July 8, 2020

Sensitivity to Complexity: Key to Leadership in Nursing

In my previous post, while discussing the structure of community, I mentioned the complexity of communities. I noted that the interconnections and interactions between the elements of a complex community cannot be fully accounted for, in part, because of their sheer number. This means that as we attempt to understand the prospect of communal meaning making in nursing communities, we must consider the very real possibility, the practical certainty, that the meanings we make are only partial at best. How can we overcome this limitation?

The structure of a community is something of a black box. It cannot be known exhaustively.  Instead, each member of the community sees the whole from a particular perspective.  For example, the shift-to-shift transfer of care between staff on an inpatient nursing unit imparts to each bedside staff member a partial view of the unit census, and each staff member’s assigned patients are known more fully by that person than those on which he or she has not received report.  Nevertheless, many units have in place specific mechanisms to supplement staff knowledge, including a pre-shift huddle.

Perhaps the most important mechanism nursing units utilize to maintain quality patient care and communication between healthcare professionals is the charge nurse role.  There is continuity between charge nurses at the unit census level that is analogous to the bedside staff level.  However, the charge nurse “complexifies” the nursing unit by virtue of being a human meaning maker in a relationship with each bedside nurse that is different from any relationship between bedside staff.

Within the shift-level community, the charge nurse serves as an aggregator of input from outside the unit as well as a connector between bedside staff, helping to stabilize the unit by performing tasks that support bedside staff and ensure ongoing unit functions.  Some of the best shift experiences I have had or observed have involved proactive charge nurses who anticipated staff and patient needs and stepped in to help when real-time resources were low.  In some cases, they helped with an untimely admission, handled a conflict between a nurse and a patient or between staff, or simply restocked frequently used supplies.  They have also provided technical guidance and education to strengthen future quality of care.

On the other hand, difficulties arise when the aggregator and connector fails to anticipate resource shortfalls or respond appropriately.  For example, a charge nurse who remains aloof from impending conflict may set bedside staff up for unsafe interaction with a patient, which in extreme cases may culminate in personal injury or the need for assistance from hospital security.  A charge nurse who neglects or omits unit-supporting activities such as instrument calibration or supply verification may open the door to failure to provide high quality care in critical situations.  When important details are omitted from a charge report, the oncoming charge nurse is rendered less prepared to navigate potential difficulties.

There is a difference between proactive and reactive behavior, and there are appropriate circumstances for each.  The former involves anticipation, adaptability, the ability to adopt multiple perspectives, and a tendency to “get out in front” of issues before they arise or become unmanageable.  On the other hand, reactive behavior involves lack of timely responsiveness to trends, impaired awareness of the adequacy of resources, and the forfeiture of initiative.  Because the elements of knowledge and initiative are crucial to this distinction, it is clear that one must be alert to which circumstances call for proactivity and which call for reactivity.

Leadership is required to distinguish between the proactive and the reactive through the maintenance and management of priorities.  However, leadership aspects of the charge nurse role are reflected at other levels of the nursing organization, from the bedside nursing and technician staff level up to the executive level.  All healthcare staff are leaders in some way.  Beyond that acknowledgment, what leadership qualities contribute to the maintenance and management of priorities?

There are certainly many possibilities, but one I have in mind while writing this is what I call sensitivity to complexity.  Sensitivity to complexity incorporates an awareness of the myriad relationships that exist in a complex system and of how one is situated within that system.  It may involve the abilities to adopt alternate perspectives and to evaluate possible interpretations of information as well as the humility to understand that one’s influence on the system may in fact be quite limited.  The complexity-sensitive leader does not seek to bring about utter change across the system with each action.  Instead, he or she seeks to contribute to the overall current and future integrity of the system by maximizing the benefit of each action.

It is easy to see that sensitivity to complexity is a desirable trait for nursing staff.  It allows staff to escape the trap of uncritical action.  Fidelity and consistency in protocol execution and policy adherence are the lifeblood of contemporary healthcare organizations.  However, protocols and policies alone are not enough to guide all aspects of practice, particularly those that require what is typically referred to as nursing judgment.

Sensitivity to complexity also offers an escape from the trap of time management.  Despite the widespread use of the phrase, the primacy of time management in nursing is debatable.  After all, one can efficiently perform a selection of nursing tasks in terms of the time required yet utterly fail to perform the tasks appropriate to the most reasonable hierarchy of priorities or to perform them under the appropriate circumstances.

Of course, there are many different issues to discuss here.  What leadership attributes do you find contribute to the maintenance and management of priorities?

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