Centered Leader demonstrates flexibility and openness to change that ebbs and flows depending upon ever-changing situations. As a Connector, an Awakener, and an Upholder, the Human-Centered Leader is aware of all 3 domains but employs mindfulness to empower whichever combination or single attribute is required in the moment. The Human-Centered Leader as Connector provides the locus of energy and influence to unify others in the system toward a common vision and mission.
The Human-Centered Leader becomes the “connector” of people by joining the health care staff, patients, family, and the community through “building” a structure that may be visible or invisible. The Connector is not the owner of a bureaucratic governance structure. Rather, the Connector recognizes and encourages independent thought, personal ownership, problem solving at the point of service, and self-organization to allow innovation to emerge through simple rules. The Connector recognizes the invisible architecture of NPG as a CAS.10 When NPG is nurtured by a Human-Centered Leader, the natural and organic interconnectedness of humans (staff, patients, family, community) emerges as a central construct for a healthier environment for all.1,10,11 A culture of trust becomes a natural outcome for all when the Human-Centered Leader acts as Connector (as the Figure illustrates). Just as Lévinas7 and Watson et al8 lay the groundwork for unity in health care settings, the Connector builds community through unity (Table 2).
Table 2. -
Attributes of the Connector in Human-Centered Leadership
||Unifies others around shared mission and vision
||Encourages independent thought, personal ownership, and problem solving at point of service
||Gives positive recognition
||Ensures people are plugged into processes/structures for emergence of new ideas
||Builds mutual respect and trust
Who is a Connector?
Connectors often walk the space between 2 worlds.3,12 There is the world of the traditional visual linear way of being and the world of the intuitive nonlinear, innovative complexity-focused way of being. To step off the edge of traditional leadership toward Human-Centered Leadership requires tremendous courage. To go against traditional methods challenges the hierarchy, the locus of control, and the top-down mechanism of leadership and decision making.8 Connectors are edgewalkers because they provide an awareness of the value of human-to-human relationships, interconnectedness, and innovation. The Connector's aim is to build communities through nurturing individuals because individuals are inherently and organically connected to comprise the whole. Connectors transcend the space between the 2 worlds by embracing unpredictability, self-organizing systems, simple rules, independent agents, and CAS.
Human-Centered Leader as Upholder: Recognizing humanity in others to create a Culture of Caring
Archbishop Desmond Tutu once stated, “All of our humanity is dependent upon recognizing the humanity in others.” The Human-Centered Leader embraces this concept and works to establish an environment that promotes and supports transformational human interactions.2 Human-Centered Leaders understand that organizational success starts with personal well-being, which includes self-care, self-compassion, self-awareness, and mindfulness. These are the essential personal elements needed to establish a solid foundation that recognizes and embraces humanity at all levels, ultimately leading to a significant impact on the larger system in creating a palpable culture of caring (refer to the Figure). Thus, as the Human-Centered Leader engages in self-care, the team models this behavior and rippling change occurs in which the current moment creates the future state of authentic caring.2,8 Self-care includes behaviors and activities required to care for oneself both physically and emotionally. Self-care involves finding the courage and commitment to take control of personal wellness, realizing that when there is a commitment to care for the self first, the ability to connect with and care for others becomes easier. The daily practice of self-care includes maintaining a healthy body, a healthy mind, and a healthy soul.
Self-compassion is the ability to form a nonjudgmental, receptive state of mind in which to observe thoughts and feelings as they are.13 Self-compassion is knowing that the world is an imperfect place and experiencing life's challenges is inevitable. Self-compassion allows those life challenges to be accepted without self-criticism or feelings of personal failure. Acknowledging that suffering and pain are universal emotions helps in understanding and accepting the concept of shared humanity.13 Mindfulness, or being present in the moment, is an active, systematic process of focusing attention, awareness, and energy within our current and present environment without judgment, therefore influencing the quality of our experience and our interactions.14
Mindful self-awareness is the capacity to notice thoughts, emotions, and physical sensations as they occur and to accept them as is, not defining them as either good or bad. While self-awareness is important in well-being and mental health, it also has a substantial impact on each moment in our day-to-day interactions.15 Being a mindful, self-aware leader helps us make proactive decisions based on the present, versus trying to predict things that could go right or wrong in the future. Williams et al16 state that becoming a mindful person is developing the ability to let go of bias, frustration, preconceptions, negative emotions, judgments, and expectations of others and often includes elements of managing negative self-talk in order to return to the present moment. Obtaining mindful self-awareness challenges us to perform an accurate self-assessment, allowing us to identify strengths and limitations. True mindfulness puts us in touch with our emotions, our values, our beliefs and encourages us to live transparently, with authentic openness. According to Goleman,14 gifted leadership occurs when the heart and the head meet (Table 3).
Table 3. -
Attributes of the Upholder in Human-Centered Leadership
||Practices self-care, self-compassion, self-awareness
||Focuses attention, awareness, and energy on present
||Supports with, respect, kindness, empathy, and empowerment
||Recognizes and embraces humanity at all levels, self-reflective
||Leads with an open mind
Who is an Upholder?
Imagine a leader who practices self-care, is self-compassionate, is self-aware, and is present in the moment. Imagine a leader who is supportive, respectful, kind, empathetic, and empowering. A Human-Centered Leader understands the concept of “it starts with me, but it's not about me.” Just as with any structure, the strength of the structure is dependent on the foundation. A strong foundation keeps the building standing upright. The leader, who embraces the traits of Upholder acts as the foundation for his or her team. The Upholder has a keen sense of social and organizational awareness and is empathetic, with the ability to grasp and understand emotions, both in self and in others. Goleman17 describes the awareness of emotions as a fundamental human competence and describes emotional awareness as being a neutral mode that maintains a self-reflective state regardless of what is happening in the moment. The Upholder embraces an others-oriented mind-set and has the ability and passion to believe in others more than others believe in themselves. This attribute merges with the Awakener who seeks to foster growth and to reveal within the team members what they themselves may not be able to see. The Upholder supports, encourages, and creates an environment that is positive, nurturing, safe, and conducive to growth. The Upholder is mindful of self and of others and leads with an open mind, leaving judgments and negative assumptions behind. The Upholder believes in, and then invests in, each individual member of the team. He or she commits to the team, both physically and emotionally. Hu and Liden18 concluded that by putting team membership first and helping team members grow and succeed as individuals, leaders develop teams that perform better, engage more, and achieve desired outcomes.
DEVELOPING THE PEOPLE WHO LEAD THE PEOPLE
There are several areas of growth and development required for a Human-Centered Leader who must be grounded in self-care while focusing on others. Development practices focus on merging the attributes of a Connector, an Awakener, and an Upholder into a mosaic that reflects what today's leader in health care should seek and embrace in order to develop people who lead people who care for people.
Mindfulness and self-care
The practice of self-care must be central to every leader's life in order to maintain the resiliency needed to lead others. Mindfulness, both a self-care and other-focused practice, fosters authentic presence and the development of trusting relationships.
The Human-Centered Leader must develop the leadership competencies of emotional intelligence: self-awareness, self-management, social awareness, and relationship management.14 Simply stated, by understanding their own feelings, leaders can better understand and evaluate others. This essential development is foundational to the Human-Centered Leader who understands that “it starts with you, but it's not about you.”
The Human-Centered Leader must reimagine and operationalize shared decision-making and NPG in a way that engenders independent agents who can offer creative solutions at the point of service.2,3,10 Both the Connector and the Awakener embrace the concept of all leadership being local and relinquish control of decisions that can and should be designed and implemented by those whose work environment is impacted. The Human-Centered Leader exposes the need for innovation within a specific context of the population or organization and ensures that processes, policies, and resources are in place to allow for and support the development of innovation. The leader also recognizes the consequences of innovation and ensures the structure is in place to integrate a new innovation.
Change management in a complex environment
According to Porter-O'Grady and Malloch, “Diversity makes chaos visible because it pushes systems to forever adapt to changes in their environment.”2(p70) Traditional approaches to leadership attempt to mitigate or prevent the unpredictable, whereas a Human-Centered Leader embraces the idea that change, the unexpected, and the subsequent consequences that may include conflict are actually much closer to the reality of today's health care industry. Both the Connector and the Awakener must develop and integrate concepts of change management in terms that are congruent with a complex system. First, the recognition that chaos is really the edge of change allows the leader to stop being reactive to situations. Instead, he or she can pause in the moment, with a mindful and authentic presence. The Connector and the Awakener recognize the turbulence or chaos as the space where momentum is gained for adaptation to a new order, which often benefits not just the individual or the unit but also the entire microsystem or larger system.19
Coaching skills include active listening, humble inquiry, and appreciative inquiry. These rely heavily on reflective practice (which is the basis of critical thinking and problem solving) and focus on capability rather than solely on competency. As with any expertise, coaching is necessary in all areas of Human-Centered Leadership, since it allows one to recognize blind spots and learn from experiences.
Focus on capability
Nursing education traditionally focuses on competencies, including skills, knowledge, and attitudes. Fraser and Greenhalgh20 discuss the impact of capability over competence by defining capability as the “extent to which individuals can adapt to change, generate new knowledge, and continue to improve their performance.”(p1) Teaching methodologies used to promote capability within the role of the Awakener include feedback on performance (reflective practice), challenges of unfamiliar contexts, storytelling, and small group problem-based learning.20
Both the Awakener and the Upholder, due to their focus on support and development of their teams, must be familiar with reflective practice, a process integral to deeper learning from experiences. Reflective thinking requires exploring different perspectives and is learned through verbal or written journaling, group discussions, and responding to skillful questioners.21 The Human-Centered Leader must practice reflective thinking and develop it in others. This practice fosters lifelong learning because it helps people recognize gaps in their own knowledge and stimulates further learning.22
In the current state of the world, the global context of complexity is reflected in the local context of how health care organizations are challenged to manage care safely and efficiently. Global and national mind-sets generate the pace for local work through regulation and reimbursement based on defined metrics. The challenge to be successful grows more difficult with each passing day. Pounding and pushing harder to meet expectations do not seem to be working so well. Turbulence seems to be the presiding tension, with leaders tentatively waiting on what will emerge as the new order. Political narratives are evolving that throw health care leaders into a continual state of expectation about what will come next. How will access, provision of care, and coverage be affected? How will resources to provide quality patient care be impacted? With no clear answers in sight, the Human-Centered Leader must consider a dynamic approach that embraces innovation and the unexpected. The call to action proposed within this article is to invite health care leaders to alter the locus of influence from top-down to a new order in which the pace is set from the center outward. The development of leaders who Connect, Awaken, and Uphold their teams will drive culture and outcomes.
As health care leaders move forward in a story with a plot and outcome that remain untold, let those charged to lead not be left with the thirst of hindsight. Rather, let them have the courage to consider where they have been, who they can be for their teams and patients, and how the lessons of humanity have equipped them to carry out health care's mission to care for our fellow humans. Human-Centered Leadership in health care is an idea that's time has come.
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