Nursing in Africa

In large parts of Africa, decades of war, conflict and instability have left its people with limited access to basic healthcare services. This is aggravated by the fact that the continent carries 25% of the global disease burden and the lowest number of global healthcare worker per capita.
The challenges that impact healthcare service delivery in Africa include (but are obviously not limited to) lacking infrastructure, poor management, lacking equipment, variable care standards and supply chain issues. In 2001, in an attempt to address some of these challenges, the countries belonging to the African Union (AU) committed to allocate 15% of their fiscal budget to healthcare (Abuja declaration 2001). Sadly only six countries succeeded in doing that. It is estimated that even if all of the AU countries allocated 15%, the size of their budgets are simply not enough to address and overcome some of the challenges that face healthcare systems in Africa.
The budget size and lack of allocation or investment in healthcare leads to another problem: dependency on donor funding. Unfortunately donor funding comes with vested interests and may inadvertently contribute to the vertical development of disease specific fields at the expense of horizontal or strengthening of the whole health system. A good example of this is HIV research that across the continent is disproportionately represented and funded.
Because the burden of disease and the demand for healthcare services that’s continuously rising, larger budgets and more healthcare workers are required. Alarmingly statistics demonstrates that in some African countries there has been a decline in the number of healthcare workers over the past twenty years. In addition, there is a known distribution of healthcare workers towards urban areas, leaving rural areas without adequate healthcare delivery structures and staffing.
In most of Africa, the first healthcare worker to provide care to a patient is a nurse (WHO2008). With nurses being the mostly widely spread and available health professionals on the continent, their role cannot be overestimated. Creating more enabling environments for nurses to be educated and work in better conditions should be prioritized. A few issues that seem to be universal to the ability of nurses to perform in Africa are highlighted below. These issues draw on my experience and my conversations with local nurses in the settings in which I’ve worked.
Quality and appropriateness of nurse training
Formal nursing education was brought to Africa by imperialism. This implies that the people who brought formal nursing education to Africa introduced it in a similar way to how it was done in the countries that they came from. Most of these models were (and still are) based on training nurses in-hospital and where one of the primary roles of the nurse is as team member with a medical doctor and others. This is very different from community based care that’s prevalent and required in rural Africa. In most of Africa, the nurse is often a solo practitioner that’s far from hospitals and other team members. The training of the nurses should prepare them for such roles and situations.
Clinical and educational gaps can be identified by furthering research, especially nursing science research in Africa. This then allows the design of curriculum’s that are contextually relevant to the needs of the continent. This is, however, complicated by other issues, namely:

Limited research on indigenous diseases in Africa
Most of the infectious diseases that are endemic to Africa such as schistosomiasis or trypanosomiasis are not well-researched. With limited evidence based guidance, there can be no best nursing practice for these endemic diseases.
The fields that are researched are according to donor specialization and interest. Sun and Larson (2015) did a review of all nursing research from Africa that was published over a decade and found that the most studied areas were associated with funding resources. They also found that prevalent conditions in Africa e.g. malnutrition, diarrhoea disease and other common causes of death were not studied and/or published. This demonstrated a clear gap between the healthcare needs and the fields researched.
Nursing research needs to focus and address the glaring healthcare issues in Africa. Often care in villages is rendered by persons with no training in healthcare, and addressing issues like the need for reliable community based care when developing curriculums or conducting research could impact the health systems tremendously.

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Training facilities
Training facilities across Africa lack enough classrooms, electricity, running tap water and technological advances. Internet has been reported as a scarce resource across various training settings in Africa. The access to electronic resources is limiting for both students and educators. Open-access resources have helped to make science more accessible globally, but there is still a high cost to obtaining research and information making it incredibly tough to stay abreast of new guidelines, especially for nurses in Africa.
Clinical guidance in hospitals is lacking and there are limited simulation models at training facilities. At some of the facilities where I’ve conducted training there have been no CPR manikin’s or other additional models for training. In most places we had to innovate and make our own manikins and other adjuncts.
For healthcare workers in rural areas, obtaining further education or refresher training means uprooting and even leaving a healthcare facility unattended for the duration of their training. This should be considered when we think about educating and upskilling nurses.
Knock-on impact of the doctor shortage in Africa
The lack of doctors, especially in rural areas has resulted in task shifting. Task shifting occurs when tasks that would normally be seen as the doctors’ domain, are shifted to nurses. It increases the nurses’ workload and the nurses are expected to perform tasks that they have not received training for.
The distribution of health facilities and different tiers of care means that the large drainage areas in the rural districts are often manned by nurses without any further medical support close by. This means that the nurses working in rural areas are isolated when dealing with cases that are not within their scope of practice, limited clinical guidelines and difficulty in obtaining help. Telemedicine and technology may offer some solutions provided that it can be reliable in areas with limited electricity, currently no internet etc.

Regulatory issues
In many African countries, graduates are not subject to registration with a statutory body. There may be professional associations, but there is no compulsory registration process and professional licensing. In countries with no regulatory body, there is no representation to lobby for nursing rights or amendments to Acts of Parliament, salaries for nurses or to promote career progression.
Often healthcare worker salaries (including doctors) are not paid on time, if at all. This leads to some healthcare workers having secondary streams of income or funding their own incomes out of privately charging patients’ higher fees.
Gender inequality
In most African societies, gender equality has not yet been achieved. Women receive less education than men, they have less rights and their voice are not heard in the same way. Nursing remains a predominantly female profession and this limits the ability of nurses to assert themselves and it impacts on the ability of the profession to influence national policy.
There is a trend where even though the nurse workforce is mainly female at service delivery level, at top management and policy level it’s represented by men. In the DRC it was established that only 1% of the nurses are male, yet more than 90% of the top levels and education facilities positions are filled by men.
The social determinants allowing people to access healthcare includes basic primary education and gender equity amongst other factors. Sadly neither one of these has been achieved for nurses in Africa and it hampers the progress of nursing education and research across the continent.
Career progression
This tie in with the above, and the fact that because of the role of women in society, nurses being mostly female and the difficulties faced by nurses to render care, career progression may be stunted. Because healthcare workers in rural areas need to travel to further education and because nurses are predominantly women, it is hard for them to leave home and obligations at home to further their career.
Lack of mentorship and language barriers
There is a lack of mentorship to help nurses further themselves as researchers and educators. Organizations such as the AFEM Nurses Group developed a mentorship program with international mentorship support to African nurses. Another program is the Nursing Education Partnership Initiative (NEPI) that was formed in 2011 by PEPFAR to improve nursing and midwifery education in Africa. We need more programs like this.
Mentorship, inclusion into global healthcare networks, research and education are complicated by language barriers. Often nurses working in rural areas do not read or speak English; the language which much of the training material and research is presented in.
Conflict
It has been postulated that there’s a statistically significant relationship between accessibility to care and civil conflict (Rhode 2015). Unrest and conflict creates havoc on the ability to deliver healthcare, train providers, obtain supplies and in violent prone areas access may be restricted as patients are afraid of travelling. During periods of increased violence, the healthcare facilities are looted and healthcare workers intimidated. In violent prone areas, malnutrition is aggravated, harvests are regularly pillaged and access to fields is restricted due to security conditions.
Conclusion
There are various challenges to improving the fragile healthcare systems in Africa. Nurses form the backbone of healthcare service delivery in Africa. The difficulties faced by nurses across the continent are only one challenge; improving dilapidated health facilities and improving on the poor distribution of essential medicines and supplies are other challenges.
In order to improve healthcare systems, nurses needs to be more involved in policy-making, developing healthcare plans and research.

Please note: Africa is not a country and in some of the African countries, the health system is well-established and working. In other’s it’s not going that well. I’m aware that this blog makes blanket statements, however it refers to my experiences and conversations in the country’s that I have travelled to.

References
Munjana OK, Kibuka S, Dovlo D. (2005) The nursing workforce in Sub-Saharan Africa. Issue paper no 7. International Council of Nurses.
Sun C. Larson E. (2015) Clinical nursing and midwifery research in African countries: a scoping review. International Journal of Nursing Studies. 2015 May;52(5):1011-6. doi:10.1016/j.ijnurstu.2015.01.012.
http://www.our-africa.org/women
http://www.who.int/healthsystems/publications/abuja_declaration/en/
Rohde JT. (2015). The relationship between Access to Healthcare and Civil conflict. College of William and Mary. Honors Theses. Paper 99
Abuja Declaration 2001
Klopper HK, Uys LR. 2012. State of Nursing and Nursing Education in Africa: a country by country review. Sigma Theta Tau international
The nursing Education Partnership Initiative in the Democratic Republic of Congo. (2012). Assessment of nursing and midwifery education and training capacity at seven training institutes in the DRC. Synthesis report. Prepared by CapacityPlus, Intrahealth International

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On ‘death and dying’ and organisational change

‘Buy-in’ is a term commonly used when talking about change in the workplace. We want everyone to buy in to the change.  Often, supervisors and managers appear completely perplexed when people do not simply buy in or change their ways when told to.  Numerous books have spoken about ‘managing change’ and ‘obtaining (the elusive) buy-in’.

The lean methodology addresses some crucial aspects of ‘obtaining buy-in’,  including involving the people performing the task in the change process, empowering people to experiment with new ways, and coaching employees in problem-solving techniques.

There is a significant human factor that, if ignored, hampers sustainability of change: emotions.  In the work environment, where change is underway, these are labelled different names such as resistance, anger, or passive aggressiveness.  In this blog we will call this emotion grief.

We become emotionally attached to our routines, and our way of doing things.  And even though we might logically know that it’s not the best way to perform a task, we experience a feeling of safety and a sense of belonging within our routines.

In organisations with strict hierarchies and bureaucracies with red tape such as hospitals, those that have been around for a long time find and establish the loop holes which enable workers to get the job done based on longstanding networks and local knowledge.  Long-serving staff may view a suggested change to the way they do a well-established process as a threat. Exposing the loop holes can lead to feelings of vulnerability, frustration and anxiety about getting into trouble with management; especially within the ‘blame culture’ typically found in these bureaucracies.

Elizabeth Kubler-Ross, a psychiatrist who studied near-death situations and the emotions involved,   identified five stages of grief as a pattern of adjustment: denial, anger, bargaining, depression, and acceptance.  Each person will pass through these stages at their own rate and in their own way.  The task of a grief counsellor is to provide support during these phases.

A criticism of the model is that Kubler-Ross did not adequately take into consideration the role that the personal environment plays.  Certain environments make grieving easier.  And not everyone experiences grief in the same way, as some people are more resilient and adapt with little grieving.   Charles Corr, a social psychologist and a critic of Kubler-Ross’s work stated that grief and resilience are influenced by patient empowerment.  The more empowered the patient, the faster and better they adapt to the end of life situation. He highlighted two important aspects from Kubler-Ross’ work that I think are also true for organisational change: 1. that each person will react in their own way to the challenges that confront them, and 2. that one cannot become an effective supporter or carer unless one has learnt to actively listen to the person grieving.

How do we create an environment where employees feel empowered during the ‘death of the old ways’?  This question is particularly difficult to answer in the beginning of a lean journey, where management (and the organisation) are using traditional methods, the ‘blame culture’ is still firmly established and people have no success stories to demonstrate that the changes are in fact improvements.

I’d like to suggest though that we can better support employees during organisational transitions by preparing people for change, supporting their emotions during change and making it ok to grieve.

Grief is personal and subjective.  We can’t measure grief by comparing it to other people’s grief or phase of adjustment. We need to create an environment in which it’s safe to express emotions without judgement, where concerns are not simply dismissed, challenges ignored and what-if scenarios discarded. Emotions and feelings should not be denied when implementing change, otherwise staff will feel oppressed and devalued.

As such, I am making a case that the direct line manager is not the most appropriate person to provide emotional support during large-scale change initiatives.  The line manager is emotionally invested in the change and going through their own grief and adjustment, especially if they are confronted with challenging their beliefs on how to manage and problem-solve within their unit. They are grieving themselves.

So who should provide support then?  Could Human Resources become more involved? Is this perhaps a role for HR departments, with an understanding in lean thinking?  I’m not sure.  What I am sure of, though, is that whoever provides emotional support needs to be like a grief counsellor:  slightly removed from the actual incidence, with little emotional investment in the operational processes and ways.

Kubler-Ross: Phases of grief in organisations

Denial:  This is often expressed through statements such as, ‘We don’t have any problems in our department.’  or, ‘If only Department XYZ worked harder, faster or better, then our results would improve.’

Anger: In organisations this is expressed as passive-aggressive behaviour rather than actual aggressive outbursts.  If the not-so-obvious symptoms of this phase are not managed, the change will not be sustainable.  It’s important to support people through all the phases; however the anger phase is probably the hardest to diagnose as its symptoms may be subtle. Behaviour or symptoms of the phase include obstruction, lateral violence and bullying of others.  Other symptoms may include threatening to resign or requesting a move to another department.

Bargaining: If anger is the hardest phase to diagnose and support, then bargaining is the tipping point for change. The following remarks may be heard in this phase: ‘This is additional work, so I will make the change if you increase my salary’, ‘This is not in my job description so we need more time/resources/payment and then we will be able to follow through with this’ or ‘If this way doesn’t work, then I will leave and go work somewhere else’.  These employee responses should be carefully managed if the organisation would like to move past a point of consistent bargaining or negotiation towards sustainable change and behavioural acceptance.

Depression:  People might appear to be sulking, sullen and unhappy at work.  An important ‘sub-stage’ of depression is testing: testing the new ways and acknowledging that the new ways are not  all bad, but the employee is still not ready to openly accept it.  This is when people come to the realisation that perhaps it is not as bad as they thought.

Acceptance:  This is the‘buy-in’ you were hoping for from the start, or acceptance of the change.

Summary

Lean organisations should strive towards resilience, a state that is at the other end of the spectrum to grief, because people feel safe, supported and are able to adapt within their environment.  This desired state of resilience takes time to attain.

The phases of grieving must be diagnosed, addressed and managed.  If this is not done appropriately it will have long-term adverse effects, including bullying or consistent bargaining to perform tasks.

Until organisations reach the point of resilience, they need to plan emotional support into the improvement process.  This emotional support should not be seen as an extension of the direct line manager’s task.  Rather it should be outside of the functional unit. This is of the utmost importance in organisations starting a large-scale lean transformation.

grief

The stages

The key to sustainability…Habit

Workplace improvement and weight loss programs are similar.  Quick and magical fixes are popular and preferred over hard work with incremental results.  Quick wins are frequently followed by worse outputs, greater weight gain and despondency.  The market is insatiable and every few months there is a new fad.

Whatever the improvement is; whether it’s an organization, job process or a diet, the X-factor appears to be that it needs to become a way of life.  There is no magic formula…its creating new ways and consistently being aware of what needs to be done.

I would like to highlight three things that I’ve seen work in organizations and uhm weight loss…

Measurements

I used to go to a personal trainer that insisted on taking measurements at every session.  The measurements kept me on track….the dread of it going up was deterrent enough not to eat that chocolate or have another glass of wine.  Once I reached my target weight, I decided that I don’t need the measurements (or the trainer) anymore….and I’m sure that you can guess what happened!

In both personal and organizational life, there are so many priorities that unless we have constant reminders of what and how we are doing at them, we lose focus.  Measuring performance can direct focus.  There is no need to have numerous measurements telling the same story.  Less is more, keep it simple, and decide on the focus areas and then focus!  It demonstrates the priorities best if it’s made as visible as possible.

Some organizations view measures as static or passive.  A purpose of measures is actions.  As soon as things change, analysis and actions are required to bring it back on track.  If the measures are going in the right direction it also needs some analysis so that the progress can continue.

Collaborate

Meetings are a great way of ensuring collaboration and sustainability.  Timeless weight loss programmes such as Weighless have regular meetings to provide support, increase morale and motivate people.

Unfortunately meetings have a bad reputation in organizations.  It’s typically perceived as useless because of pointless conversations, limited decision making, and the complaints sessions or dominated by a few opinions.

I’m referring to regular, short meetings.  Assess the measures, identify when it’s going well and anticipate any potential obstacles today and decide how it will be dealt with.  People can become very busy with their own things and lose sight of the bigger picture so introducing a quick daily huddle where everyone can look at the measured priorities will promote focus.

Consistent Continuous improvement

I learnt that there are two battles to keeping weight off.  The first and easiest is to reach is the target condition.  The second and tougher battle is to sustain the target condition, never mind improve on that! The only way to sustain is to pay attention every day. Some days are better and easier than others and bad days are ok, as long as a bad day is not turning into a bad week or month.  If poor performance is allowed it to slip beyond a certain point, it’s very hard to get back on track.

Organizational improvements are the same.  The real battle is not improvement or even implementation; the real battle is sustaining.  Big interventions less frequently are not sustainable.  It should become habit to experiment and improve every day, every process, and every habit.  The word continuous says it all; there is no end or selectivity to it.

Summary

Sustainability requires engagement, planning, preparations and constant attention.  There is no easy way. There is saying that nothing in life is good or bad, it’s what you think about it that makes it good or bad. Thus sustainability is dependent on thought processes which are demonstrated through attitude.

As Aristotle said: “We are what we repeatedly do. Excellence, then, is not an act, but a habit”

Analysing organizational rhythm…shock advised…charging

Place two fingers on the inside of your wrist just the below the thumb and feel your heartbeat…every 0.8 seconds your cardiovascular system completes a cycle of complex interactions enabling it to pump 60 – 100 times a minute.

The cardiovascular system is highly intricate with centralised and decentralised operating systems synchronizing a variety of functions.  Extensive feedback mechanisms provide constant information on performance and fluctuation in demand.  Via continuous small adjustments capacity remains within boundaries whilst meeting the demand.  These may include changes to the interval between contractions, the strength of contraction or chemical composition of blood.

The SA node sets the pace for the mechanical actions by initiating impulses or messages within the heart.  The messages are sent at regular intervals following a predictable path; hence the rhythmic beating.

When chaos erupts…

In the worst case scenario chaos erupts due to complete failure in the communication cascade.  The pacemaker messages are not sent or they are disorganized.  With no coordination of the heart function; muscles pull in their own time and direction. The breakdown in feedback mechanisms cause the muscles to work ferociously, stretching and contracting harder than ever.  Sadly though, the heart rapidly becomes a quivering mass with no output.

Because there is no output the body’s demand is not met, oxygen starvation occurs, waste accumulates and irreversible cellular damage occurs within minutes.

This state of quivering chaos with no output is called ventricular fibrillation. The exact cause is unknown but it is believed that in most cases warning signs were present.

Buying time

If ventricular fibrillation is not treated death is inevitable despite prolonged efforts to buy time.

One method to buy time is doing CPR.  The main purpose of doing CPR is to restore blood flow to the vital organs until the problem is fixed.  During chest compressions the heart is rapidly squeezed between the sternum and vertebrae taking over from the quivering pump to create partial output.  For as long as compressions are continued there is hope for survival.

A sacred cow of resuscitation is the administration of medication such as Adrenaline.  It is resource intensive on time and people.  According to the American Heart Association the value and safety of these drugs remain controversial. Retrospective studies suggest that high dosages are associated with worse outcomes.   Yet we continue to use it religiously…because it’s what we’ve always done and everybody has a success story involving Adrenaline!

Treating the root cause

Defibrillation is the administration of a controlled electric shock to the heart. It literally shocks the quivering heart to a standstill for a few seconds until the pacemaker can kick in and restart the functioning of the heart.

Organizations

So many organizations find themselves quivering!  Each department works away frantically, fighting individual battles, pulling in their own direction with little coordination.  It ripples throughout the organization producing poor outputs and unhappy customers (internal and external).  Projects to resolve issues is implemented, however if it’s not addressing the underlying cause it’s only buying time and the organization remain quivering.

The efficiency lies not in every individual part working in as hard as it can, stretched beyond capacity.  Efficiency is created by the perfect harmony of various activities, strengths and functions making every single beat effective.

In organizations a common cause for quivering is lack of shared direction because of communication failure or disjointed messages from leadership.  The early warning signs are there, yet ignored.  A fire fighting mentality neglects feedback mechanisms leaving the organizations stretched beyond safe boundaries of capacity.

Interventions to buy time include external measures rhythmically squeezing every last little bit of output from of the organization. Or implementation of sacred cows that produce limited (sometimes detrimental) results yet consumes resources (time and people).  Think of workarounds, over processing, duplications, inspections and bureaucracies.

In the end people burn out, the organization falter and nobody wins.

What if the quivering was dramatically forced to stop with a brief interlude allowing leadership to restart the organization with clear communication pathways, shared direction and collaborating towards the same outputs.  What if?

Tell me; if we had to analyse your organization’s rhythm would defibrillation be advised?

The unsafe workspace…patient rage caused by waiting

Waiting feels like a waste of time and is intensely disliked by most people. I used to avoid the waiting area of the emergency centre like the plague, especially on busy days.  At times it would feel like the patients in the waiting room has become an angry mob and I was uncomfortable just walking past. It’s like there is a “peer pressure” in waiting rooms and if one patient complains shouts or is rude it gives permission to others to join in.

As manager I had to deal with patient complaints and staff emotions after a busy day, staff was left feeling emotionally depleted after some shifts.  Last week I attended staff meetings in different parts of an outpatient clinic.  Their previously day was exceptionally busy and the staff expressed similar emotions. There was an increased burden to process more patients, files, scripts and exposure to what I would like to call “patient rage caused by waiting”.

Why the rage?

Hospitals are emotionally taxing environments. Visiting a hospital is stressful for patients and their family. Whilst waiting in line the patients may be in pain, they might’ve just received bad news about their condition; they might lack clarity about their condition or need to come back for more tests or results.  They are required to join a variety of queues for different functions:  registration, doctor consultation, tests, scripts, to make a follow-up appointment and so on.

Add in the length of some queues, poor communication on why they are waiting and duplicated work. Now add in the environment that is crowded, with poor ventilation, unsettling amounts of noise and limited signage of where to go next.

Truth is that patients spend a disproportionate amount of time waiting for that little value adding step and reason why they came to the facility, and then…it’s over in minutes. They might wait three hours for a repeat script. They might wait four hours to be attended to for ten minutes by an absent-minded doctor.

There is so much uncertainty of not knowing what is happening and when it’s happening that it is no wonder that the patients become agitated.

How patients demonstrate their agitation

Both verbal and non-verbal ways of demonstrating unhappiness are traumatic to the staff involved. Verbal rage includes speaking in a raised voice or making verbal threats and insults.  Non-verbal rage may include glaring, rolled eyes or shaking the head.  Emotions can evolve and escalate so basically if the patient’s agitation is not addressed constructively the more queues the patient joins in this emotional state, the more likely emotionally fallout are.

In a study done with Emergency Centre nurses in the USA 97% of nurses reported to have been victims of verbal abuse in the year preceding the study.

A study done in Japan took it one step further. Staff that reported verbal abuse was asked to complete a questionnaire designed to diagnose Post –traumatic stress disorder. The result: 21.3% scored positive for PTSD.

The patient is always right…Not

The buzz words the past few years have been patient centred care, quality care and the patient journey. Regrettably quality patient care and service delivery is associated with the idea that the patient is always right. This idea has resulted in excessive tolerance to be displayed towards patients that are misbehaving fuelling unrealistic expectations by the patients and perhaps creating a certain sense of entitlement.

There’s been this message that the patient’s emotional outbursts and verbal abuse of staff is the result of bad service practise. In one of the hospitals that I worked at we were consistently told that patient outbursts were due to us being lazy, that’s it root cause: lazy staff.

It creates pressure that you will end up in trouble for the patient’s behaviour. Frontline staff feels responsible for patient aggression and if only we did this or that; the patients would not have shouted at us. It is overwhelming and when you compare the emotions and if only’s with the three stage cycle of domestic violence, the similarities are scary.

Patient expectation is often unrealistic and a large part of frontline staff’s jobs revolves around managing expectations and fire fighting. It’s time to acknowledge that it may be unrealistic or hard to deal with.  It also needs to be acknowledged that patients do step out of line.

Where is management?

Bishop et al (2005) did a study on violence in employment services. They demonstrated that although service providers experienced customer behaviour as violent, it was systematically denied by management who failed to acknowledge the behaviour as violent.

Hospital management owe it to the staff to provide a healthy and safe work environment. And perhaps on a busy day hospital management should support frontline staff by visiting patient waiting areas to speak with patients and check in on staff.

Yes to make it better for the patient. Yes the patient is important.  Yes we should be patient centred.

However we need staff to care for patients, to feel compassionate and to pitch at work.   The impact of a verbally abusive patient may linger long after the patient has left.  Exposure to aggressive behaviour by patients has long-term psychological effects on staff including staff burnout, diminished job satisfaction, reduced self-esteem and morale.

This can increase absenteeism which creates a vicious cycle of more pressure on the remaining staff, high turnover of staff and a negative work space.

Summary

I’m not sure if there is any fixes to ultimately resolve waiting times and queues.

What I do know is that we need to think about the impact that our dysfunctional system has on staff retention and satisfaction.

I wish that I could find the right words to express that emotion felt by health workers, the sense of futility, regardless of how hard I work and try, they shout at me and then it’s my fault.

For too long in health care we have said that it’s ok if patients direct their rage at us. That it’s part of the job and that it’s something that staff on the floor just need to accept.  You are seen as street savvy if you can cope with it. We need to change this thought process, now!

Bishop, V., Korczynski, M., Cohen L. The invisibility of violence: Constructing violence out of the job centre workplace in the UK. Work, Employment and Society, 19 (2005), pp. 583–602

Relentless leadership

Lead like a relentless but reflective bulldozer.   I’m off course referring to the LEAN Institute Africa’s 2014 summit theme.  I’ve summarized some of the summit’s consistent themes regarding the traits of such a leader.

The LEAN Africa’s Institute’s pamphlet for the 2014 summit defines the relentless leader as a purposeful leader, continually driving for improvement whilst simultaneously being compassionate. Thesaurus defines the word relentless as sustained, unremitting and unyieldingly severe.

Traits and ways of the relentless leader:

  • The relentless leader acknowledges participation.  The relentless LEAN leader realizes that people are more involved when they feel appreciated and acknowledged; therefor they find time and ways to encourage participation and experimentation.  The relentless leader not only knows that it’s about the people but also cares deeply about the people.
  • A relentless leader sets direction.  They do not simply introduce a toolbox.   They start by creating a shared vision and philosophy. The most applicable tools are adapted to suit organizational need and support the shared vision.
  • A relentless leader is persistent. There is no end to improvement.  The relentless leader makes LEAN stick; the relentless leader takes the organization beyond LEAN being a project, fad or process with an end date.
  • Relentless leaders are information conduits working consistently towards creating a corporate memory.  Relentless leader creates a focus on producing knowledge in the same way that one produces work.  Every problem is an opportunity to learn and generate knowledge.   The relentless leader ensures that there is no space for exclusivity and knowledge is shared across functional boundaries.  They know that functions may be specialised or specific to a work area; however the significance of knowledge is collective.
  • The relentless leader is a good listener and finds the problem before offering solutions.  In emergency medicine we teach that the most dramatic injury is not necessarily the most serious injury.  For example if a person has an obviously broken bone that you see as you approach and you immediately focus attention on that, you may miss that the person is not breathing and has no pulse.  So they will have pretty splint but also be pretty dead, because you didn’t address the real problem.  So don’t get side-tracked by the noise and always follow the same systematic approach. It’s the same with solving problems what appears to be an immediate problem and/or solution is most likely not addressing the root cause of the problem.
  • The relentless leader is visible at the workspace and makes gemba tangible.  Gemba is not simply going to the workspace to “see” the problem.  Gemba is going to the workplace and observing until your mind shuts up, applying all the senses.  It’s like meditation, you need to feel the workspace and observe the work cycle.
  • The relentless LEAN leader leads by example:  their office is neat, they use visual management tools, they can find data easily and they share knowledge.  They know that you can’t “delegate” LEAN or not have time for “LEAN” expecting that the team will then make the time, and buy into LEAN if it’s not visible from leadership.
  • The relentless leader is consistent. LEAN is not just for when things are going poorly.  It is habits that are formed by practising it every day.  These habits includes measuring performance, huddles, daily activities, workplace discipline, the relentless leader is consistently setting the pace and leading by example.
  • The relentless leader respects and values the team.  As such the relentless leader considers that when bringing about change for the first time, it’s scary and unknown.  They know that there will be resistance.  To add a little bit of my own spice, with regards to change I’ve been taught to apply the grief process as extensively described by Elizabeth Kuber-Ross to understand the initial resistance.  The relentless LEAN leader intuitively plans and allows for some adjustment and that there may initially be denial, maybe even anger because the workplace is changing.
  • The relentless leader measures performance.  The analogy presented was if you are a rugby fan and its 20 minutes into the second half when you first tune in on the tv.  What is the first thing that you look at?  The score.  Because that gives you an instant update of how the game is going.  The relentless leader knows that in order to know the score, the right score must be kept and displayed to the team.

I think that it’s the mission of the relentless leader that sets them apart. And I would like to add a quote by management guru Peter Drucker:  “The three most charismatic leaders in this (last) century inflicted more suffering on the human race than almost any trio in the history: Hitler, Staling and Mao.  What matters most are not the leader’s charisma, what matters is the leader’s mission. “