@helenbevan the art and science of nursing and midwifery: how to rock the boat and stay in it helen...

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The art and science of nursing and midwifery:

How to rock the boat and stay in it

Helen BevanDelivery teamNHS Improving Quality@helenbevan@NHSIQ

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The art and science of midwifery

As nurses and midwives we have two jobs:1.To deliver safe effective care

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The art and science of midwifery

As nurses and midwives we have two jobs:1.To deliver safe effective care 2.To continuously improve our services

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What happens to heretics/radicals/rebels/mavericks

in organisations?

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Are you a boat rocker?• One who challenges the

status quo when they see that there could be a better way

• Capable of working with others to create success NOT a destructive troublemaker

• Walk the fine line between difference and fit, inside and outside, rock the boat but manage to stay in it

Source: adapted from Debra E Meyerson

@helenbevan #IQTGOLD Source : Lois Kelly www.foghound.com

Sometimes leaders see radicals as troublemakers

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Task

• Talk to others around you about your experiences around “rebels” and “troublemakers”

• Which have you been and why?• What moves people from being “good” to

“bad”?• How do we protect against this?

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First they ignore you, then they laugh at you, then they fight you, then you win

Gandhi

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Valuing radicals

• “New truths begin as heresies” (Huxley, defending Darwin’s theory of natural selection)

• big things only happen in organisations because of heretics and radicals

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Four tactics for change agents

1. Start with myself2. Build alliances3. Work out what might help others to

change4. Don't be a martyr

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"There’s only one corner of the universe you can be certain of

improving, and that’s your own self." Aldous Huxley

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What are the risks for a boat rocker?

1. Our experiences of “being different” can be fundamentally disempowering. This can lead us to conform because we see no other choice

Source: adapted from Debra E Meyerson

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What are the risks for a boat rocker?

1. Our experiences of “being different” can be fundamentally disempowering. This can lead us to conform because we see no other choice we surrender a part of ourselves, and silence

our commitment, in order to survive

Source: adapted from Debra E Meyerson

@helenbevan Source: Foghound

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What are the risks for a boat rocker?

1. Our experiences of “being different” can be fundamentally disempowering. This can lead us to conform because we see no other choice we surrender a part of ourselves, and silence

our commitment, in order to survive2. leave the organisation

Source: adapted from Debra E Meyerson

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What are the risks for a boat rocker?

1. Our experiences of “being different” can be fundamentally disempowering. This can lead us to conform because we see no other choice we surrender a part of ourselves, and silence

our commitment, in order to survive2. leave the organisation

we cannot find a way to be true to our values and commitments and still survive

Source: adapted from Debra E Meyerson

@helenbevan

What are the risks for a boat rocker?

1. Our experiences of “being different” can be fundamentally disempowering. This can lead us to conform because we see no other choice we surrender a part of ourselves, and silence

our commitment, in order to survive2. leave the organisation

we cannot find a way to be true to our values and commitments and still survive

3. stridently challenge the status quo in a manner which is increasingly radical and self-defeating

Source: adapted from Debra E Meyerson

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What are the risks for a boat rocker?

1. Our experiences of “being different” can be fundamentally disempowering. This can lead us to conform because we see no other choice we surrender a part of ourselves, and silence

our commitment, in order to survive2. leave the organisation

we cannot find a way to be true to our values and commitments and still survive

3. stridently challenge the status quo in a manner which is increasingly radical and self-defeating this just confirms what we already know – that

we don’t belongSource: adapted from Debra E Meyerson

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1. convictions and values – driven2. strong sense of “self-efficacy”

belief that I am personally able to create change belief in others

3. action orientated ignite collective action mobilising others, inspiring change

4. able to join forces with others work as a collective body for commonly valued changes

5. able to achieve small wins which create a sense of hope, self-efficacy and confidence

6. optimistic in the face of challenge see opportunities take account of obstacles

What do we know about successful boat rockers?

Source: adapted from Debra E Meyerson

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Four tactics for change agents

1. Start with myself2. Build alliances3. Work out what might help others to

change4. Don't be a martyr

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“if you want to go fast, go alone. If you want to go far, go together”African proverb quoted by Al Gore

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Four tactics for change agents

1. Start with myself2. Build alliances3. Work out what might help others to

change4. Don't be a martyr

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“Stages of change” Transtheoretical model of behaviour change

Prochaska, DiClemente & Norcross (1992)

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The model is mostly used around health-related behaviours

• smoking cessation • exercise adoption• alcohol and drug use• weight control • fruit and vegetable intake• domestic violence• HIV prevention• use of sunscreens to prevent skin cancer • medication compliance • mammography screening

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The model is mostly used around health-related behaviours

• smoking cessation • exercise adoption• alcohol and drug use• weight control • fruit and vegetable intake• domestic violence• HIV prevention• use of sunscreens to prevent skin cancer • medication compliance • mammography screening

It works for organisational and

service change too!

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“Stages of change” Smoking

Prochaska, DiClemente & Norcross (1992)

I am not aware my smoking is a

problem – I have no intention to quit

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“Stages of change” Smoking

Prochaska, DiClemente & Norcross (1992)

I am not aware my smoking is a

problem – I have no intention to quit

I know my smoking is a problem – I

want to stop but no plans yet

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“Stages of change” Smoking

Prochaska, DiClemente & Norcross (1992)

I am not aware my smoking is a

problem – I have no intention to quit

I know my smoking is a problem – I

want to stop but no plans yet

I am making plans & changing things

I do in preparation.

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“Stages of change” Smoking

Prochaska, DiClemente & Norcross (1992)

I am not aware my smoking is a

problem – I have no intention to quit

I know my smoking is a problem – I

want to stop but no plans yet

I am making plans & changing things

I do in preparation.

I have stopped

smoking!

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“Stages of change” Smoking

Prochaska, DiClemente & Norcross (1992)

I am not aware my smoking is a

problem – I have no intention to quit

I know my smoking is a problem – I

want to stop but no plans yet

I am making plans & changing things

I do in preparation.

I have stopped

smoking!

I am continuing to not smoke.

I sometimes miss it – but I am still not

smoking

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“Stages of change” Smoking

Prochaska, DiClemente & Norcross (1992)

I am not aware my smoking is a

problem – I have no intention to quit

I know my smoking is a problem – I

want to stop but no plans yet

I am making plans & changing things

I do in preparation.

I have stopped

smoking!

I am continuing to not smoke.

I sometimes miss it – but I am still not

smoking

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“Stages of change” Transtheoretical model of behaviour change

Prochaska, DiClemente & Norcross (1992)

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90% of our change efforts are aimed at the “action” stage

• Our tools are often not effective at the stage of change that most people we work with are at

• It’s hard to engage people in change• It’s hard to get people to make the changes

we want them to make• People get irritated, defensive, irrational• We feel powerless in our ability to make the

change happen

@helenbevan #IQTGOLD

Example - Surgical Checklist

• Designed for Stage 4 – ACTION!

• Mandated it through targets

• Despite compelling case for change – people resisted it – no values connection

• People did the task and missed the point

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“One key issue is that many doctors already feel that they are delivering patient centred care – unfortunately that is not what patients report.”Dr Nigel Mathers, Vice Chair, Royal College of General Practice

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So what do we TEND to do?• Lower our ambitions for improvement• Put negative labels on those who are not

yet at the action stage such as “blocker” or “resister” or “laggard”

• Blame “the management” for not enforcing change

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So what SHOULD we do

• Listen and understand• appreciate others’ starting point for change

• Build meaning and conviction in the change• Roll with resistance (Singh) • Don’t argue against it• Understand why people are resisting the change• What makes it so hard?• What would help?

• Build shared purpose

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....the last era of management was about how much performance we could extract from people .....the next is all about how much humanity we can inspireDov Seidman