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W2939950265 abstract "The culture of health care creates important challenges for health care professionals. In particular, we work in a culture that is (1) hierarchical, (2) competitive, and (3) perfectionistic. Unfortunately, the consequence of acquiescing to those demands is contrary to promoting Resonant teamwork, and it is important for leaders of multidisciplinary teams to understand how to create environments that flatten the hierarchy (by encouraging all members of the team to contribute; and to genuinely seek the wisdom and knowledge of their colleagues), that encourage collaboration and cooperation (emphasizing collective wins and losses both for the immediate team as well as for all of us, as a profession), and that invites excellence (which is a process) versus expectation of perfection (which is an unrealistic outcome). The culture of health care creates important challenges for health care professionals. In particular, we work in a culture that is (1) hierarchical, (2) competitive, and (3) perfectionistic. Unfortunately, the consequence of acquiescing to those demands is contrary to promoting Resonant teamwork, and it is important for leaders of multidisciplinary teams to understand how to create environments that flatten the hierarchy (by encouraging all members of the team to contribute; and to genuinely seek the wisdom and knowledge of their colleagues), that encourage collaboration and cooperation (emphasizing collective wins and losses both for the immediate team as well as for all of us, as a profession), and that invites excellence (which is a process) versus expectation of perfection (which is an unrealistic outcome). An expanding body of information links leadership to a combination of operational and relational skills [1Alvarez G. Coiera E. Interdisciplinary communication: an uncharted source of medical error?.J Crit Care. 2006; 21 (discussion 242): 236-242Crossref PubMed Scopus (141) Google Scholar, 2McGilchrist I. The Master and His Emissary: The Divided Brain and the Making of the Western World. Yale University Press, New Haven, CT2009Google Scholar, 3Pink D.H. A Whole New Mind: Why Right-Brainers Will Rule the Future. Riverhead Books, New York, NY2005Google Scholar]. Beliefs about brain function would generally attribute task-oriented focus to left-brain function and relationship-oriented focus to right-brain function. Of interest, this dichotomy has been alluded to in health care as the difference between mechanical (predictable, linear) systems versus complex adaptive (unpredictable, nonlinear) systems [4Institute of MedicineTo Err is Human. National Academy Press, Washington, DC1999Google Scholar]. In mechanical systems, behavior (and expected outcomes) conforms to reproducible patterns and emergent (innovative or individualized) behavior is discouraged [5Ungerleider R.M. Ungerleider J.D. Seven practices of highly resonant teams.in: Da Cruz E.M. Ivy D. Jaggers J. Pediatric and Congenital Cardiology, Cardiac Surgery and Intensive Care. 1st ed. Springer-Verlag, London, United Kingdom2014: 3423-3450Google Scholar]. For example, a ventilator is a mechanical system and if it does not perform according to its settings, a repair person is called to interrogate, judge, and fix the system. Complex adaptive systems are unpredictable, and emergent (creative and unique) behaviors can be embraced with curiosity and enthusiasm. In complex adaptive systems, differences are explored to be understood and connected (joined). A growing body of literature on leadership records a variety of leadership traits such as those listed in Table 1. These leadership traits can be reorganized (Table 2) to better demonstrate the importance of what we refer to as Whole Brain Leadership. To develop and promote this kind of leadership thinking, this article outlines a few concepts that promote development of our model of Whole Brain Leadership.Table 1Qualities Attributed to Leadership SkillLeadership TraitsAbility to be logical and realisticBig picture orientationRelationship-focusedStrategic/aware of past historyDetailedValues facts as informationImaginative/creativeProcess orientedInvites possibilities/divergent thinkingIntuitiveTask focused—outcomes orientedValue measurements, numbers graphs and spreadsheetsValues stories as informationGood with conceptsAnalyticalConvergent thinking—find best solution Open table in a new tab Table 2Leadership Qualities Reorganized Into Whole Brain CapacityLeft BrainRight BrainAbility to be logical and realisticInvites possibilities/divergent thinkingDetailedBig picture orientationTask focused—outcomes orientedRelationship focusedValues facts as informationValues stories as informationConvergent thinking—find best solutionIntuitiveValue measurements, numbers, graphs, and spreadsheetsGood with conceptsStrategic/aware of past historyImaginative/creativeAnalyticalProcess oriented Open table in a new tab We define integration as the linkage of differentiated parts. That is essentially what great leaders do—they link differentiated parts. Integration is a delicate and dynamic process. Dan Siegel describes an integrated state as FACES (Flexible, Adaptive, Coherent, Energized, and Stable). Coherence is in itself an acronym for (Connected, Open, Harmonious, Engaged, Receptive, Emergent [creative], Noetic [inviting spontaneity and newness], Compassionate, Empathic) [6Siegel D.J. Pocket Guide to Interpersonal Neurobiology: An Integrative Handbook of the Mind. W.W. Norton & Co, New York, NY2012Google Scholar]—and all of these are important characteristics for a Whole Brain Leader. With the use of this concept of integration, it is helpful to think of integration as the flowing of a river. Integrated states (FACES) are found in the middle of the river. On one riverbank is rigidity (linkage without differentiation) and on the other is chaos (differentiation without linkage). In rigid systems, there is no allowance for or acceptance of individual differences. A mechanical system is rigid. It is predictable and linear. Protocols and checklists can be rigid, and there is a space for them in all health care practices. Protocols and checklists prevent errors of omission, but they will not prevent errors of commission, such as technical errors or errors of judgment. Protocols and checklists create conformity for tasks that lend themselves to conformity, but they do not necessarily create safety (for instance, if the system is so rigid that no one is allowed to speak up to challenge a protocol, even when they see something that concerns them or when they have an emergent idea that might be better, because it challenges a well-engrained protocol—then the system becomes less flexible, adaptive, and safe). Making one-size-fit-all and abolishing the unique and variable experiences and abilities of the differentiated members of a group creates potential for rigidity and ironically leads to the outcomes that the organization most likely fears—mediocrity, failure, lack of innovative spark, loss of job satisfaction, and a disengaged workforce. However, in chaotic systems, there is no conformity. Differentiation abounds and there is nothing linking the group—no common behavior norms, no shared beliefs, and no support of an identified leader. Chaotic systems can be rich with ideas and energy, but without linkage through integrated leadership, there is no way to harness this collective wisdom, and this gives more understandable meaning to the eventual outcome for these teams, which is dis-integration. To describe Whole Brain Leadership in practical terms, we like to imagine that Whole Brain Leaders are integrating three primary elements: Self, Others, and Context [7Dickey J. Ungerleider R.M. Professionalism and balance for thoracic surgeons.Ann Thorac Surg. 2004; 77 (discussion 1150–1): 1145-1148PubMed Scopus (6) Google Scholar, 8Dickey J, Ungerleider RM. Teamwork: a systems-based practice. In: Gravlee GP, Davis RF, Hammon JW, Kussmasn BD, eds. Cardiopulmonary Bypass and Mechanical Support: Principles and Practice. Philadelphia, PA: Lippincott, Williams and Wilkins; 572–588.Google Scholar]. The challenges we face on teams generally revolve around these three entities. What are my needs? What are my beliefs? What are my values, what is meaningful to me? What are my commitments? What are my authentic strengths? What are my fears, and do I have enough self-awareness and courage to be able to acknowledge them and the tools and resources to manage them? What are my biases? Can I access any potential unconscious biases? Self-awareness is the first element for emotional intelligence [9Goleman D. Boyatizis R. McKee A. Primal Leadership. Harvard Business Press, Boston, MA2002Google Scholar] and Whole Brain Leaders practice emotional intelligence. Whole Brain Leadership is relational leadership and requires the ability and willingness to value others. Resonant, Whole Brain Leaders understand that just like themselves, all individuals in the system have needs, perceptions, knowledge, and commitments. Whole Brain Leaders create Resonance by making it apparent to team members that their individual and collective needs, values, opinions, ideas, and information are also respected and considered as important. This ability to develop genuine caring and understanding for the members of the team is considered by many to be the keystone for successful leadership [9Goleman D. Boyatizis R. McKee A. Primal Leadership. Harvard Business Press, Boston, MA2002Google Scholar, 10Weinberg G.M. Becoming a Technical Leader. Dorsett House, New York, NY1986Google Scholar], and it is an essential cultivator for Resonance within the system. Whole Brain Leaders genuinely care, and they also care in general, meaning that they understand the power of story. Everyone in the system has a story, and when we can know the story, then the system and how people are behaving or what they are wanting makes more sense. A powerful example of caring in general was created by the Cleveland Clinic Foundation in their video on empathy [11Cleveland Clinic. Empathy: the human connection to patient care. Available at https://www.youtube.com/watch?v=cDDWvj_q-o8. Accessed May 20, 2019.Google Scholar]. Context is the patient, the situation, the reason for us working together, the ever present need that drives our health care world. Health care Context is huge and, just like each of us, has needs that must be acknowledged and valued. Teamwork would be difficult enough if it simply required us getting along with each other—it becomes daunting when we have to do this in the shadow of urgent, life-threatening, win, or lose situations that challenge all that we might know and be capable of doing. Add to that challenge the perceived need for perfection, and we invite the perfect storm. Whole Brain Leaders create Resonance by understanding that rigid adherence to certain styles might fail to integrate the competing needs of Self, Others, and Context and over time will lead to Dissonance within a system. When there is Dissonance, there is lack of positive energy, and members of these teams describe their working environment as “sucking the energy from me,” “oppressive,” “it feels unsafe,” “there is no point to me being here because no one cares what I think,” “I just show up and do what I’m told” (which is symptomatic of a system that has disregarded someone’s potential for unique contribution), “I’m looking for another job somewhere” (I’m checking out), or “I just come to work to make money so I can have a life outside of here” (I’ve checked out). Any of these and other comments that we have collected and reported are all indicative that the system (team) is Dissonant [12Ungerleider J.D. Ungerleider R.M. Improved quality and outcomes through congruent leadership, teamwork and life choices.Prog Pediatr Cardiol. 2011; 32: 75-83Crossref Scopus (8) Google Scholar]. We have identified seven behaviors that we have observed in health care professionals that are Dissonant styles when used exclusively and exhaustively over time. Each of these behaviors shares lack of integration of Self, Others, and Context. They are briefly described in the sections below. These leaders are driven to be in charge and lack curiosity to explore, value, or validate (by accepting influence) the experiences of others. They commonly blame others or circumstances when things go wrong, have difficulty accepting any accountability, and exhibit little capacity for listening, asking, inquiring. They already know. Commanding leaders simply say: “Do it because I say so.” The Federal Aviation Administration created cockpit resource management to counteract the potential damage that can be done by a commanding leader who is unable or unwilling to access the ideas, opinions, or information from others [13Wiener E.L. Kanki B.G. Helmreich R.L. Cockpit Resource Management. Academic Press, San Diego, CA1993Google Scholar]. Likewise, Karl Weick [14Weick K.E. Sutcliffe K.M. Managing the Unexpected: Resilient Performance in an Age of Uncertainty. Jossey-Bass, San Francisco, CA2007Google Scholar] has written about how High Consequence Organizations can become High Reliability Organizations by flattening the hierarchy to protect against commanding leaders when there are unexpected and potentially catastrophic events. In Weick’s model, the most valuable person on a team, at any moment in time, is the person with the most important and relevant information. It is the role of the leader to access that information, wherever and in whomever it resides. An example of a commanding leader is nicely demonstrated in this video [15Hoskand. Captain, divert your course immediately. Available at https://www.youtube.com/watch?v=sYsdUgEgJrY. Accessed May 20, 2019.Google Scholar]. This Dissonant style is especially prevalent on cardiac teams when perfection is often the goal [9Goleman D. Boyatizis R. McKee A. Primal Leadership. Harvard Business Press, Boston, MA2002Google Scholar]. Ironically, many people who have trained in medicine have been taught that “If you want a job done right, do it yourself.” That is pacesetting. (Actually, if you want a job done your way, do it yourself; if you want it done right, then it can be done by many people and their right way may look different and often unique and innovative). Pacesetters demand perfection (meaning the outcome must be precisely their way), and it is often simply not possible to satisfy them, so team members stop trying (and this leads to the experience of being no longer valuable to the team because one’s opinions, knowledge, experience, or ideas are not welcomed). Ironically, pacesetters often become blamers when, despite their best intentions, things do (as they ultimately can in the complex and unpredictable world of cardiac care) fail. Pacesetting can be insidious. Although pacesetting might be manifested by open disregard for the ideas of others, it can also be conveyed by the leader who simply comes along and undoes whatever the team has already been performing to accomplish a task. See if you can recognize the pacesetting in this video [16Walt Disney Studios. Toy Story 3 - HD Trailer. Available at https://www.youtube.com/watch?v=ZZv1vki4ou4. Accessed May 20, 2019.Google Scholar]. Manipulation creates mistrust. Leaders who manipulate are typically unable or unwilling to communicate their needs. They frequently abuse their position of authority to pressure people into giving in to what they, the leader, wants. A leader can gain insight that they are possibly being motivated to manipulate when they approach a dialog, conflict, or problem with a predetermined conclusion in mind about what they want, and plan strategies to get those needs met without directly expressing them or exploring the perspectives of others. Manipulators are master strategists, and they are often fairly remorseless about the impact of their actions on others. The end justifies their means. They are primarily driven to get their needs met without engaging in direct and open communication and thus are rarely transparent [17Babiak P. Hare R.D. Snakes in Suits. Harper Collins, New York, NY2006Google Scholar]. Placaters are driven by the need to be liked and to make people on the team happy. Ironically, they generally fail at both. They become non-trusted because they do not commit to consistently expressed values. Instead, they seem to be constantly influenced by the last person who has talked with them. They can be paralyzed from making critical decisions because they are constantly worried about how they might be perceived or judged by others, particularly if they fail. Placaters invite chaos because rather than know how to link the diverse perspective of team members, they give into the constant demands of unending differentiation in the system. Unfortunately, our health care culture risks the development of placating as a cultural norm as we are constantly reminded to put the needs of others before our own [18Institute of MedicineCrossing the Quality Chasm: A New Health System for the 21st Century. National Academy Press, Washington, DC2001Google Scholar]. In fact, the Accreditation Council for Graduate Medical Education (ACGME) definition of professionalism uses those precise words as an example of what professionalism requires. The conundrum is that we are all human and we also have needs. Whereas commanding, pacesetting, and manipulating styles eradicate Others, placating eradicates the Self; therefore, it is simply not sustainable. In our work with (and in our own development as) leaders, this insatiable need to please others has created a common challenge, and the solution is to gently reacquaint ourselves with our humanness, the validity of our needs (values, opinions, knowledge, and skills), and some tools for integrating ourselves into a culture that has normalized disregard of the Self. Your team needs you and all the unique and extraordinary features that an authentic you can bring to the team [19Ungerleider J.D. Strand A. Ungerleider R.M. An Explorer’s Guide to Living with Mindful Authenticity: Reclaiming Your Internal Resources for Managing the Demands of Personal and Professional Life. Balboa Press, Portland, OR2008Google Scholar]. We have observed this style most frequently when we have measured Dissonant styles in medical systems. It seems to be the most convenient style that satisfies the need for our systems to be predictable and reproducible—mechanical. Mechanical focus works for mechanical systems (ventilators, heart lung machines, elevators, airplanes) that can be interrogated (inspected) and fixed. Human systems are complex adaptive, and the beauty of complex adaptive systems is that they express emergent (innovative) and unique behaviors that are not always predictable. None of us wants to be fixed. We would rather be explored and understood. Super reasonable Dissonance treats people like robots [20hilMERICA. Ally Bank - Robot. Available at https://www.youtube.com/watch?v=753eH92u2B0. Accessed May 20, 2019.Google Scholar], and a machine cannot give you what a person can. When leaders treat people like machines, they essentially are devaluing and dismissing the importance of our human factor. In the super reasonable style of Dissonance, the only thing that is important is the Context. Context is ubiquitous. There is always a sick patient, an article that needs to be written, a lecture to prepare, teaching rounds to attend, a meeting for making an important decision … always something to occupy us and distract us from our humanness. Super reasonable drives disconnection. The syndrome of physician burnout includes depersonalization, which is a measured consequence of our medical education process. (We have reported a progressive increase in depersonalization across 4 years of medical school education for one group of students at a nationally recognized medical school [21Ungerleider R.M. Ungerleider J.D. Ungerleider G.D. Occupational wellness for the surgical workforce.in: Sanchez J.A. Bareach P. Johnson J. Jacobs J.P. Surgical Patient Safety. Springer, Basel, Switzerland2017: 205-224Google Scholar]. The class cohort shows an increase of depersonalization from approximately 10% of students at the beginning of medical school—during orientation—to approximately 45% of students at the completion of 4 years of medical school. From this one medical school, almost half the graduating physicians are depersonalized at the time they begin their medical residency training!) Depersonalized physicians have just as many needs as they had before they became depersonalized—they are simply less aware of and less compassionate toward these needs that are perceived as human and therefore unimportant. Ultimately, they begin to treat all people in the system (including their patients) as they have learned to treat themselves—as objects that need to be dealt with. Depersonalized (super reasonable) systems are subject to an 11-fold increase in medical errors, as well as to unprofessional and immoral acts, in addition to ultimate disengagement from people who want more for their lives than burnout. Systems with depersonalized leaders feel oppressive and dehumanized. They are driven to achieve perfection (which is not possible) and deny the human need to struggle and fail as a requisite to learning. It is not possible to exist in them over the long haul, and they exhibit frequent turnover or disintegration. Irrelevance occurs when people become overwhelmed and are no longer capable of accessing their own needs or being available to the needs of Others or the Context. Irrelevance is non-attuned leadership and it fails to connect. The members of the team become discouraged that their leader is not available to connect with them around their concerns and instead is a distracting presence (talking about other, less relevant issues, or making jokes) when they need to have focus. Irrelevance might seem funny and creative to the leader, but they are unattuned to the present-moment needs of Self, Others, and Context. Invisible leaders are not present for their leadership moments. This is nicely described by Sidney Dekker in his work on Just Culture [22Dekker S. Just Culture: Balancing Safety and Accountability. Dorset Press, Dorchester, United Kingdom2012Google Scholar], and the members of these teams can become secondary victims of unexpected or untoward events. There are times when the team needs a leader to step up and take accountability for the team or to make a critical decision or to simply be the leader. Invisible leaders tend to hide at these times in the hope that the moment will pass (unnoticed) or that they might escape unscathed. All of the above-mentioned styles are Dissonant when they are used exclusively, over time, as the most predictable response by the leader to a problem. Each of us has access to these styles and, when integrated into a complete repertoire of response, can create a more vibrant ability to adapt and perform effectively. These styles actually exist on a continuum or spectrum of strengths. When the strengths are overdone, they can lead to Dissonance, but a strength used appropriately can be a powerful tool or style. In Table 3, we indicate how the style might look along this spectrum, with the strength overdone being represented as the Dissonant style and the strength being used when needed and at appropriate times representing the more Resonant version. Whole Brain Leaders create Resonance through their ability to integrate the various and changing needs of Self, Others, and Context into a dynamic and stable system. They access a wide range of possibilities that include tasks that need to be accomplished, problems that need to be solved, and the needs of the people in the system that need to be valued. An example of this is nicely portrayed in the story of a young surgeon on vacation with his wife published many years ago when the ACGME first introduced their duty hour restriction, and we recommend reading it now that you can integrate the information above into your understanding of the story [7Dickey J. Ungerleider R.M. Professionalism and balance for thoracic surgeons.Ann Thorac Surg. 2004; 77 (discussion 1150–1): 1145-1148PubMed Scopus (6) Google Scholar]. Several decades ago, a researcher in Seattle began to investigate how couples managed conflict and how their relationship styles were connected with the ultimate fate of their marriage. John Gottman, a research psychologist, believed that he could find logical explanations for how relationships thrived or disintegrated. His early book, Why Marriages Succeed or Fail [23Gottman J. Why Marriages Succeed or Fail. Simon and Schuster, New York, NY1994Google Scholar], was seminal work and interestingly has relevance to teams that take care of critically ill patients when the word teams is inserted in place of the word marriages. Gottman’s work (based on extensive quantitative and qualitative research) became nationally prominent when it was recognized that he could watch a couple in conflict for about 2 minutes and then predict (with more than 90% accuracy over 15-year follow-up) whether the couple would stay married or end up divorced! His work has influenced our own work with Resonance in medical teams and the development of our model of Whole Brain Leadership. Gottman described four conditions that eroded relationships; we believe his findings are relevant for team relationships. Whole Brain Leaders need to be aware of these four destructive influences and be acquainted with the antidotes for them. We briefly describe them in the sections below. Criticism is highly toxic poison and it is ubiquitous on medical teams. Criticism is personal and it is designed to identify and blame a culprit. When we criticize or chastise someone for making a mistake, we invite them to experience fear, anger, or shame. Criticism is destructive, and it generally makes everyone on a team feel demoralized and afraid that either they may be next to be criticized or to feel bad for their colleague and teammate who is the recipient of the criticism. Criticism rarely creates problem solving. The antidote for criticism is complaint. A complaint is not personal and it invites all team members to engage in problem solving. Problems do not have names—they are gender neutral. Imagine the difference between criticism and complaint as if the problem is represented as a soccer ball. Criticism is like putting the soccer ball inside someone and then kicking them around. A complaint is like putting the soccer ball on the floor and letting everyone kick it around. The problem is not “why do you keep trying to kill all my patients with your poor management?” (personal; ouch!). The problem is: “We keep struggling with our attempts at early extubation. What kinds of things can we try and do differently?” Of the four destroyers, contempt may be the most destructive. Contempt does not necessarily require words—contempt can be conveyed by an expression (such as a slight tilt of the head and a rolling of the eyes). Contempt is a total annihilation of an other and minimizing their importance to the team. Whole Brain Leaders develop antennae for contempt, and they do everything they can to prevent it. The antidote for contempt is appreciation for what others know and can bring to the system. It has been written that great leadership requires great followership—meaning there are times to stop pacesetting and commanding and let another team member do what they do best. Pacesetting is a subtle form of contempt because pacesetters have a belief that there is only one way to do a job—their way. When contempt is expressed openly as disdain for the abilities of someone in the system, the system will need intervention to heal or it will polarize and disintegrate. Defensiveness is the flip side of blame. It is in effect the same as saying: “I didn’t do it. She did it.” Defensiveness is often found in systems in which the leader has allowed punishment and criticism to exist, so defensiveness is expressed as a way to avoid these consequences. The antidote to defensiveness is self-accountability. Next time you have a quality improvement conference (morbidity and mortality conference) and a difficult outcome is being examined, try going around the room and, instead of assigning blame, have each team member courageously take accountability for some piece of the outcome. What would each member have done differently, in retrospect? Have each team member imagine something they might wish they could have done now that they know what happened. This creates a culture that reinforces our connectedness and dependence on one another. Flooding refers to emotional overload. When we get flooded, we simply want to withdraw, shut down, and not address the moment—stonewall. This can leave others on the team feeling abandoned, unheard, or ignored. When I (R.M.U.) finish a challenging operation and return to my office, I am sometimes flooded. If my administrative assistant bombards me with a lot of requests—phone calls to return, tasks that need attention, etc—I just want to ignore them. She might take this personally, when actually, the person with the immediate need is me! So, I have told my assistant that when I come back from the operating room and close the door to my office—it has nothing to do with her—I simply need time to re-center myself so that I am ready to be available. The antidote for flooding is self-soothing that can simply be acknowledging as a leader that people have needs (including the leader) to center and reconnect to their internal resources so that they can move on to the next deman" @default.
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W2939950265 title "Whole Brain Leadership for Creating Resonant Multidisciplinary Health Care Teams" @default.
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