1. CMSA-OK Leadership Summit Role Transitions: From Novice to Expert Carol A. Mannahan, Ed.D., R.N., NEA-BC Assistant Professor, Oklahoma City University camannahan@okcu.edu camannahan@okcu.edu

2. Objectives for Today 1. Examine impact of changing roles on health care consumers, professionals, and organizations. 2. Formulate strategies to address both individual and organizational challenges of role transition. 3. Consider a variety of metaphors that are useful for defining & describing role transition.

3. Guiding Thoughts… Guiding Thoughts… The world we have created is a product of our thinking; it cannot be changed without changing our thinking. (Albert Einstein) The world we have created is a product of our thinking; it cannot be changed without changing our thinking. (Albert Einstein) We think in generalities, but we live in detail. (Alfred North Whitehead, British philosopher) We think in generalities, but we live in detail. (Alfred North Whitehead, British philosopher)

4. Where does change happen? “ Who are you?” said the caterpillar… ”I hardly know, Sir”, just at present,” Alice replied rather shyly, “at least I know who I was when I got up this morning, but I think I must have changed several times since then.” (Lewis Carroll, Alice in Wonderland

5. Where does change happen? (continued ) “Change your thoughts & change your world.” “Change your thoughts & change your world.” (Dr. Norman Vincent Peale) (Dr. Norman Vincent Peale) Only I can change my life. No one can do it for me. Only I can change my life. No one can do it for me. ( Carol Burnett) ( Carol Burnett)

6. Where does change happen? (continued ) “When we are no longer able to change a situation, we are challenged to change ourselves.” “When we are no longer able to change a situation, we are challenged to change ourselves.” (Victor Frankl) (Victor Frankl) “Resolve to be a master of change rather than a victim of change.” (Brian Tracy) “Resolve to be a master of change rather than a victim of change.” (Brian Tracy)

7. Nature of change “Know what’s weird? Day by day, nothing seems to change, but pretty soon…everything’s different.” (Calvin, Calvin & Hobbs) “Know what’s weird? Day by day, nothing seems to change, but pretty soon…everything’s different.” (Calvin, Calvin & Hobbs)

8. Nature of Change (continued) “If you want to make enemies, try to change something.” (Woodrow Wilson) “If you want to make enemies, try to change something.” (Woodrow Wilson) “It is not necessary to change. Survival is not mandatory.” (W. Edwards Deming) “It is not necessary to change. Survival is not mandatory.” (W. Edwards Deming)

9. Why do we resist change? “All changes, even the most longed for, have their melancholy; for what we leave behind us is a part of ourselves; we must die to one life before we can enter another.” (Anatole France) “All changes, even the most longed for, have their melancholy; for what we leave behind us is a part of ourselves; we must die to one life before we can enter another.” (Anatole France) Homeostasis – maintenance of the “steady state” Homeostasis – maintenance of the “steady state”

10. Like waves on the sand …

11. Out at Sea…

12. Think about it: Think about it: Can you identify at least 10 driving forces which create challenges to health care leaders today? (ex: growth in aging population)

13. Major Driving Forces: Chaos & Complexity “I think that the next century (21 st ) will be the century of complexity.”

14. Chaos Theory: The universe is filled with unpredictable & random events…(Hawking, 1987). To survive, organisms must: Must be self-organizing & adapt readily to change. Must be self-organizing & adapt readily to change. Give up a permanent structure; tolerate ambiguity, & respond to each day’s unique situation/environment Give up a permanent structure; tolerate ambiguity, & respond to each day’s unique situation/environment Bottom line: Constant change results in little long-term stability.

15. Complexity Science The most current attempt by science to: Understand & explain the behavior & dynamics of systems composed of many interacting elements Understand & explain the behavior & dynamics of systems composed of many interacting elements Uncover the principles & processes that explain how order and change emerge in these systems. Uncover the principles & processes that explain how order and change emerge in these systems.

16. Understanding systems… General systems Theory: input, throughput, feedback, output Complexity Theory: concerned with behavior over time of certain complex systems; focus is on systems that defy prediction

17. What Disciplines are Studying complexity Science? Biology Biology Economics Economics Sociology Sociology Nursing Nursing Mathematics Mathematics Physics Physics Anthropology Anthropology Management Management Medicine Medicine

18. What is a “complex adaptive system”? “System” implies: Multiple parts Multiple parts Parts are interdependent & connected Parts are interdependent & connected Cells, organs, patients, families, communities, health care professionals, & healthcare systems are all complex adaptive systems … Cells, organs, patients, families, communities, health care professionals, & healthcare systems are all complex adaptive systems … “Complex” implies: Diversity Diversity Many elements Many elements Large # of connections Large # of connections “Adaptive Implies: Capacity to alter or change Capacity to alter or change

19. Properties of CAS Embeddedness: Each CAS is made up of other CAS & is part of (embedded in) a larger CAS Example: heart; person; unit; hospital; health system Diversity: A CAS has many different elements; these help the CAS to change

20. Properties of CAS (continued) Distributed control Control is shared by many elements, rather than centralized in a single command center Control is shared by many elements, rather than centralized in a single command center Coexistence of order & disorder In a healthy, adaptive, system, order and disorder coexist In a healthy, adaptive, system, order and disorder coexist

21. Properties of CAS (continued) Outcomes are inherently unpredictable CAS are nonlinear; a small change may produce a large effect or a large change may product a small effect CAS are nonlinear; a small change may produce a large effect or a large change may product a small effect Butterfly Effect….

22. Implications for health care? Complexity science helps us understand & work creatively… With patients with multiple chronic diseases; With patients with multiple chronic diseases; In our interactions with staff, patients & families; In our interactions with staff, patients & families; To improve healthcare quality; To improve healthcare quality; With individual & system change. With individual & system change.Why???

23. Reality Shock (Kramer, 1974) Reality shock: The total social, physical, & emotional response of a person to the unexpected, unwanted, undesired, or even intolerable. Reality shock: The total social, physical, & emotional response of a person to the unexpected, unwanted, undesired, or even intolerable. A startling reaction to the discovery that school- bred (or personal) values conflict with work- world values. A startling reaction to the discovery that school- bred (or personal) values conflict with work- world values. Follows a fairly consistent pattern with 4 phases. Follows a fairly consistent pattern with 4 phases.

24. Phases of Reality Shock 1. Honeymoon 2. Shock & rejection 3. Recovery 4. Resolution Goal: Seek to integrate cultures; become bicultural! become bicultural!

25. Novice-Expert: Stages of Development (Benner, 1984) 1. Novice – no experience 2. Advanced Beginner – some experience; marginal performance 3. Competent – feels mastery but lacks speed & flexibility 4. Proficient – sees the “whole” of situations; picks up on nuances 5. Expert – has intuitive grasp of situations; deep understanding of total situation; performance fluid & flexible

26. Change & Transition Change & Transition Change is situational Move to a new home Birth of a baby New job Transition is psychological Requires adjustment Not optional!

27. Transition Model (Bridges, 2003)

28. Transition Shock: Initial Stage of Role Adaptation (Duchscher, 2007)

29. Phases of Role Transition (Gray, 2007) Intimate Relationship Dating Dating Commitment Commitment Honeymoon Honeymoon Disillusionment Disillusionment Resolution Resolution Maturation Maturation Role Transition Preview Preview Acceptance Acceptance Exploration Exploration Discrepancy Discrepancy Development Development Internalization Internalization

30. Focus Areas for Effective Role Transition Physical Physical Emotional Emotional Intellectual Intellectual Developmental Developmental

31. Tying it all together… Fire, change, & transition Fire, change, & transition Context for health care delivery Context for health care delivery Chaos Theory Chaos Theory Complexity science Complexity science Kramer, Benner, Bridges, Duchscher & Gray Kramer, Benner, Bridges, Duchscher & Gray Strategies for effective role Strategies for effective roletransition

32. Response to Change “The only man I know who behaves sensibly is my tailor – he takes my measurements anew each time he sees me. The rest go on with their old measurements and expect me to fit them.” (George Bernard Shaw). “The only man I know who behaves sensibly is my tailor – he takes my measurements anew each time he sees me. The rest go on with their old measurements and expect me to fit them.” (George Bernard Shaw).

33. References 1. Benner, P. From novice to Expert: Excellence and Power in Clinical Nursing. Menlo Park, CA: Addison- Wesley; 1984. 2. Bridges, W. Managing Transitions; Making the Most of Change. 2 nd ed. Cambridge: DaCapo Press; 2003. 3. Duchscher, J. (2008). Transition Shock: the initial stage of role adaptation for newly graduated registered nurses. Journal of Advanced Nursing. 4. Gray, J. (2007) in Leading & Managing in Nursing. 4 th ed., author: Yoder-Wise, P. 5. Hawking, S. (1987). A Brief History of Time. London: Bantam Press 6. Kramer, M. Reality Shock. St. Louis: CV Mosby Company; 1974.