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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
@helenbevan
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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@helenbevan
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
@helenbevan Source: Foghound
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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
@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 survive
Source: adapted from Debra E Meyerson
@helenbevan Source: Foghound
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@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
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
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
@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 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
@helenbevan
Four tactics for change agents
1. Start with myself2. Build alliances3. Work out what might help others to
change4. Don't be a martyr
@helenbevan
“if you want to go fast, go alone. If you want to go far, go together”African proverb quoted by Al Gore
@helenbevan
@helenbevan
Four tactics for change agents
1. Start with myself2. Build alliances3. Work out what might help others to
change4. Don't be a martyr
@helenbevan
@helenbevan
“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!
@helenbevan
“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
@helenbevan
“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.
@helenbevan
“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!
@helenbevan
“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
@helenbevan
“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
@helenbevan
“Stages of change” Transtheoretical model of behaviour change
Prochaska, DiClemente & Norcross (1992)
@helenbevan
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