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There is much discussion of late in political and social circles regarding health reform and the inclusion of the so-called “public option”. The suggestion from opponents often includes comments about their concern for small businesses and the need to stimulate opportunities for small businesses. I own a small consulting practice and am considered a small business person. I’ve come to believe all of this emphasis on small business in reflection of healthcare reform has yielded no rewards for me from the current private sector driven frame for health insurance management. Currently my monthly health care premium costs are $750 for each employee (yes, that is monthly)! Every year, when I have to renegotiate price, while it is undeclared, I am ominously suspicious that the previous year’s use of our practices health insurance coverage somehow plays a significant role in the percentage increase in costs that I will pay in premiums for the forthcoming year.

There have been moments in the negotiation with health insurance providers where I have had suspicions that the private insurance company would be just as happy to take my money and not have the bother of insuring our small business at all. In all of the 30 years I have been providing health coverage in our practice I have never had a sense that the insurance companies were interested in the quality and effectiveness of my healthcare coverage and services. Indeed, when my  health insurance company’s services were actually utilized for covered events, I have suspected that it is somehow related to a higher percentage increase in premiums for those years.

I have come to the conclusion that there is precious little real competition in the private sector with regard to health insurance. Besides, in my consulting work and travels around the world I’ve discovered that the level of access, satisfaction, and health in countries with a public health plans is, at a minimum, comparable to the United States. In fact, I have a difficult time getting past comparative data produced by the Commonwealth Fund, the World Health Organization, the Organization for Economic Co-operation and Development, and the Kaiser Family Foundation and a host of others that clearly demonstrates that while the United States is number one in terms of cost of healthcare, it hovers close to 22 or 23 in terms of its citizens comparable health status. Regardless of the arguments that can be made for private healthcare in the United States, they simply do not alter the data. Private healthcare has not been cost effective, service effective, nor has it advanced the net health status of American citizens to the extent experienced by other first world countries. However, there is no argument with regard to the financial health of the health-insurance industry, demonstrated by some of the healthiest profit margins of any businesses in the United States. It’s one of the few industries where their success demonstrates little relationship between the profitability and quality, efficacy, service reliability, and outcome (healthy people), of its product.

I have now come to believe that simply tinkering another time with the private system and adjusting the mechanics of how it’s paid for or regulated simply avoids the real issues. While private healthcare has certainly advanced the technology associated with the tools addressing illness intervention, there is precious little evidence that it has affected, in any comparable way, the primary and basic health of Americans. Good evidence suggests that whatever health gains have been made on behalf of Americans relates more to good public health measures than by the efforts of private health care. Its focus on illness and treatment merely extends life already compromised by poor health choices, bad diet, a serious lack of primary health care priorities, and a healthcare system focusing on late stage, illness-based interventions. Doctors and other healthcare providers are paid for how many procedures and processes they undertake rather than by how much health they produce. It’s simply a bad compact, the foundations of which have simply fanned the flames of chronic illness, high cost, and late stage intervention.

At this point, it is reasonable to pursue the dialogue and decision-making regarding an effective health care system along the lines of a public-private partnership. This is certainly not a radical departure or an untried process. Both Germany and Australia have such workable systems producing health status data superior to US health statistics. Still, private insurers cry out that a public option would mean the death knell for private health insurance. Yet, the fact that private health insurance is prospering internationally in a number of different public-private national partnerships fails to inform their thinking. The competition embedded in such a public-private partnership has caused private health insurance to perform more effectively, ultimately outperforming their public partners while attending to service-centered and cost effective care. While no system is without challenges, such a partnership begins to introduce into the United States opportunity for a transforming set of standards related to payment, performance, impact, and health outcomes. It challenges the private sector to match performance in each of those arenas and to be able to do so in a truly competitive framework.

I fully recognize that legal parameters must be established in the public option that manages the probability that corporations and others may “turf” their employees or undesirable persons (meaning those sicker and more expensive than others) into the public sector in order to avoid or eliminate any obligation they might have to them. Also, standards of performance and measures of quality and efficacy must be more clearly articulated in a way that creates comparable expectations and a level playing field in both the public and private sectors. Much has been written about this. At any rate, it’s now time to build an evidentiary and value-based frame for health service. The technology and tools are available today to make this happen.

As an international health consultant and traveler, I have many opportunities to share my reasons why I am a proud and confident American. However, American healthcare is not one of them. As a clinical professional for 40 years, I’ve experienced a consistent struggle with the design and delivery of American healthcare. It seems, we Americans are very nation-centric; not always available to learning, data, and insight gained by those in other parts of the world that can better inform our own thinking and help us make better decisions. There are times when I have felt that the United States is intellectually, politically, and socially narcissistic, ignoring the evidence of good thinking, planning, and applications that come from outside of our borders. Healthcare is clearly one of those arenas. When we broaden the discussion to include the health system experiences of other nations, Americans become very polarized, narrow, rigid, and defensive. Nothing is a better example of this than when the American healthcare system is compared to Canadian healthcare. While the Canadian healthcare system simply could not be imported in its current form to the United States, that does not mean that there are not elements in it that can positively inform future design and structure of a uniquely American system. Instead, many American providers, insurance leaders, and policymakers, deride the Canadian healthcare system, attacking it as though it is inadequate and ineffective. In fact, that’s simply not true. My 11 brothers and sisters with their children, nieces and nephews uncles, aunts, etc. are all residents of Canada and partakers of the Canadian healthcare system. They are not dissatisfied with their healthcare, do not have greater or more substantial problems with health service than Americans do. They have comparable or better clinical outcomes, are more satisfied with their providers, have better more timely provider visits, all with lower total costs of healthcare delivery. The Canadian healthcare system is not better, it’s just different. Here again castigating it, or any other, doesn’t change the facts and, indeed, is simply a waste of good time. At the end of the day, we will still need to develop an effective American healthcare system that represents America needs, values, politics, and dollars.

In the end, I believe if there is no public option, there is no real incentive to transform the health-care system and change it in ways that will positively affect both the cost of the system and the health status of the American public. Without building this new kind of public-private partnership, costs will continue to spiral, access will continue to be a challenge, the private sector will continue to fail to meet the real health needs of the American public in a cost effective manner and we will not become a better nation. With those options likely in our future we must work hard to build a more effective American private-public healthcare partnership that can ultimately advance the health and sustainability of people of the United States.  — Dr. Tim

 

 

 

Innovation is always a collaborative process. In it organizations and people provide an opportunity to continuously and dynamically re-create themselves in a way that is congruent with an ever-emerging future. Ideas for innovation come from many places and include the negative forces and pressures both internal and external which create the conditions for innovation. However, innovation is also a discipline. While ideas are critical to the success of any innovation, a disciplined organized and systematic process is critical to ensuring a viable outcome for ideas and creativity.

If an idea is to move away from merely a wish or a hope, it is important for it to be disciplined by good structure and process that can assure the idea has direction and that a strong foundation is laid to sustain it. It might be important at the outset to identify what we know innovation is not:

·         No innovation is sustained unilaterally. Individuals cannot single-handedly drive and control in innovation and expect positive results and a sustainable outcome. The old traditional “hero” idea of an individual struggling against the world with an idea that he or she holds a loan against all opposition is simply a myth. Real innovation cannot be developed or sustained single-handedly.

·         Innovation means more than just creating, planning, or discussing ideas. While ideas are a critical part of the innovation process, in themselves, they are not sufficient to result in a useful innovation. Ideas are just that, ideas. What serves as the difference between an idea and innovation is the work that results after the idea takes shape and goes through the processes necessary to make it successful.

·         Sustainability and innovation is the result of hard work. While hard work is important, work alone is not enough to assure the success of an innovation. The work of innovation must align all of the stages and elements necessary to make the innovation process work and to lead in that direction where there is a viable product or outcome for the innovation. It is the convergence of relevance in the wind action advances the potential for successful innovation.

Collaboration

Innovation is always the result of a collaborative process. The innovation dynamic or process involves gathering stakeholders together within a framework that can positively contribute to each stage of translating an idea into action and /or product. Team process is the usual format for successful innovation. What is critical to the team’s ability to build towards a successful innovation are the interactions and processes that they undergo on the journey toward making an innovation successful. The innovation process is not limited to simply creating new or originating ideas but can also relate to expanding, rethinking, or reconfiguring existing processes and products in new and different ways. The important elements of innovation is that something new and useful results that makes a difference in the lives to which the innovation is directed. Those who were involved in innovation are willing to challenge existing thinking and processes and, more importantly, are willing to do something about them.

At the same time, it should be understood that diversity is essential to creativity. While collaboration is important it simply doesn’t just happen. Using techniques and methodology, innovation facilitators move diverse people and ideas through a process that helps refine them and firm them up in a way that will result in a desirable and viable innovation.

The Seeds of Innovation

Ideas are generated constantly. Sometimes they are the result of formally structured processes other times they are accidents or incidents of thought and other times they are the results of attempting to respond to challenging or changing circumstances. For ideas to take form they generally fall on fertile ground which is represented by any particular desire or need for them. Sometimes the ideas respond to the need for change. Other times ideas of the response to the desire for something new and different. Whatever the source ideas that move closer toward innovation are usually those that are informed by a purpose which responds to the action of people willing to advance that purpose. Often the pressure of changing circumstances, whether positive or negative, creates the conditions that result in fertile ground for ideas becoming innovations.

Often ideas are generated because of constraints, challenge, or difficulty for people and organizations. These challenges can be driven by changes in the external environment, or even crises in the internal environment. Many times ideas are generated as a way out of conditions and circumstances that are unacceptable or untenable to the people experiencing them. Many times creative ideas result from new thinking about old processes or products that are either fading in their effectiveness or simply no longer viable or reasonable. Accidental discovery or revelation can often result from reflection and action taken on completely unrelated issues. Yet, when applied to other circumstances ideas which would otherwise be untenable provide a great opportunity for problem solving or for pursuing new directions, processes, or products. Whatever the source of an innovation, in the hands of positive and purposeful people, these ideas take form and under the direction of good critical process are translated into useful processes and products that ultimately change things.

It is important to recognize that innovation is often associated with challenging and changing paradigms. Paradigm shifts often mean a significant adjustment in reality and in people’s perceptions of their lived experience. When things are no longer working are operating as they always have, clear indications of shifting paradigms associated to structural or circumstance changing in a way that people can no longer sustain and be successful. Frequently, it is during crisis and challenge or even in untenable circumstances that many creative ideas lead to meaningful mechanisms that positively change organizations, people, processes and products in a way that dramatically engages a different future. Companies like Google, Apple computers, Amazon.com, etc. provided ample evidence of emerging business practices reflecting new uses for technology and the establishment of new premises for doing business and for the relationships engendered in their changing approaches.

Critical to the innovation process is the ability of people and organizations to abandon those things that, while at one time very successful, are either no longer relevant or have been eclipsed by newer technologies and emerging realities. As a result, different policies, protocols, practices, and products must arise in a way that enables people and organizations to continue the trajectory towards success and future viability. Without abandoning the status quo or existing models, many ideas simply die on the vine and never move toward the discipline of innovation sufficient enough to translate them into something that makes a difference and reflects relevance in an emerging age. New thinking, rules, practices, and processes often newly describe the approaches that would be necessary to take ideas from conception into formation. Having the capacity to think within the context of the emerging paradigm rather than of the diminishing paradigm is often one of the most critical elements of assuring the success of an innovation.

Blockages to Innovation.

Judging from the number of new ideas that never see the light of day, there are many ways to block or prevent ideas becoming real and useful innovations. Attachment to current and past reality is perhaps the first major block demonstrating a lack of readiness for innovation. Attachment to rituals routines and past practices is perhaps the most dangerous single impact affecting the potential for innovation. Health care is especially burdened with structural and practice barriers that have powerful precedence and history resulting in standardized practices, rituals, and routines which act as solid walls against the emergence of new thinking in different practices.

Attitudes play a major role in affecting people and organizations ability to translate ideas into action. Employee passivity and past work group behaviors often create the conditions where new ideas and creative thinking are not encouraged and through lack of facilitation never get generated. People and organizations and systems see their work merely as jobs. Often the same people do not feel ownership of the community within which they work and therefore sense no personal obligation to advancing interests of the organization and moving it creatively forward. Managers also contribute to this lack of creativity through strong hierarchical and controlling structures and practices that limit decision-making, availability of information, and creative response to practical problems. Such attitudes and behaviors on the part of management create a contextual framework which keeps employees dependent, focused on task, process oriented and the way from direct engagement in decisions and actions which would seek newer and more creative solutions.

An organization’s availability to idea generation and openness to point of service involvement and engagement is critical to idea generation and innovation. The work of the organization is continually done at the point of service. It is at that place that the life of the organization is fully engaged. Whatever is possible to occur there is reflected back to the organization. If the attitude and behaviors of the point of service reflect dependence, obedience, passivity, lack of engagement, no ownership, fixation on task and function, and resemble a tightly controlled and ordered system, not much exposure to new and creative ideas results. There is nothing more limiting to the expression of ideas and the movement of innovation and creativity than an inordinate attachment to policy, budgets, practices, protocols, approvals, and work routines. Management leadership must create an environment where ownership, openness, partnership, and engagement are the mechanisms for doing business in the organization. It is only in that kind of environment is there enough freedom and connection between players to stimulate the formation and generation of ideas and translate them into meaningful innovations.

Everyone in an organization or system has the potential to be an innovator. These people depend on the openness and freedom to able to generate thinking in a noncritical, yet evaluating environment. Full participation and ownership of work and related thinking and processes creates the conditions necessary to stimulate idea of formulation and generation and the translation work necessary to move it towards innovation. It is in generating this environment and leadership of innovation that provides the critical backdrop to the innovation process is essential before innovation can even begin in an organization.

Here we are simply covered the backdrop to innovation. What is necessary for the discipline of innovation to even emerge in the organization requires a context and construct in systems that make it possible for innovation to emerge. The conditions for the potential for innovation are even more important than the processes associated with the innovation dynamic. Here is the obligation of leadership to create the context, conditions, and circumstances which provide a frame for the innovation process and assure that the people engaged in it sends the openness and readiness for involvement, investment, personal ownership, and engagement in the life of the organization. Through this level of connection and communication, the organization assures that there is a structure and readiness, and even an availability, to the potential embedded in idea generation and the constant readiness for innovation. Many of the blockages to innovation can be addressed and even prevented through good management process. The innovation process itself begins with the strategic and operational commitment to creating an organization that is open and dynamic, ever responsive to the external and internal “dance” that represents its commitment to its own life and future. Creating the context is the first step in any successful innovation process.

The Innovation Process.

Having spent some time on the background and organizational conditions and circumstances influencing the generation process, it is now time to focus on the dynamic stages of innovation that make up the innovation process. While not a linear process, the dynamics of innovation do call for a particular discipline that requires points of emphasis along a continuum of assuring the movement of idea toward a truly useful and successful innovation.

There are many suggested models are approaches to the innovation process. Most of them enumerate stages that include the generation of ideas, translation of ideas into specifics, the formalization of ideas and to design and potential action, the development of the business plan and trajectory from idea to actual innovation, engagement of the human dynamics in moving the innovation toward success, and a process for evaluating adjusting, challenging, and changing the innovation at a time and as the need requires. Any number of structured approaches can be developed in ways that address these various stages yet; each one of them provides an important component of successful movement from idea to innovation.

Stage 1: Generating ideas.

As stated previously, innovation is purposeful. A successful innovation is generally the product of good design and its related processes. The ability to stimulate good dialogue and purpose-directed idea generation is a critical foundation upon which innovation bills. Clearly there must be a desire or need for the innovation sufficiently clear to translate it from desire to purpose to product. The strategic requirements of the organization for its continuing viability serves as the driving force or the frame for innovation thinking in the conversations related to it. If ideas are to have meaning, participants must drill down to how ideas relate to the integrity and function of the organization and to its general mission and purpose. Without doing so ideas remain simply ideas.

Today innovation is more often thought of as a more radical process directed to significantly altering or changing circumstances affecting organizational integrity and life. While not always radical, real innovation does lead to a dramatic change in process and/or product in a way that alters life and experience. Therefore normal and usual mechanisms often related to quality improvements, process improvement and other quality processes are not generally included in the rubrics related to innovation. This notion that significant or even “radical” change occurs guides the kind of dialogue and process undertaken by organizations in very real ways.

Generating ideas and relationship to specific innovation means undertaking the group process of idea management that helps give form and basic structure to the generation of ideas without limiting the breadth of access to those ideas. While there are a whole host of techniques available to group facilitation process there a number of specific approaches which can be especially helpful in focused and purposeful innovation dynamics.

Diversity.

Perhaps the most important first step in any group dynamic is how the table is set for the processes which the group will undertake. The first step in any series of processes is to make sure that the right stakeholders are at the table. In any idea generation the diversity of stakeholders is a critical first stage and an important step. Planning for who should be present to the innovation process is as important as the process itself. A wide range of stakeholders from abroad number of roles and positions related to the innovation should be included. Innovation dynamics requires a high level of equity and the removal to the fullest extent possible of positional authority and vertical orientation to dialogue. In a series of initiating steps at barrier breaking, rolled challenging, equity producing oral helpful first steps in engaging stakeholders in the kind of medium necessary to generate equity and value driven conversation. Role and position power simply play no part in the successful gathering of appropriate stakeholders who now must equitably engage in idea generation and management in a non-judgmental and nonhierarchical manner.

Creative thinking will require good facilitation and every member playing his or her role fully and well. Some preliminary foundations are necessary as our other process elements and tools (see chapters on directed creativity and transdisciplinary design). Furthermore the following elements are critical to the good facilitation of innovation groups in the first stage of idea generation:

·         facilitators who understand the dynamics of group process and have access to the full range of group techniques and methodologies that stimulate an indication, interaction, idea generation and recording as well as the coalescing and consolidation of ideas into purposeful decisions, actions and processes.

·         The creation of an appropriate space (see chapter on transdisciplinary design) that contributes to focused work, creative thinking, directed dialogue, and focused interaction.

·         Facilitators have the capacity to use methods and tools which assist in breaking blockages, taking down barriers, stimulating the horizontal and mode of thinking and interacting, and moving the process continuously and dynamically towards goal achievement.

·         The necessary tools, materials, and supports are present and available for participants’ access and use with appropriate directions and guides which can assist in an annotation application for a broad variety of idea to innovation activities.

·         Facilitation and member competence can help participants move past performance and current activities as a beginning place for conceptual challenges, confronting best practice, and giving language to shifting paradigms.

·         The innovation group is aware of organizational and senior leadership support for innovation activities evidenced by strategic endorsement of the process and the inclusion of senior leadership in the activities and dynamics of the innovation process.

·         Ideas are captured in form and format to demonstrate full engagement and inclusion with sorting and acceptance processes designed in a way which facilitates the equitable consideration of all ideas regardless of their source.

·         The methods and process associated with idea generation and management are able to successfully move the group toward consensus and consolidation evidenced by the emergence of clear goals which lead to a clarity of understanding, visualization, and articulation of participants around specific innovations emerging from the idea management process.

These foundational elements simply create the gateway for meaningful idea generation and provided a frame for that which is exemplified by good process. Innovation processing has no value if ideas do not become specific, directed, and meaningful in light of their relation to the strategic imperative which drives the organization and its work. Without producing some meaningful and critical outcome idea generation remains stuck use, on directed and nonproductive. It is the goal of the facilitators (most prepared for that role) and the participants that deliverables be obtained and that these outcomes relate specifically to meeting identified organizational purposes, goals, or objectives.

Some Essential Tools.

Visualizing the Future.

Visualizing the future or future-search is a well researched and disciplined process which reflects how diverse idea and thinking groups work cooperatively and collaboratively to view and construct solid visions and ideas related to the construction of preferred futures. It were flocks along stream of the work of social sciences in examining how groups work collectively to do purposeful thinking and processing around unformed ideas and projections about position and movement within an emergent context.. Through use of whole systems interactions and communication processes as well as planning techniques, innovation participants can bring their expertise together in mutual conversation where their resources, communication, format, and values can converge to create meaningful, specific, and concrete decisions, designs, and plans. Through the visualization process those representing the full range of stakeholders related to an issue or present and share stake in the outcome. In addition all layers of understanding and input are considered and visualized or demonstrated before movement towards more specific and narrower ranges of understanding and application. Expectations include accountability for presence, mechanisms for full participation of all participants, and use of all ideas in the process of refinement and convergence around specific trajectories and goals. While future search is one of a number of like techniques the emphasis on the creative and on the “viewing forward” is a critical characteristic that contributes to its effectiveness and success. The strength of future-search techniques and disciplines in the innovation process at the idea stage is:

·         celebration an emphasis on what has already been accomplished in the history of the “journey” to the present and the relationship of the future to the continuum,

·         the use of mind mapping technology which links present conditions, external trends that impact with internal dynamics and identifies those critical elements affecting choice and action,

·         the focus on alignment between present reality and circumstances and the potential challenges, changes, and opportunities being driven by the convergence between external forces and internal dynamics,

·         creation of scenarios and goodness of fit between emerging reality, potential solutions, and ideas created as a part of establishing preferred choices with regard to innovations and outcomes,

·         identification and confirmation of consensus, agreement, and common ground establishes a basis for group identity and commitment to the innovation and aggregates effort around group consensus,

·         The confirmation of, and ground leads to specific action planning and innovation staging that allows the group to begin with form to the subsequent stages of design implementation and transition through the innovation process.

These and similar approaches provide a strong vessel for the creation, translation, and coalescing of ideas toward specific innovation of objectives in an open yet systematic way. The approach depends on skilled and unformed facilitation and broad-based inclusion and contribution of all participants who have a stake in moving successfully through the idea phase toward the next stage of the innovation process.

Mind mapping Tools.

Mind mapping has special implications for idea management and innovation processing. It is an excellent tool in so far as that demand strong integration and consolidation of ideas with synthesis of them in a way that gives a sense of direction and expresses in explicit detail all the elements related to translating ideas and planning or “mapping” the application of ideas in a way that shows their relationship and their synthesis. Mind mapping is a terrific bridge between the idea generation and translation stages in the next stage of innovation processing that takes the more formative phases of the innovation process and gives them clarity and a sense of direction. Special characteristics in consideration of the use of mind mapping in the innovation process are:

·         serves as a great vehicle for brainstorming, coalescing note taking, organizing complex information, creating relational intersections between and among ideas, and more clearly delineating ideas around the specific vision or purpose,

·         mind mapping enables the full powers of brain mechanisms and information management in so far as linear processes and sequencing is avoided and network and Association approaches are used in the management of ideas,

·         concepts can be more fully developed, related, and translated into actionable items and the functional relationship between them can be better established, plus guiding users to more potential direction and application with powerful alignment of ideas generating potential relationships necessary to good design,

·         the full array of related elements, intersections, and interactions can be explored such that duplication, vacancy, or incomplete notions can be easily discoverable and visualized in a way that informs open space and incomplete relationship or design,

·         Contrary to linear processing and work, graphic presentations through mapping can indicate degrees of intensity of relationship and importance and quickly facilitate the selection and rejection of ideas in a way that reflects the relative importance and impact on the innovation trajectory.

Use of mind mapping usually requires the application of mind mapping software especially when a wide variety of complex word numerous bits of information need to be correlated and integrated in one place. However mind mapping is an efficient and effective way of managing ideas, consolidating them and synthesizing them in a way that makes it easier to apply them to decision-making, design, and the subsequent stages of the innovation process. Furthermore, they serve as a record of the journey through the innovation process and of the dynamics of process, change, and adjustment embedded in the various stages of innovation giving the user a chance to evaluate progress and the impact of changes and adjustments.

Brainstorming and Free Form Group Process.

There is a huge array of brainstorming techniques and free-form processes. Rewriting that allows thoughts to flow freely without any constraint; breaking down topical items into constituent idea components; listing and bulleting ideas, notions, imaginations; pursuing perspectives helps enable the sharing of different views on a common idea; to being enables users to consider the notion or idea from six different directions which describe, compare, associate, analyze, apply, who argue for and against any one direction: similes, which allows participants to suggest specific ideas and brainstorm as many varieties where variations on the idea as is possible; and an array of others such as clustering, sharing, webbing, etc. Brainstorming provides a lot of latitude in getting many ideas out on the table quickly and effectively free of judgment or assessment. Some of the unique considerations with regard to brainstorming are:

·         Free-flowing and open non-judgmental thought and communication is a centerpiece of brainstorming requiring an open process the specified time limit.

·         Important to brainstorming is maintaining focus even though critique is suspended and broad-based idea generation is a requisite,

·         Brainstorming expresses value insofar as it suspends judgment, encourages free-flowing of ideas, is not limited by quantity, and ideas can be directly related to each other.

·         Brainstorming sessions usually generates connection, relatedness, good interaction, and builds collaboration and purpose-identity around the room

·         while brainstorming requires a great deal of ideas sorting it does increase the potential for getting ideas out that might not otherwise be generated in a more controlled or directed process.

Brainstorming is a sound initial group activity because of its impact on building more group interaction and in creating a context amenable to continuous idea-generation. It is also one of the more common tools used by groups in directing ideas and getting clarity around worthless ideas lead. Another strength of brainstorming is that it can be used at varying levels of deliberation and dialogue so that’s ideas get more refined and more directional brainstorming subsequent steps in the clarification process can assist in continuing to refine or discern further ideas related to emerging actions or goals.

There are clearly a host of team-based ideas generating and management techniques and methodologies with which good facilitators are familiar. The facilitation process of idea generation and management is critical to its initial success and demands good facilitation and coordination of efforts. Awareness of the wide variety of tools available in a wide range of group process activities is important to the effectiveness of the facilitator, especially in the first stages of the innovation process. With experience and exposure in continual use of various methodologies and techniques, their refinement yields increasingly improving results and allows groups a measure of initial success that helps further stimulate commitment to the process and movement through the innovation stages. Many of these tools and techniques can be characterized as Rogers does as “The Knowledge Stage”. The goodness of fit with his theoretical foundations are demonstrated by the coalescing of ideas around the various kinds of knowledge that will be necessary to translate ideas into innovation (awareness knowledge, how to knowledge, and principles knowledge).

Stage 2: From Idea to Innovation

Using these textbook readers are reminded that ideas contained in any one chapter are dependent on the ideas and processes identified in other chapters. Clearly innovation cannot be successful it is not part of a larger strategic imperative that gives innovation contexts, form, and operational support. Also, all of the input processes necessary to inform the organization needs to be in place with regard to its location in the external environment, it’s internal dynamics, alignment with mission, vision, and goals, the organization’s human capital approaches, resource allocation for innovation, and, finally, the organization’s awareness and availability to innovation opportunity. All of this forms the backdrop and informs the dynamic of innovation in the organization. This is most important that the second stage of innovation where much of the translational work between idea and innovation is undertaken. Here are all the forces mentioned herein operates to inform participants in a way that advances tactics, choices made, and actions taken to act upon the ideas, translate them, and begin the processes associated with action planning. All of these factors can be accurately aligned with the characteristics of an innovation culture. Such culture needs to be promulgated as a way of ensuring and assuring that the potential for real innovation can be realized.

The use of tools suggested in stage I should have helped refine the idea or ideas into a manageable focus leading to better discernment and greater clarity. These decisions will need to be clearly articulated and identified in a way and with the language that participants can clearly identify and through which general consensus and agreement can be evidenced. Those directly involved in the innovation process and choice-making become “champions” for the particular innovation choices. They also become participants in a more focused on specific activities involved in moving from idea to innovation and choice. Several activities are associated with this particular stage of choice making and structuring design:

1.      Ideas have been refined, coalesced, and more specifically directed to clarity around specific choices related to the innovation and its potential.

2.      Consensus processes are used to clearly identify best case scenarios and best practice choices which would lead to more narrowly to a specific innovation.

3.      Innovation choices would be tested against strategic decisions and priorities to determine their goodness of fit with the organization’s mission, vision, and strategic plan.

4.      Clarity with regard to the impact of the innovation, its value and impact on process or product is well defined in this stage and the case made to the organization with regard to the innovation’s viability.

5.      Alignment with issues of resources, timeline, commitments, and activities are clarified as design and planning activities are initiated.

6.      Design elements emerge with regard to specific characteristics of process or product essential to more focused activities which translate idea into specified innovation which informs design.

7.      Metrics are threaded in the design planning and timelines in order to more clearly evaluate staging, progress, costs, viability, and the inevitable annotations and changes.

It is at this point in the innovation process that specificity and clarity begin to emerge with regard to the innovation itself. Not only is the innovation becoming clearer, the image and visualization of the process or product is also clarified. While complete clarity cannot be obtained at this early stage in the process, it can be visualized and characterized in a way that provides an image of its application and use. In understanding important at this stage of the process relates particularly to the developmental and resource costs and challenges in making the innovation work.

Contemporary innovation and design are among the most complex processes, both technically and socially. Elements of human factors, design processes, and indicators of performance (both process and product) must be included as a part of the design infrastructure. As the innovation team moves closer to making concerted decisions with regard to the innovation itself various factors must converge to both inform their strategy and formative work and to move from design to action. Some of the elements that must be specifically addressed at this stage are:

·         When the specific innovation process and activity are more clearly articulated questions related to time demands and timeline become paramount. Since the external environment is constantly changing demand and circumstances the ability of the team to create an innovation in a timely fashion and relevant to the needs and desire for the innovation becomes critical.

·         Budgeting for development and design becomes important in consideration of the institution’s financial plan so that sufficient resources are made available to assure appropriate attention on appropriately unfolding the stages of the innovation process.

·         The human resource energy time and commitment now must be more tightly aligned to the work being accomplished. Those involved in the initial idea and translation stages may not necessarily be the same individuals involved in the design and application faces. Leaders need to be aware of the need for reallocation and re-delineation of appropriate and adequate human resources for this more concrete phase of the innovation process.

·         Increased engagement of the broader array of stakeholders now becomes important to the consideration of implementation in the design process. More stakeholders are implicated in the design and application of the innovation and therefore play a more direct role in either informing or unfolding the innovation.

·         Techniques, methods, and models of goal setting and staging the innovation as it moves from design into action now become important elements of the design process itself.

·         Narrowing and selection methodologies and techniques such as nominal group process helps both narrow and prioritize elements and activities related to specific innovation choices and goals being more clearly established in the stage.

Clearer integration of goals, steps, metrics, and timelines serve as the database for moving through the design phase to the next stages of the innovation process. Here also the products of the mind map in future search activities begin to merge and point in the clearer direction with regard to advising priority decision-making and choice making related to the selected innovation. The convergence mentioned earlier occurs especially at this point and begins to inform the elements of the design phase and more clearly enumerate what actions related to design will be preeminent. Rational and appropriate choices begin to appear apparent and logically deduced from the aggregate of information “float-out” on the flip chart or linked and integrated on the mind map. Simple numeric or symbolic (such as colored dots or highlighters) are often tools that are used to help indicate priority choices and to narrow participant selections.

In addition the most significant barriers and challenges to the choices that are made are also identified during this phase. Here, the analysis associated with innovation choices begins to point out unaddressed concerns, threats, challenges with regard to information, resources, and competencies. As the choices begin to tie it more fully into the strategic and tactical structure and processes of the organization, the various challenges take on more clarity and begin to demand specific responses in order to adequately confront them and to address the steps necessary to either accommodate or change them.

IDEO, an innovations and design firm uses this point in the innovation process to do what they call “deep-dive work. Within the context of their deep-dive they identify for process strategies, learn, look, ask, and try as vehicles for narrowing choice in guiding and informing the clarification process. These four approaches simplify both strategic thinking and planning process into hands-on activities broken down into logical stages that help groups hone their analysis and refinement skills and assist them in making appropriate choices. IDEO uses each phase as a vehicle for thoroughly assuring that all the elements related to an idea which might lead to a potential innovation are worked through carefully and systematically in a way that helps influence good choice-making. Learning refers to the management of information obtained through gathering at, analyzing and integrating it and then synthesizing it in a way that makes sense with regard to particular innovation’s choice. Looking in this process involves high level experiential observation techniques directed to gaining insights from participants experiences including observations of business and customer interactions. Use of questionnaires, surveys, observation tools, and flow diagrams serve as vehicles for honing and refining observations. Here again use of mapping tools can also indicate relationships and flows as participants attempt to get a handle on movement and activities. For IDEO, asking includes a number of techniques directed to obtaining information from a variety of sources, generally users and those associated with their work. A number of techniques and tools can be used such as surveys, analysis instruments, attitudinal assessments, workflow, and behavioral toolsets, depending on the activities or behaviors being assessed. Finally, IDEO isolates trying is the physical activities associated with learning by doing. Here, actual experiences, work processes, real-time analysis, prototyping, and constructing particular vehicles for testing out models or approaches are actually applied in real-time circumstances. Use of scenario, computer models, virtual processes, and prototyping are common vehicles that use real-time opportunities and circumstances to test out ideas, notions, and thinking about particular processes or products. The results of these approaches lend value to the designers and users with regard to interpreting personal experiences and testing out analysis and applications in real and practical circumstances.

Stage 3: Strategy, Planning, and Acting.

The initial stages of the innovation process relate particularly and specifically to the generation and management of ideas in an effort to do identification, clarification, affirmation, and choice work with regard to establishing priorities related to the selection, planning, and application of a particular innovation. As briefly mentioned earlier, such processes are not simply valuable because one does some; innovation processes are valuable to the extent that they make a difference, have an impact, change something. For businesses or services the direction and intent of innovation is to maintain the relevance and viability of the system in a way that fulfills its mission and purpose and achieves something the organization and its users find valuable. All the creative generation of ideas and the initial idea-innovation dynamics and processes mean little if the products of that work don’t in some way make a significant difference and have an impact on the business or service.

The earlier processes, methods, and techniques have been devoted to managing ideas and preparing them for the more formalized processes associated with stage 3 and beyond. While the number of stages identified in an innovation process can be variable (some as few as 3 others as many as 9), they generally point in the same direction with regard to required activities. At this stage, the translation of ideas into innovations and innovations into reality takes place in earnest. Here the planning stages in the elements of planning become critical to the effectiveness of implementation process.

There are several elements related to innovation planning is critical to its success. Here the more fun, imaginative, and “loose” activities become more structured and formalized as this movement from idea to innovation becomes more specific. Planning now involves components usually associated with the strategic process. Some of the elements related to good innovation action plans are:

·         Follow the KISS principle: keep it simple and sustainable. As with most everything in organizations related to the process, a less is always better. Here the innovation team wants to plan objectives and processes that focus the work on making the innovation real and possible and relating it to the vitality of the organization.

·         In action plans related to a particular innovation, steps, actions, and processes should be kept to only those necessary to actually move the innovation in a meaningful way. Emphasis on “good enough” means that participants understand innovation as a process and, thus, realize that enhancement and improvement occurs in the midst of the process. Also, planners note that the vagaries existing in the internal and external relationships in the system often change quickly affecting the innovation trajectory and calling the team to the table to make necessary adjustments. The less the process intensity and effort at creating perfections occurs early in the process, the more likely accommodation to changing vagaries can be successfully made.

·         Old team participants should clearly understand the stages of the innovation planning process and recognize it as a methodology and a discipline. Steps shouldn’t be diminished or skipped by participants or in any other way diminished since doing so creates later challenges to the extent of creating barriers to potential success.

·         Keep in mind that the innovation planning process should continuously reflect mission and purposes of the organization. If emerging environmental or practice realities challenge the success of the innovation planning process because of their conflict with the mission of the organization, strategic questions should be raised with senior leadership and board members in order to assure continuing goodness-of-fit between developing and innovation and its relevance to facilitating the viability of the organization.

·         In the planning process help keep the team focused on the potential for challenge. Since the innovation will likely create significant change in process or product, “noise” can be expected, indeed, should be anticipated. Innovation generally always challenges existing states of being and ways of working. Innovation planning team members should anticipate and expect organizational reactions is a normative part of both plan design and action.

·         As the tactical elements of an innovation plan unfold there is always the temptation to solutions seek early in the process, failing to give the process sufficient opportunity to unfold. Problem solving will be important as a part of the dynamic but is usually the focus of implementing the plan.

·         Remember to pay attention to process metrics and what they say about the challenges and successes as the stages of the plan unfold. Metrics allow the team to develop and use objective tools for assessing and measuring progress. They provide real-time opportunity to evaluate and adjust action in a way that better assures unfolding the innovation plan and maintaining an appropriate trajectory for it. Dependence on the metrics suggest commitment to “managing by fact” and will more directly facilitate leadership in identifying “root” issues influencing plant flow and effectiveness.

·         Keep in mind that users, customers, patients, and other partners are considered stakeholders and, therefore, play a direct and particular role in designing, constructing, and unfolding the implementation plan. It is not solely the leader’s role to participate in design and evaluation. Instead the leader ensures that the right stakeholders play appropriate roles of value in a way that positively affects the innovation plan and application. They also inform the innovation team in ways the team might not access themselves.

Elements of the Innovation Plan

Innovation plans have many of the same elements as any other rational planning process. The key elements of an innovation plan are:

ü  clarity of definition around the specific innovation

ü  needs and desires driving the creation of the innovation

ü  facts and concepts derived from idea phases

ü  clear steps and goals directly related to innovation creation/outcome

ü  process activities associated with innovation plan/trajectory

o   capital resources

o   human resources

o   information resources

o   physical resources

o   technology

o   performance metrics

o   timeline

o   evaluation

Each of these are specific line items in the innovation plan that must be specifically addressed in order to assure that the stages of innovation activity are adequately addressed and fully engaged.

More on the plan of innovation in a future contribution.

It comes as no surprise that nursing and health care are at a crossroads.  As we confront a new age for human experience, the very foundations of health practices and therapeutic interventions are being dramatically altered by significantly transformed scientific, technological, cultural, political, and social realities (Tim Porter-O’Grady, 2003).  It is within the context of these emerging realities that the future framework for nursing practice and for those that will lead it must now be re-conceptualized (Hein, 2001).  The traditional realities that form the frame of reference and contextual framework for thinking and acting for the majority of nurses no longer operates to form the foundations for reality for contemporary and future nursing practice and leadership (Sheila Grossman & Valiga, 2000).

 

It is vital for those leading the profession to carefully consider these emerging contextual realities and to apply the impact of their transformations to the thinking and applications related to creating new models and modes of practice for the future of nursing.  At every level of consideration, from system, profession, self, and the relationship to patient and family, every aspect of nursing practice must now be re-examined.  This transformation calls the profession to make decisions about what principles and foundations established over the past century of considered thought and relevant action can be easily translated into this new world of digital and virtual reality and political and social globalization (Friedman, 2006).  Certainly, the principles and foundations upon which the nursing profession is based can stand the stress of shifting realities and new applications and call practitioners and leaders to determine a new goodness of fit between those principles and future practice (S. Grossman & Valiga, 2005).  In this endeavor, it becomes essential for nursing leaders to successfully re-language the practice of nursing and to formulate a new frame for nursing practice which reflects the emerging realities impacting practice in the domains of system, profession, person, and the interaction (Domains of Nursing Leadership: system, person, patient/family, profession) of all of these with regard to patient and families (the “users”).

 

Nursing in a Transforming Health System

 

The challenges of technology, culture, society, and globalization have worked together to create a challenging context for the contemporary delivery of healthcare services (Porter-O’Grady et al., 2005).  The traditional medically dominated and medically prescribed model of high intensity and late stage intervention which has comprised the majority framework for the American healthcare system has failed to yield in the United States a standard of health and health status comparable to the other GATT (General Agreement on Tariffs & Trade) nations (Commonwealth Fund, 2007).  Across almost all measures of social health status, the United States fails to reach the top tier of health status measures with the notable exception of one measure, the national price of health care.  Without reiterating what has been clearly evidenced in other reports, it is notably apparent that the system as currently constructed fails to adequately serve the needs of the American population (Kleinke, 2001).  The evidence is overwhelming; the devastating and shameful fact that approaching 50 million people fail to have adequate health coverage to the more clinically notable deficits located across the lifespan revealing devastating data related to infant mortality, childhood illness, adult heart disease, diabetes, obesity, and a growing looming crisis related to aging (Porter & Teisberg, 2006).

 

 

The System

 

This is the healthcare system within which nurses spend the majority of their time in processes and activities which ultimately serve to support and sustain the existing infrastructure, processes, and clinical focus through a wide ranging array of functions and activities (Siegler, Mirafzali, & Foust, 2003).  Increasingly, nurses are finding their usual and ordinary clinical practices, activities, and functions both less viable and less sustainable (L. Aiken, Clarke, Sloane, Sochalski, & Silber, 2002).  Increasingly, nurses at every level of function are finding it impossible to continue to apply traditional approaches in practice within the clinical setting (Kuokkanen, Leino-Kilpi, & Katajisto, 2003).  In addition, contemporary data suggest that nurses are less motivated, energized, or satisfied by their current realities and practice obligations in accelerating challenging circumstances (Ulrich, Buerhaus, Donelan, Norman, & Dittus, 2005).  In short, nurses sense the failure of the system to support practice, and the failure of current practices to heal either the professional or the patient (Bowles & Candela, 2005).

 

Many nurses suggest a sense of being overwhelmed by the breadth of the systems issues and the complexity of its problems (Vonfrolio, 2006).  From issues of regulation and accreditation and performance expectations for excellence and impact, these growing demands overwhelm the capacity of the individual practitioner to adequately address them.  Issues of a lack of control over one’s practice, an inability to contest regulations, rules, protocols, accreditation and internal quality demands increasingly draw the life and energy from each practitioner until little remains except for the intent to do what one can within the context of a narrowing scope of perceived opportunity (Roman, 2006).

 

Adding to this generalized professional malaise is the nursing leader’s sense of being overwhelmed and challenged beyond any existing level of competence (Kane-Urrabazo, 2006).  The growing dichotomy between current infrastructure and service frameworks and the accelerating need for a transformed approach to healthcare delivery continually serve to overwhelm and challenge even the most committed and motivated leaders.  In many ways, leaders feel as though they are simply maintaining the status quo and barely keeping their own efforts one step ahead of the next challenge or requisite which will take them beyond their capacity to adequately respond (Judkins, Massey, & Huff, 2006).  As a result, there is increasing fallout in the roles of leadership and a growing difficulty in finding qualified and motivated nurses to assume vacant leadership positions (Bonczek & Woodard, 2006).

 

This contemporary reality serves to create an opportunity to recognize the changing characteristics of the health system, the need for strong leadership in creating new models and approaches to health service, and in challenging past practices to the extent that they act as an impediment to relevance and viability for future nursing practice (Chaska, 2001; Christensen, Bohmer, & Kenagy, 2000; Kathy Malloch & Tim Porter-O’Grady, 2006).  No longer can leaders at any level of conception move forward without acknowledging the necessity to create newer models, approaches, and practices in the new world of healthcare.  This will require leaders, whether they be management or clinical, to recognize their inclusion and involvement in planning and decision-making at every level of the health system (McClure & Hinshaw, 2002).  It will no longer be appropriate for nursing leadership, in any capacity, to simply undertake any mechanism of change in health care delivery involving the nursing resource without having first been actively involved in the conceiving, planning, and designing a new and relevant approaches to meeting healthcare needs (Kleinman, 2003).  These leaders will need to be educated for and exhibit systems savvy and readiness by demonstrating commitment and skill in the following capacities:

 

1. Nurse leaders must recognize that political competence is not an option in leadership and engaging political realities is a fundamental construct of the leader’s role at all levels of leadership.
2. It is not acceptable to implement approaches, plans, or programs which will require nurses, at the end stage, to either facilitate, coordinate, or integrate without the active inclusion and incorporation of nurses in the planning and designing stages.
3. It is not optional for nurse leaders at any level of performance to be unaware of the political, cultural, social, and professional fit of nursing in the broader health system within the context of the historical realities of Nursing’s professional journey.
4. Nursing leaders must articulate an understanding of the financial framework for the payment of health services including the ability to articulate the challenges to leadership and nursing services contemporary payment policies and processes create.
5. The role of advocacy in nursing operates at a level broader than individual patient considerations.  Failure to advocate on behalf of the patients from a systems perspective is equally ethically comparable with failure to advocate for individual patient needs.
6. Leaders understand that, for the professions, power is driven by practice.  Nursing leaders understand and commit professional energies to creating interdisciplinary equity related to nursing role, performance, contribution, and value at any place in the health system.
7. The nurse leader understands the fundamental role in addressing systems problems and inequities related to profession and patient, joining with others to find and implement sustainable resolutions and innovations which advance the value of the nurse and the experience of the patient.
8. Leadership involves the ability to engage new realities, translate them, and incorporate them into shifting applications for practice in a way that informs new practices and creates a foundation for constructing the future of nursing practice.
9. Knowledge can no longer be considered a capacity.  It is, instead, a utility, available to all.  For the nurse leader, this informs leadership and nursing practice with emphasis on the implications related to knowledge creation, generation, utility, and evaluation.  Knowledge continually grows and transforms requiring practice leaders to guide the construction of infrastructure and process which keeps the profession and the professional open to the constant and ever-changing processes associated with knowledge management and application.
10. The world is indeed flat, and mobility and portability are the contemporary visible characteristics of this reality.  Every discipline in every arena of human activity now must incorporate this reality of portability and mobility within the very construct guiding the thinking and practice of the professions.  Nursing leadership must help the profession and the professional translate out of past practice foundation’s born in a system that was fixed, finite, functional, and institutional to one that is now predominantly flexible, fluid, focused, portable and mobile.

 

Programs of leadership development and education must incorporate the above capacities as a part of basic expectation for adequate clinical and administrative leadership.  Any leadership program identified at the undergraduate level should introduce leadership concepts within the context of these systems realities (Hatch, Kostera, & Koþzmiþnski, 2005).  The American Organization of Nurse Executive’s “Guiding Principles for Patient Care Delivery” clearly serves as the template for leader competence and development in the service setting (Everett & Black, 2007). Graduate education in leadership requires that these realities be the cornerstone of systems leadership development and application for formal positions of clinical or management leadership.  Service-based leadership development programs must be constructed in a way that incorporates broader systems understanding into learned roles and functional attributes of practicing clinical and management leadership (AONE, 2005; Kleinman, 2003).  A failure to provide a systems contextual framework for the content of leadership learning ensures an inadequate contextual framework for the application of leadership skills and the use of shortsighted strategies for addressing issues and resolving problems (Van Wart, 2005).

 

The Profession

 

Unless the individual professional recognizes the obligation to both care for and advance the interests of the profession, it is impossible to claim any capacity in advancing the interests of the patient.  In nursing, to care for the patient is a direct corollary to care for the profession (ANA, 2004; ANCC, 2005a).  A lack of identification with and commitment to the profession as an agent of care for the patient creates a value impediment affecting the role and practice of every nurse.  Perhaps the source of the strongest systems malaise within the profession of nursing is the individual nurse’s lack of clear and understandable identity with the profession and failure to demonstrate a common understanding of what that means and how professional membership performs (Apker, Ford, & Fox, 2003).

 

Developing a sense of professionalism and a clear relationship to the profession is a foundational activity of all members of the profession.  Relationship to and membership in the profession does not imply that every person who works under the auspices of the profession meets the requisites of being defined as a professional.  However, those who define themselves as professionals must clearly demonstrate that they do meet such requisites (Cicatiello, 2001).  Professional accountability begins where role responsibility ends (Porter-O’Grady & Malloch, 2003).  It can be argued that licensed practical nurses and associate degree registered nurses can exercise high degrees of functional capacity and responsible practice behavior.  However, there are significant classification challenges when identifying these two roles within the context of professional definitions.  Clearly enumerating professional foundations in traditionally recognized academic frames (baccalaureate education), advanced education (masters and doctoral) and a growing body of knowledge created, generated, applied, and validated (research) are all essential foundations for professional definition (IOM, 2003).  Additional professional elements which include an ethical frame, code of conduct, and membership requisites, build on the knowledge generated foundations of education and practice (ANA, 2004).

 

These foundations are well defined and broadly accepted across a full range of disciplines and are generally acknowledged internationally as the medium for professional delineation (Corey, Schneider, & Callahan, 2006).  Slowly, yet inexorably, the profession of nursing is exemplifying, through implication and active application, these same foundations as a part of the maturation of the nursing profession.  Challenges continue to exist in clearly delineating differentiation between categories of practice aligned with role, function, preparation, application, assignment, and remuneration (Joel, 2002).  However, in order to exemplify professional delineation and act in comparable accord with other disciplines, these delineations must be clear, precise, and valid.

 

In addition, is the obligation of the profession and the professional to enumerate value not with process, but with outcome.  One of the growing realities of professional delineation is the understanding that the value of the profession is not so much located in what it does but instead in what it achieves; its impact (Freshwater & Rolfe, 2004).  The products of work are the best indicators of the value of the processes of work.  For the professional nurse in the contemporary values-driven world, it is important to identify the character of the profession and the professional in light of the impact, outcome, or difference that work achieves to affect the health of the individual and the community (K. Malloch & T. Porter-O’Grady, 2006).  This values-driven frame must now form the foundation of the definition of the profession, the professional, and their place in the world.  It is no longer sufficient for the profession or the professional to simply enumerate actions, activities, functions, scopes of practice, and rules as a way of delineating character, meaning, and value (Pfeffer & Sutton, 2006).  In the 21st century, sustainable value for any professional or workgroup relates directly to the contribution made to further refinement, development, innovation, and transformation of practices and approaches within the context of an emerging and fast-growing socio–technical reality.  Failing to accomplish this value, and failure to give evidence of engagement and translation of these emerging realities bodes ill for the profession and the professional and assures a short term future (Wickramasinghe, Gupta, & Sharma, 2005).

 

Advocacy for the profession means addressing these critical issues with the result that there be a clarity of definition, expectation, and commitment to retooling and reconfiguring the profession for a changing context.  It means that there is a general energy in the profession and the professional to evidence relevance and to demonstrate a full and overarching individual and collective participation in further refining and advancing the profession to meet the demands of a transforming clinical environment (Tim Porter-O’Grady, 2003).  Every activity associated with the innovation process and the developmental dynamics that serve as the necessary corollaries of change such as mentoring, coaching, challenging, harnessing normative conflict, novice to expert development, destructive technologies, shedding irrelevant practice capital, creativity, experimentation, and risk-taking must become the normative experience of the profession and of practice (Trompenaars & Hampden-Turner, 2002). 

 

The leadership capacity to engender the urgency of critical transformative activity can no longer be delayed.  The leader’s collegial obligation is to demonstrate a personal engagement of the agenda for change in the profession.  This leader converts that personal leadership energy into a framework for action.  For those in the profession, this person leads, guides, managers, coaches, and directs into new patterns of behavior and performance that better reflect the demands of value and the changing needs of “users”, our patients and communities (Bettis, 2005).  Therefore, the following elements are the necessary foundations for leaders who exemplify their identification within the profession of nursing:

 

1. Professional practice leaders and educators must agree and commit to a clearly articulated set of professional parameters and associated behaviors which clearly enumerate the conditions and expectations for membership in the community of nursing professionals.  This set of expectations forms the foundation for education, development, performance, and evaluation of the professional character and role of professional nurses.
2. Leaders must exemplify and demonstrate within the context of their own patterns of behavior, their commitment to a consistency with and a delineation of professional nursing expectations and the translation of those expectations into the framework which facilitates compatible behaviors in all categories of nursing practice.
3. Advocacy for the profession is advocacy for the patient.  Academic and service educators and leaders need to communicate to groups and individuals within the profession the message that failing to attend to the interests and needs of the profession ultimately compromise patient care and fail to establish a generally accepted set of standards upon which measures of excellence in patient care can be based.  The long history of individual nurses assuring each other and the patient that they are offering excellent care with no reference to commonly accepted standards of performance or measures of outcome must now end.
4. Evidence-based principles and practices must now form the foundation upon which the future of sound nursing practice and value is based.  In all nursing learning and service settings, the foundations in curriculum design, practice and performance expectations must be grounded in an evidentiary discipline that suggests a rigor which validates the effectiveness and efficacy of clinical practice.
5. No discipline can sustain its place in the world without strong professional leadership and advocacy on the broader social and political stage.  A strong commitment and carefully constructed development and mentorship process for emerging leaders must be incorporated into both the structural and relational framework for development in nursing leadership.  Mentorship and coaching that issue from good leadership must be identified as a fundamental characteristic of leadership practice and incorporated into the development and expectations related to the application and exercise of the leader’s role.
6. Good stewardship of the profession now demands that academic and service leaders ground the work of the profession on clear indicators of value and impact.  Process excellence, patient safety, risk reduction, are essentially more means than ends.  Nursing value suggests that the profession as a whole and professionals individually can articulate, specific to the work of nurses, the value of that work to patients and the system, the impact of nurse’s work on patient outcomes, and, ultimately, the difference nurses work makes in assuring or advancing the health of the community.  This measure of the difference nurses make must, in the age of evidence, be specific, precise, and meaningful.
7. The history of the profession of nursing indicates its ascendant role in coordinating, integrating, and facilitating the patient’s health journey in all kinds of circumstances.  This central role of the profession is grounded in the value of continuity and integration and demands that nurses assume the chief obligation for addressing the issue of continuity and integration of health services at every place in healthcare delivery.  In the contemporary age, this means that nurses have the primary obligation to coordinate activities, systems, structures, and processes which address, advance, and improve the continuity of services across the patient’s health journey.
8. The professional nurse generally operates at the center or in the middle of a broad array of multidisciplinary professionals.  The fundamental obligation of the nurse both by law and professional disposition is to ultimately ensure the safety of the patient’s healthcare experience and to advance the continuity of all the efforts directed to addressing the patient’s healthcare needs.  This primary obligation lies at the core of all professional nursing practice regardless of role.  Reflected in this obligation and implied by the nurse’s location, facilitating the integrative clinical efforts of the broad array of disciplines with specific roles and functions with regard to individual patients serves as a natural alignment within the role of the nurse.  Nursing leaders must fully understand the inherent integrative capacity in the role of nurse and the primary obligation of each professional nurse to lead initiatives, problem solving, and collective activity in the exercise of the coordinating, facilitating, and integrative role of Nursing in its relationship and interaction with other disciplines.
9. The theoretical foundations of nursing practice are grounded in caring.  Whatever context, concepts, and applications of nursing practice unfold in a 21st-century framework, principles and the foundation of caring remain constant.  The application of theoretical constructs of caring in unfolding evidence-driven practice provide a firm underpinning for the translation of caring concepts and principles, practices, and patient outcomes.  Nursing leadership grounds its role firmly upon concepts of caring, evidencing the implications of the caring frame in all measures of value and outcome in patient care.
10. The structural configuration and organizational infrastructure within which the profession operates and does its professional work is equal in importance to the work itself.  Creating an organization whose structural and operational configurations demonstrate professional characteristics in the way of undertaking the business of the profession and the application of its work is critical to its viability and sustainability.  Professional structures for shared decision-making and subsequent action reflect elements of internally congruent partnership, equity, accountability, and ownership.  Each member of the professional community exemplifies individual and collective accountability for contribution to the work of the profession, advancing its interests and translating its values into the work of patient care.

 

The profession of nursing has demonstrated an evolving and continuous commitment to advancing the health of individuals and communities (Diers, 2004).  The character and content of this historic commitment is radically changing in the 21st century digital and virtual world.  While the context and content for nursing care and professional services continues its rapid transformation, the foundations of human caring and professional integrity deeply embedded in the profession of nursing remains unchallenged (Baer, 2001).  However, if professional sustainability is to be advanced in the new millennium, reflecting radically shifting technological, global, political, and economic realities, the profession of nursing will just as radically need to alter its practices.  In this case, time is of the essence and a considerable level of urgency must drive the action of professional leadership.

 

The Person of the Nurse

 

The disposition and vision of the profession of nursing is seen through the lens of all those who observe or are influenced by the character and behavior of individual practitioners.  The full embodiment of the profession and all it implies is visibly and actually represented by the person in the action of each practicing nurse (Ambrose, 2005).  Who that person is and how she or he best exemplify in their own person and role the character and content of the profession is the only realistic window the observer has into the character and value of the profession.  All of the descriptors, principles, standards, codes, and behavioral protocols will serve as naught if the individual nurse does not represent them in her or his consciousness, attitude, behavior, and action.  To do so or to fail to do so reflects a lasting image, difficult, if not impossible, to extinguish, seared into the consciousness of other colleagues, disciplines, and patients with regard to what Nursing is or is not (Johns, 2004).

 

The profession simply cannot take the risk that emerges when individual nurses are not fully prepared to understand and exemplify in their own practice the character, obligations, and appropriate expressions of the nursing professional.  The profession has a right to expect that those identifying themselves as members of the profession understand what that means, embody that ownership in their own patterns of behavior and represent a strongly identified internal locus of control with regard to their representation of the profession to themselves and others (Arnold, 2002).  Leadership in the development of the individual nurse consistent with professional expectations includes the understanding of the power and influence embedded in language, disposition, communication, and action (Bennis, Spreitzer, & Cummings, 2001; T. Porter-O’Grady, 2003; Trompenaars & Hampden-Turner, 2002).  For example, language that moves from use of the word “job” toward the more professional word “practice” creates an entirely different vision and perspective of the work and actions of the nurse.  Job oriented language has the potential for removing the professional overlay to the work of the nurse and reducing it to a set of functions, processes, and procedures.  Contemporary nursing history is rife with the impact of this language on the nurse’s self perception of her or his work and its importance in the scheme of things when job orientation and considerations predominate over professional practice delineations.

 

Imagine for a moment a different mental model that is created when a new nurse goes to the work environment and applies for “privileges to practice nursing” instead of simply looking for a “job”.  Here the language shift implies a significantly different approach to identifying professional nurse expectations.  When applying for privileges, assumptions about the requisites of a “membership community” and the professional community’s obligation to provide a privileging mechanism are vital, where the individual can demonstrate and represent her or his individual compatibility with a set of professional expectations and accountabilities clearly enumerated in the requisites of privileging rather than simply delineating job characteristics.  In building the next stages of the nursing profession’s maturity, considerations of language, structure, performance, and the individual’s demonstrated capacity to exemplify the expectations of the profession will become increasingly essential (Joel & Kelly, 2002).

 

Nursing professionals will not be perceived equitably with other disciplines unless two conditions are met.  First, the academic delineations for professional practice must operate at a level of comparability with those same definitions accepted almost universally by other professional disciplines.  Secondly, professional and personal expectations of equity must be incorporated into the behavioral patterns and relational processes of practicing nurses (Higgs, Richardson, & Dahlgren, 2004; Schermer, 2002; Trossman, 2002).  Here clinical and management leadership plays a critical role in providing both the expectation and patterns of behavior that exemplify equity-based activities and expressions.  Here again, equity becomes evident to others through the language, interactions, expectations, and behaviors of the individual nurse and the perceptions of ownership, investment, and engagement through which those patterns are expressed (Stack & Burlington, 2002).  In short, if one seeks to be treated equitably one must live within the context of the expectation of equity.  This is a learned process and the skills attendant to the expression of equitable behavior have been well enumerated.  Leadership development should always include these elements as a part of more clearly elucidating the role of the professional and behavioral attributes which demonstrate value and equity (Goleman, Boyatzis, & McKee, 2002; Gunden & Crissman, 1992; Kotter & Cohen, 2002).

 

Advocacy for patients and for the profession requires a broader notion of the principle of advocacy and of its applications (Taylor, Lillis, & LeMone, 2001).  Nurses cannot adequately advocate for patients and healthcare if it is perceived that they have no right to do so.  Historic notions of physician ownership of patients are simply no longer relevant in any “user driven” social context (Rosenstein, 2002).  In contemporary thinking, patients have primary obligation for decisions and actions which affect what happens to them (Osborne, 2002).  In a multifocal, widely distributive, interdisciplinary healthcare delivery network, the patient will have many “captains” that partner with the patient at various points along the patient care continuum (Mycek, 2007).  The role of the nurse is to foster appropriate interactions, decisions, and relationships in a way that advances the interests of the patient and connects the various clinical stakeholders in a communion of efforts that, when well coordinated, serves to best advance the interests of the patient and effect positive outcomes (Orem, Renpenning, & Taylor, 2003).  It is no longer optional for nurses not to see themselves as a key coordinator of this effort, and the driving force for assuring the broadest range of access and partnership in a way that advances patient service.

 

Increasingly, the human dynamic partnership and interaction is accelerated by newer realities of patient data management and integration (Maysys, 2002).  The growing requisite for confidence in both “access” and “utility” skills with regard to the management of clinical information requires higher levels of information management competence from nurses.  The expanding efficacy of digital and virtual technologies now makes it a requisite for nurses to understand and utilize new tools for practice in ways that fundamentally alter the mechanisms with which nurses and others communicate, interact, and apply practice skills (Ball, 2000).  Virtuality now changes the definition of “presence” and today allows a broader array of relational options to be incorporated into practice applications that fundamentally alter the patient-provider relationship, the nurse’s role, and the application of clinical services (Power, 2005).  The following issues of individual nursing capacity and competence are now the requisites for every individual professional nurse in the exercise of her or his role:

 

1. An ability to demonstrate an internal locus of control with regard to professional identity with emphasis on exemplifying as strong a commitment to the profession of nursing as one has to the practice of patient care.  This commitment to the profession is demonstrated through the individual nurse’s engagement and participation in activities and processes which address the governance and decisional needs of the profession in the workplace with the same equity as that devoted to the activities of patient care.
2. Often implied but frequently unspoken in the front lines of professional practice is the prevailing historic reality of the growth of the profession within the context of the women’s movement in the United States.  The issues of historic gender inequity have been well postulated and clearly enumerated.  The nursing profession’s own history is rife with examples to this day of socially entrenched and systemic gender-based inequities, some of them conscious, some of them systemic.  The human obligation for changing the realities of inequity or oppression has always been the obligation of the oppressed if lasting change is to occur.  The well-established adage that one is treated precisely as one expects to be treated certainly is the operating rubric here.  Expectation of equity, role balance, and inclusion precede these factors operating in reality.  Therefore it is the obligation of clinical and management leadership to exemplify, model, and demonstrate the practices and behaviors, which illustrate living equity.  It will be only in clarifying and expecting equity and actively living the expectation in practice that past practices of discrimination, exclusion, and inequity will be overcome.
3. Conflict is a normative circumstance of human existence.  At all levels of complexity in the universe, conflicting and opposing forces are constantly operating in a mosaic of movement that positively balances the dynamics of existence.  These realities affect human interaction and relationships as strongly as any other forces in the universe.  Conflict is always present, never disappears, and is a constituent in the vibrancy of all human relationships.  Clinical and management leaders in the profession must work diligently to overcome the systemic fear and ignorance of normative conflict and translate it into a catalyst for dynamic change that conflict truly represents.  Through skill and technique, conflict can be harnessed and act as a transformative agent between and among stakeholders in a way that can drive meaningful change.  The role of the nurse places her or him at the center of the conflict exchange, most able to harness and actualize the transformative power embedded at the heart of conflict.  Avoidance, fear, and trepidation for both the potential and presence of conflict create the very conditions that accelerate it and transform it into a dark and diminishing force.  Nursing leader’s capacity to develop good conflict skills, model them in practice, develop them in others, and apply them consistently can do much to create the vigorous balance that underpins all sustainable change.
4. Nurses must exemplify a willingness and facility to develop the technical competence necessary to manage the communication and information systems with a high level of “access” and “utility” skills, incorporating them into the ordinary and usual practice activities of nursing.  Since digital and virtual technology will simply continue to expand, the expectation of every practicing nurse is full engagement and participation in the application of these technologies to the shifting requisites of nursing practice and patient care.
5. The requisites of obtaining value in healthcare now demand nurses focus beyond process responsibility toward outcome accountability.  The practicing nurse must realize that the value in her or his practice more strongly relates to what one achieves with that practice rather than what one does in the work.  Nursing work is not inherently valuable because one is doing it.  The value of nursing’s work is located in its products; achieving clinical outcomes, improving the health of individuals, meeting individual health/life goals, and advancing the health of the larger community.  These form the sources of value and provide the framework for the expressed accountability of the profession and the work of each nurse.
6. Educational preparation and competence is not the exclusive domain of the academic arena of nursing.  Continuing development and growing competence is even more the life blood of the profession in the 21st century.  The drama of shifting realities of practice and the emergence of new foundations for the exercise of clinical roles is creating a constant shift in the nurses work realities.  The ability of each nurse to respond to these shifts with flexibility, fluidity, portability, and mobility is no longer optional.  Educational preparation can no longer be looked at as foundational; instead, it must be seen by each nurse (as well as the profession) as a continuum, essential to maintaining an ongoing level of practice competence.  Entry into practice is no longer the issue, the continuum of learning is.  Regardless of the point of entry into the profession, every practicing nurse now must commit to a dynamic continuum of systematic education and learning as a fundamental set of her or his own practice activities.  The profession too, must reconfigure nursing education to increase the academic/service partnerships and make it easier and more fluid for nurses to incorporate ongoing practice with advancing education within the clinical setting in the normal course of doing the work of practice.
7. There is a growing diversity in the membership of the profession of nursing.  Demographic realities representing the impact of ethnicity, age, preparation, and roles are together creating a broad mosaic of professional membership.  Accommodating these shifting demographic realities calls for a level of cultural sensitivity and leadership response to demonstrate effectiveness through programs of cultural awareness, leadership mechanisms which accommodate generational and ethnic variances, and a creation of an organizational framework that is inclusive, participative, and seamlessly addresses the normative conflicts embedded in the very nature of human diversity.
8. Administrative, management, and clinical leadership must create a context that makes it possible for the practicing nurse to fully participate in those decisions which affect nursing practice, quality, and competence.  Professional shared governance models have been well described and their value well established.  It should no longer be optional that the profession of nursing be governed, led, and integrated through the auspice of a professional governance model unique to the discipline of nursing yet consonant with the equity-based and inclusive governance practices of other major professions.  Participation in the life of a profession by its professional members should not be an invitation; instead, it is an expectation of membership and mechanisms for assuring that expectation is fulfilled through the actions of every member is a precise requisite of each member.

 

Professional nurses at all levels of practice must now see themselves as equal partners with other disciplines in creating a new template and landscape for the future of health care in the United States.  The paradigm shift into an entirely new human actuality, driven by emerging and unfolding technical and economic realities on a global scale, creates a level playing field where there is no rational justification for inequitable change strategies and non-inclusion (Peterson & Mannix, 2003).  However, nurses must accept the elemental political reality that others do not make space at the broader table within the context of an invitational scenario.  Each professional nurse must carry the expectation for equity and inclusion and, if necessary, “set the table” with the expectation that nurses will coordinate, integrate, and facilitate the dialogue and activities necessary to create a thriving and effective response to the transformative demands of new realities in unfolding health care in the United States.

 

It is generally understood and indicated by contemporary measures of excellence, that nurses create the predominant culture in the organizations of which they are a part (Linda Aiken, Clark, Silber, & Sloane, 2003; ANCC, 2005b; Marlene Kramer, 1990; McClure & Hinshaw, 2002).  Because of their predominance and centrality of role, nurses, often unknowingly, exert a powerful influence over what initiatives in their health systems will succeed or fail.  Regardless of the prevailing awareness of this reality, direct or subtle influence by nurses is one of the significant critical factors which determine the success or failure of an undertaking regardless of where and by whom it was generated (Califano, 1993; Group & Roberts, 2001).  This referred influence exerts a powerful cultural force in the organization and calls for nurse leaders to understand its value and to manage it with care (Havens, 2001; Urden & Monarch, 2002).  Clinical and management leaders must come to more fully understand this dynamic, validate and enumerate its significance with greater clarity, and positively harness it in partnership with others in the organization in ways which best advance the interests of patient care and the integrity and viability of the organization (AONE, 2005; M. Kramer & Schmalenburg, 2003).

 

Nursing work is not easy.  The particular and unique demands of nursing practice require individuals who are knowledgeable, competent, and committed.  Professional nursing requires an aptitude for managing complex and competing circumstances, continuous learning, adaptability, critical change, differing interdisciplinary demands, radical technological shifts, and the inadequacies of resource allocation and time constraints (Apker, Ford, & Fox, 2003; Bower, 2000; Cherry & Jacob, 2005; Diers, 2004).  The one constant in the history of the nursing profession has been the consistent presence of these challenging and often conflicting forces.  They have not diminished and will remain constituents of nursing practice for the foreseeable future.  Individuals not prepared to confront and embrace these realities need not seek entry here.  Those who do become members of the nursing profession will find that their being available to these prevailing conditions and circumstances will yield to them levels of challenge, satisfaction, accomplishment, meaning, and value not as readily available to other pursuits (Katz, 2003).

 

The Patient and Community

 

There is perhaps no greater arena of change and transformation for the nursing profession than that related to direct patient care.  The shift in therapeutics and technology has created a contextual framework for practice that is so unique and different that it represents a radical alteration from the historic and traditional practices associated with nursing.  Innovations (some of them destructive technologies) in chemo-therapeutics, pharma-therapeutics, digital diagnostics and intervention, nanotechnology, and virtual reality have completely altered the clinical landscape and the patient’s experience (Schermer, 2002; Shi & Singh, 2004).  This shift has done more than simply change the conditions of healthcare work and the processes and activities associated with it.  What has occurred as a result of these changes is a complete paradigm shift for both provider and patient.  In fact, the shift has been so transformative that practices, roles, and behaviors have been dramatically altered.  Indeed, even the locus of control for decision-making has inexorably shifted from provider to “user” (Frampton, Gilpin, & Charmel, 2003).  The notion of “user” replacing the concept of “patient” indicates a significant shift in ownership, obligation, and locus of control for decision-making and for direction in the individual’s healthcare experience.

 

Notions related to consumer-driven healthcare, electronic medical record, pay for performance, universal access, patient safety, evidence-based clinical outcomes and a host of other contemporary initiatives are redefining the relationship between system, provider, and user (Siegler, Mirafzali, & Foust, 2003; Thielst, 2007).  Systematically affecting the nature of this interaction is the clinical and therapeutic shift from residency-based, long term, institutional, and patient-passive care (Maysys, 2002; McKenna, 2002; Stock, 2002).  Today the majority of therapeutic services are short-term, minimally invasive, early recovery, and mobility-facilitating experiences.  Users now spend less time inside the institution or the system with regard to their healing and therapeutic processes and more time recovering and healing in the context of their own lives and personal circumstances (Schappert & National Center for Health Statistics (U.S.), 2002).  Increasingly, the issue for the user is not so much the interruptive conditions and circumstances of the institution and health service setting, but more, what resources patients have to facilitate the healing experience in their own circumstances (Schermer, 2002).

 

It is the end of space and time as a major resource consideration for service provision (Alakeson, 2003; Carlson, 1994; Hildreth & Kimble, 2004; Lucas, 1995; Willmore, 2003).  Nurses simply do not have the same time content and conditions in the digital, virtual, portable, and mobility-based clinical environment.  Currently and for the foreseeable future, users will spend a shorter period of time in the intervention process where the majority of nurses have historically been located.  As the healthcare system continues to decentralize around more short-term, technology-driven, and minimally-invasive clinical services, more user access to information and support outside the clinical environment, at home, and in other settings will be required (Ball, 2000; Johnson, Kralwwski, Lemak, Cote, & Deane, 2002; Lumpkin & Richards, 2002).  Professional nurses will need to demonstrate their accommodation of this portability reality through reconfiguring practice activities, relocating to other points along the healthcare continuum, and to the use of increasingly technology-based and virtual strategies for the provision of nursing services (Cassey, 2007; McSherry, Simmons, & Abbott, 2002).

 

The principles of caring which underpin the very character of the profession clearly need to be reaffirmed and reconfigured in a way that represents inclusion of newer knowledge and technology in the expression of that care (Cassey, 2007).  Reconnecting with the fundamental obligation of the nurse to ensure the safety of the user will need to be reaffirmed in a much more fluid context.  Evidence of efficiency, effectiveness, and efficacy (E₃ ) must be present within the practice of each nurse and, furthermore, must give evidence of positive impact, outcome, and value to both user and system (Plost & Nelson, 2007).  In addition, continuity of care can no longer be attained or maintained simply through the action of the nurse and the communication across disciplines.  Continuity is now embedded in the human-technology infrastructure and the interface between practitioner, user, and technology and is essential to build and sustain an effective continuum of care (Gandhi, 2005).  The professional nurse’s commitment to the integration of human dynamics, technology, evidence, and user outcome now forms the core of the clinical priorities of nursing practice (McNamara, 2002; P. Smith, 2004).

 

It is the end of the medical model as it has been historically configured.  The multifocal nature of healthcare delivery and the complex intersection of roles, relationships, and practices have now overwhelmed the notion of a unilateral locus of control and compartmental decision-making (Thomson, 2007).  It is no secret that the physician is not prepared by role or by disposition to the presence, time, and intensity of activities necessary to the investment required to coordinate, integrate, and facilitate the continuum of interdisciplinary activities necessary to effective patient care (Moanojovich, 2005).  The role of the physician is primarily as interventionist, as clearly delineated both by preparation and performance.  Certainly, new definitions and scripts for the role of the physician must also unfold in this new age for healthcare.  More delineations of the role need yet to be defined in relationship to equilateral clinical partnerships, inclusionary decision-making, and the leadership role of other clinicians in guiding the therapeutic team and clinical activities at different points across the continuum of service (A. Smith, 2004).  All of this will directly impact the role of nursing professionals.

 

Nurses will continue to be the central focal point in the integration, coordination, and facilitation of clinical relationships and processes across the continuum of care (Barnum, 1994; Tim Porter-O’Grady, 2003).  In accessing these resources, coordinating their activities, facilitating the team’s dynamics, and evaluating the effectiveness and impact of the interaction, nurses will play an accelerating pivotal role.  This will require from the nurse a degree of facility in articulating multiple roles, bridging the activities of other professionals, managing the integration of communication and documentation technology, and ultimately, evaluating impact and effectiveness.  Failure to adequately address this critical emphasis on the evolving role of the nurse will ultimately diminish the value of that role and increase the requisite of the assumption of that role by another (or new) player in the healthcare system.  Indeed, this role is becoming so important to the effectiveness of the system that many of the contemporary failures in the clinical continuum of services can be related to the paucity of coordination, integration, and facilitation of the process (Mittelstaedt, 2005).

 

Emphasis on the evolution and transformation of nursing practice and practitioner will need to include focus on the following priorities:

 

1.      Clinical leadership development which leads to leadership roles exemplifying the capacity to incorporate the above circumstances and skills into nursing practice roles and to reflect their exercise in the normative course of rendering care.  Clinical leaders, advanced practice nurses and others which represent the evolution to advanced or expert practice must not only be able to articulate these shifting role characteristics but to exemplify them within the character and content of their own practice.  Leadership in this age increasingly will mean modeling, demonstration, and actualizing the principles, character, and content of these shifting professional practice roles.

2.      Evidence-driven practice approaches represent an entirely different foundation for provider practices and healthcare delivery.  Evidence is not the domain of any single discipline and cannot be successfully undertaken within their unilateral contextual framework.  Evidence-based practice is fundamentally interdisciplinary, requiring the interface of all relevant clinical providers and activities.  It is the congruence and consonance as well as the fusion among the activities of these various stakeholders that, when synthesized, presents evidence of excellence and best practices.  It is in the nurse’s role where these activities converge, and is therefore appropriate to manage and coordinate the processes associated with a sound evidence-based approach in any clinical setting.

3.      Professional nursing practice operates on a continuum of knowledge and practice.  Delineating differentiation in practice and clinical expectations continues to be an important mechanism for distinguishing performance, clarifying expectations, and measuring clinical outcomes.  Clinical advancement programs which differentiate and articulate various categories of practice expectation moving from novice and advancing along stages of enumerated expertise remains the best mechanism for ensuring accountability and establishing the relationship between competence and performance.  While competence, action, and performance expectations are being transformed in this new age for practice, the requisites for delineating outcomes aligned with competence and the maturity of knowledge remains essential to good practice.

4.      Within the context of an advancing socio-technical reality, users are now able to more fully participate in accessing, interpreting, using, and evaluating clinical options in relationship to their health and life choices.  This primary source of access changes the equation of knowledge management and the locus of control between provider and user.  No longer is the user held hostage to the knowledge capacity of the provider without access to resources not controlled by providers.  In addition, provider performance measures, grades, evaluations and interpretations are becoming increasingly refined and useful tools for users to make decisions with regard to provider choices.  For the nurse, this calls for a growing awareness of the nurse’s role in mediating between the various access points, informational constituencies, providers, in a way that affects the accuracy and adequacy of the resources and tools available to the user.  Increasing capability with regard to this role is critical to the nurse’s effective exercise of it and demands from the nurse a level of engagement and capacity to guide user’s access, utility, interpretation, and evaluation of important clinical data in a way that is both meaningful and liable to the user.

9.      In the United States, changing data and demographic realities related to citizens health strongly indicate that for all our interventional science, technology, talent, and applications, the health of the nation is not comparable with other first world nations in almost all the measures of the status of societal health save one, the cost of health care.  When compared with other first world nations, American health indicators generally place the nation in the bottom categories of measure.  One of the ethical characteristics of professions is that they operate in a way that acts in the best interests of a larger community.  If the health of America is to be advanced and the quality of life improved, the commitment of every nursing professional must be broader than the personal quality of good patient care and clinical excellence.  The outcome of the work of the profession should ultimately be an improvement in the health of the larger community.  Nursing certainly plays a major role in addressing national, regional, and local health needs.  Just as clearly in the language and armamentarium of every individual nurse is a requirement that she or he be able to identify work and role with the advancement of health and the improvement of the quality of life in the greater community.  Individual and local practices must be clearly linked with the broader script for healthcare and a direct relationship established between the practices of the individual and the health status of the community.  It is only when this connection is well established will the true value of nursing advocacy be evidenced, not as an exception to the normative work of daily practice, but as evidence of the impact of the work of each practicing nurse on the health status and quality of life of the community and, ultimately, of the nation.

 

Nurses continually articulate the commitment of the profession and its practitioners to the needs and interests of the patients in the communities nurses serve.  If this is not to remain simply a vacuous statement, empty of evidence, it must be translated into a living presence and verified by a clearly articulated and discernible impact on person and community (McNamara, 2002).  As a nation and a profession we are awash in data which suggests where we are in relationship to the actualization of quality of care in the health status of the American people (Mazurek, Melnyk, & Fineout-Overholt, 2004).  By all measures of comparison on the global stage, with nations comparable to the American standard of living, we simply do not meet the outcomes of the promises we make.  From measures of access, quality, safety, clinical outcome, satisfaction, and cost-benefit, the United States simply does not favorably compare with our international partners (Commonwealth Fund, 2007). 

 

The truth of this data calls the profession of nursing to reassess its role and function in relationship to users of the healthcare system and nursing services and to reconfigure the professional script in a way that joins with others in, at a minimum, achieving parity with our international partners and, if possible, establishing a new standard of excellence and quality of life (Fottler, Ford, & Heaton, 2002).  If nursing is to fulfill its professional mandate to act in the best interests of the society it serves, the formation of this new script and the performance against its requisites is not an option (Parker, 2005).  It is a new age for health care and for the nursing profession.  It is early in its formation.  The opportunity to write the new script and the transformative impact of living it presents an exceptional potential and opportunity for improving health and advancing the quality of human life.  Will we do this work?  Urgency is critical; time is of the essence.

 

 

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McNamara, O. (2002). Becoming an evidence-based practitioner: a framework for teacher-researchers. London; New York: Routledge/Falmer.

McSherry, R., Simmons, M., & Abbott, P. (2002). Evidence-informed nursing: a guide for clinical nurses. New York: Routledge.

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*Based on discussions of: Global Nursing Exchange Leadership Discussion Group

 

Rhonda Anderson, PhD

Carol Bradley, MSN

Barbara Brewer, PhD

Vicki Buchda, MS

Jayne Felgen, MSN

Elaine Goehner, PhD

Ann Kobs, MS

Terry Pickering, BS

Tim Porter-O’Grady, DM, EdD

Marilyn Rantz, PhD

Catherin Robinson-Walker, MBA

Pamela Thompson, MSN

Beth Ulrich, EdD

 

It’s here. The new “Interdisciplinary Shared Governance” text from Jones and Bartlett is now available for sale at their website and can also be found for purchase on Amazon.com. The new text has been completely edited and reconfigured for contemporary healthcare and serves as a useful tool for those who have developed nursing shared governance approaches and are now ready for the next step of interdisciplinary integration.

 

The move from concepts of whole systems shared governance to more specific interdisciplinary shared governance was driven by the desire to help disciplinary leadership more easily navigate contemporary quantum thinking on leadership and relationships and build the necessary infrastructure to support it. There is more interest in the intersection and relationships between the disciplines driven by such concepts as evidence-based practice, clinical networks, continuum of care, and clinical service delivery seen as a system. These and other contemporary challenges to traditional organizational structure now require a complete rethinking of the systems, structures, and relationships in health care organizations and agencies necessary to support contemporary practice.

 

Shared governance in nursing has not only stood the test of time but has proven to be a necessary element of the exemplars of excellence in any clinical organization. Recognizing nursing as a profession and structuring it in a way that assures it operates as a profession has been an essential foundation in establishing professional governance with a profession which serves at the center of healthcare delivery. The requisite role of coordinating, integrating, and facilitating the work of patient care in a variety of settings over 24 hours 7 days a week 365 days a year serves as a central operating framework for the professional practice of nursing. Indeed, nurses manage the continuum of the patient’s experience and all the relationships necessary to assure a positive and effective patient experience at any point along the clinical continuum. In fact, failure to do so creates impediments to flow and clinical integrity serious enough to negatively affect efficacy and excellence with regard to the patient experience. Having made the point clearly and demonstrating the centrality of nursing’s role in a number of different research efforts, it is now time to move that coordinating and integrating role to embrace and engaged relationship with key partners in other disciplines and functions in the healthcare organization. Indeed, it is appropriate to completely rethink these relationships and structure the organization in a way that reflects an infrastructure essential to the support of equity-based and parallel professional clinical functions.

 

The organization of the new text helps flow through the elements of understanding related to building an entirely different infrastructure reflecting new thinking about complex adaptive systems and the relational networks essential to address the multiple vagaries of affective relationships intersecting around good patient care. The book moves from establishing the foundations of quantum thinking and complex adaptive processes into a rationale supporting interdisciplinary shared governance as a tool for integrating professional practice. The foundations necessary to transform the organization and to think differently about the patient experience in the continuum of care drive the reader to consider new constructs and models for integrating care delivery in building an effective service continuum. While it is appropriate here to suggest that the model simply serves as a foundation for refining and building new approaches to interdisciplinary decision-making and structuring, it does challenge existing infrastructure and calls for significant change. Chapters 5 through 10 focus specifically on the structural and infrastructure elements essential for redefining the healthcare organization, decision-making, infrastructure, governance, and the integrated roles of the professionals in moving clinical practice into an evidence-based information governed clinical context. For the first time in healthcare, an entirely new premise is established for the future of professional relationships, governance, and interaction that recognizes the components and characteristics of 21st century thinking and calls leaders in each healthcare discipline to an interdisciplinary table to work out the structures and relationships necessary to sustain clinical effectiveness in a new world of practice.

 

It cannot be overstated that the rules governing relationship, practice, and effective delivery of service are fundamentally different from those established in the industrial age. Traditional and industrial views of organization, relationship, and function are not so much incorrect as inadequate to the demands of the time. Current healthcare structures no longer reflect the realities within which systems and people live. It’s time now for discipline leaders to come to the interdisciplinary table to reconceptualize roles, relationships, and structures that better defined the essential elements of the relevant clinical environment supporting essential decision-making and action. No one discipline can decide for itself ever again what it will be or do out of context of its relationship with those upon whom it has an impact and those who impact it. Reconceptualizing and reconfiguring organizational structure, interdisciplinary interaction, decision-making, and evidence-based practice are now central requisites in assuring a more effective and sustainable healthcare system. This new text on interdisciplinary shared governance will serve as an essential foundation for undertaking this dialogue and building new models of interdisciplinary practice that can advance health care in the 21st century in a way that assures more effective and sustainable healthcare outcomes.

 

And if you are ready for the next step into interdisciplinary shared governance and need support please contact our administrator at mark@tpogassociates.com and we’ll connect with you ASAP.-Dr. Tim