Dan:
Lucy and Kay, welcome to the show.

Kay Kennedy:
Thank you so much, Dan. We couldn't be happier than we are to be here and to get to talk about interesting things like complexity with you. I'm Kay Kennedy. And I've been a nurse for over 30 years. And been in leadership positions from bedside to the CNO position. And my passion is leadership development, and of course, quality and safety, which goes hand in hand with leadership. I'll turn it over to Lucy.

Lucy Leclerc:
Hey, Dan. Thanks for having us here. I'm Lucy Leclerc. And like, Kay, I have been in nursing for a little over 30 years. And have been in leadership positions from bedside to executive director to my favorite one, I always like to mention that I was a flight nurse in the Air Force Reserve for a few years and, of course, that was a leadership position, and that's where I fell in love at a very young age with leadership. And my passion is around research in leadership and practice and in academia, but particularly in practice to connect nursing leadership with the million-dollar question of outcomes, how does the nursing leadership style influence outcomes like turnover, retention, engagement, patient satisfaction, and all that?

Dan:
That's awesome. I'm excited to dive into that because as you both know, my research and dissertation was related to leadership and recently been really interested in the kind of the negative impacts of bad leadership on organizations. But you guys have done a lot of research, you have a book coming out I think in December. Talk to me about what inspired you to do that and what message you're trying to get across?

Kay Kennedy:
The book is called Human-Centered Leadership in Healthcare: Evolution of a Revolution. And I think what we're trying to get across with this book is just that the old ways of nursing leadership are not the ways that are needed right now. And we need more of a contemporary approach that really values the leader be an embedded in the system, the staff being considered those innovative and influential in the organization. When I say staff, I mean those nurses closest to the bedside or to the point of care. The whole idea behind it is to change cultures so that the culture supports sustainable outcomes. So we're trying to get across the idea that there is a movement stirring and we want people to join in and be a part of it.

Dan:
I want to dive into that a little bit too, because I'm totally on the same page. And I think when I go out and speak, and I've heard others talk about kind of the old style leadership, people get confused of what does that mean? Can you talk a little bit more about the kind of foundations of what's not working and the kind of ways we should rethink that?

Lucy Leclerc:
Human-centered leadership, the challenges that we've seen in healthcare and the differences between human-centered leadership, which is our contemporary evidence-based approach to leadership. And for example, the business world is that we're dealing with complexity, complex environments. The environments we work in healthcare are made up of complex humans, they are customers. And then we have teams who are caring for them who are also made up of complex humans. So as we mentioned early on, this is all about leading through chaos and complexity with a human-centered approach. And how we got there was through coming together as experienced nurse leaders who had served our way into burnout by being really good at the metrics and the numbers and those parts of the culture, but we kind of forgot ourselves in the mix.

Lucy Leclerc:
And so what we think is very different with a human-centered leadership approach than the other styles of leadership that are generally borrowed in nursing, for example, transactional, traditional transformational servant is that the leader really is lost in those theories, is how we have viewed it. The gap there is the leader themselves and the self care of the leader, because that's where it starts. One thing we repeat it's our mantra is that it starts with you, but it's not about you. We have to take care of ourselves before we can take care of our teams.

Dan:
I love that. And one of the things I noticed with, like you said, transactional leader member exchange, all these theories that are out there up until basically complexity kind of conceptualize it differently is that all of those theories put the leader as being in charge and having power over others. And I think when you look at complex environments, while there's certain influences that the quote-unquote formal leader has, it's not necessarily the power that we've described it in the past. And we know that teams of nurses can quickly stop an initiative, rerouted initiative influence initiative, way more than the nurse manager or CNO, whatever name, the formal title. And so I think reconceptualizing this teamwork, this human kind of influence is so needed and it kind of frees leaders. I don't know if you see that when you talk about leadership in this way, it kind of frees you from having to be in charge all the time to having conversations and influencing people?

Kay Kennedy:
That's right. But it really takes being able to step away from that idea that the leader has to know everything. The leader can be more authentic and say, okay, I need to go to my experts on this and get their perspective and their insight and innovation to be able to come to a decision about this or that? That's really something that the bedside nurse would have more information on and answers about.

Dan:
Lucy, you mentioned the idea that we borrowed these theories, which is true. We pulled these from business literature and much of the research on leadership has done and the industrial revolution. And that's why on White guys that led big industrial organizations and that's why we're kind of sideways on how we conceptualize this stuff. But what's different about healthcare that you're finding and how do you incorporate those kind of nuances of both clinical leadership, but also the craziness of healthcare that maybe other industries don't experience?

Lucy Leclerc:
That's such a good question. And one of the first things I would say that's very different in healthcare that we've seen that's been documented, as you said in the research is the complexity of the system itself in healthcare. We have micro systems embedded in macro systems and that creates this architecture that is in some ways like the business world. But I think the big differentiator here is that our customers are human beings. And the second biggest challenge and something that differentiates us from the business world is that our customers are in a vulnerable place. They're sick, they need some type of care or an intervention, and the stakes are high for the patients and as we all know for the organization itself. And this leads to that a stressed-out pressured nurse or healthcare leader. The biggest challenge is trying to balance metrics while maintaining a human-centered approach. So what we see is turnover in leaders and frontline staff, and they're stressed out right now.

Dan:
I love your conceptualization of kind of the two buckets of leaders, the ones that people will follow them to the ends of the earth and the other ones that make employees want to quit. I've definitely worked for both, and in a recent role ended up quitting specifically because of the behaviors of an executive leader. And I don't think people realize how impactful that is to the team and to the individual. I mean, personal health, mental health, family health, everything spirals when you're working for somebody who in the way I described it was toxic. Can you talk to me about those two types and what maybe differentiates them?

Lucy Leclerc:
Sure. Well, I'm going to take you back just a few steps to logically get us to how we came to labeling these end-of-earth leaders as human-centered leaders and then the second bucket of make me quit my job. Early on in our journey when we did come together and I mentioned this before, is that we were super successful, Kay, and Susan and I, the third author and researcher who we work with. And we served our nurses, we changed cultures, but we forgot ourselves in the mix. And it was during those conversations early on years ago when we realized that there were leaders in our past, who we would fall to the end of the earth. And we also realized that we had worked for, and alongside leaders, you described as toxic, who made us want to leave the job or even the profession, we've seen that as well. But these questions motivated us to see if others felt the same way.

Lucy Leclerc:
So this is leading through our research journey, but we wanted to validate that what we saw in the end-of-earth leaders in our life was a similar concept with other nurses. So that led us through this research process, constructivist grounded theory, that we were able to get focus groups together. And this is really interesting to us is that we had IRB approval, we were getting our focus groups together. We had a list of questions, this long list of questions of what we were going to ask because we were afraid people wouldn't talk to us.

Lucy Leclerc:
And we only asked really the first question we said, "Describe the leader you would follow to the end of the earth?" And about an hour and a half later, we were still on the first question they were describing that. And we said, "Well, wait, describe to us the leader who would make you leave or quit a job?" And those were the only two questions we had to ask because there was cathartic, it was like a therapy session for the nurses, and we had nurses from bedside to boardroom. So that's how we came to the tributes and dimensions of what is human-centered leader end-of-earth leader looks like.

Dan:
What were some of the core behaviors that were identified there?

Lucy Leclerc:
That's interesting because what we found, because when we first talked about the positive attributes, who are the leaders you would follow to the end of the earth? And when we asked the opposite, they were counter concepts. They were, for example, if someone said that their end-of-earth leader was someone who would awaken their potential and help them get their certifications and grow as a professional. The opposite of that, the leader who made them want to leave was the leader who just expected them to come to work, do their job, there wasn't enough time, energy, or resources to help them grow. And we all want to grow in some ways. So that's one example. Kay, you can help me out on this. I'm trying to think there were so many too, but they countered. We're very appreciative inquiry focused so our theory ends up being about all the positive attributes. But Kay what are some of the other toxic behaviors that our participants mentioned?

Kay Kennedy:
One thing that resonated with me that we heard over and over was that the leader would take credit for something that someone on their team had come up with. They wouldn't give credit where credit was due, and that can be so frustrating and belittling really to people. There were so many things that just surrounded being a trustworthy person and knowing that that person cared about you as a person as well. Those were the sorts of things that were positive, and the negative just the opposite. You didn't feel like you had the respect that you knew you deserved. You didn't feel like you had the level of importance in the organization that you were look to for answers, any of that. You just felt more like you were there to produce. And that was kind of it.

Dan:
That resonates. And there's literature on that too. I mean, there's behaviors like the in-group, out-group kind of creation of you never know where you stand, the taking credit for things, belittling your contribution and getting excited about stuff that the leader cares about, but nothing that the team cares about. And then on the positive side, and you all know this, there's been a ton of research on what are the traits of leaders and the behaviors of leaders and blah, blah, blah, and there's never, ever been a list that has fit any situation. And so it's more of these kinds of ways of being in interacting that work. People are like, well, I'm a charismatic leader, ultimately that doesn't work all the time. So it's really how do you flex and make relationships with people and interact with them? That's the whole crux of it. Does that kind of align with what you found?

Kay Kennedy:
It really does. When we ask all these questions, we were able to line them up into what we called attributes and then divide the attributes up into three different dimensions for the outward focused leader. And the first dimension was the leaders focus on their own self-care, taking care of themselves and modeling the importance of self care to their team and making sure that everyone recognize that that was a priority, not just for the leader, but for all the team members as well. So we came up with these four different dimensions. The first one self, and Lucy mentioned that the tagline for our approach is it starts with you, but it's not about you. So self is the first one.

Kay Kennedy:
And then those outward focused aspects of leadership, the three dimensions are the awakener, the connector and the upholders. So that's the part it's not about you. So the awakener is really focused on developing and growing and cultivating those team members while the connector is focused on uniting the team. And then the upholder is focused on really the caring aspect. We say recognizing the humanity and self and others, which really boils down to the caring ability to connect and to show that you care.

Dan:
And we're in the middle of this, especially for nurse leaders, just a crisis that's gone on for close to two years. There's burnout, there's frustration, there's ethical issues, all combining into just pushing nurse leaders to the brink. We're seeing retirements, we're seeing people leaving the profession. How in the middle of this crisis can healthcare leaders, specifically nurse leaders take care of themselves and model that for employees?

Kay Kennedy:
Well, Dan, we want to get across the idea that self care is not a luxury, it's not just going to the spa on your day off, which would be really nice, but that's not what it's about. It's about a daily habit of honoring your mind, body and spirit, and it's really a form of self-discipline. And I kind of think about it as a responsibility that I have to myself. Because these small behaviors like daily meditation, getting enough sleep, trying to fit, exercise into your routine and walking your dog, these habits actually not only make you a better person, but as a leader, it makes you a better leader.

Kay Kennedy:
And part of that comes from the idea that when you're taking care of yourself, you have, or you demonstrate a higher level of emotional intelligence. I mean, if you kind of think about how you handle problems when you're wrested and feeling in control as compared to when you didn't get enough sleep and you're a little extra irritable, and you're feeling overwhelmed, this idea of self care, I think is so much more important than certainly I realized when I was in some of my past leadership positions.

Dan:
And I think one thing that I noticed and we've talked about on the show before is that self care is usually done after whatever the shift is. And for nurses, it's after the 12 hours you're expected to go figure it out yourself. A lot of times that's going to a bar or venting, or just compartmentalizing it completely and saying I'm just not going to talk about it anymore. For leaders, similar it's not part of their day, they have to do it on their own time. Do you have tips on how people can incorporate that into the actual workday and help their teams even if it's small little check-ins that can kind of set the tone and change the behavior from doing it on your own time to actually embedding it in the work?

Lucy Leclerc:
One thing we've seen and we've changed, we've shifted. I love that you used the word shifted because it means so much in nursing and how we work and how we think. And this is part of being that human-centered leader who can be a connector and engineer innovation within the workflow in the workspace. And we've seen hospitals around the country who have created onsite reflection rooms. And Kay has a good example from one of the hospitals here in Atlanta that set up a mic in a room and allowed the staff members to come in and just share privately but on this recorded venue how they were feeling to express and debrief? And then later the comments were shared back with the staff so that people didn't feel like they were alone.

Lucy Leclerc:
And we've seen debriefing as a great way to infuse and integrate self-care into the day is to know that nurses, whether it's at a scheduled huddle or an impromptu huddle that they can safely share how they're feeling about how their day's going and then of course, integrating that mindful pause. And this is something that we talk about a lot within human-centered leadership is that being mindful during our day and taking mindful pause allows us to reset whether it's the mindful pause before you get ready to walk into your next patient room, your mindful pause while you're hand washing. If you think of that how many times a day a nurse washes their hands? And that's an opportunity to take a mindful pause and reset. We think that's actually a really good way to integrate it into every nurse's day would be to take mindful pauses.

Kay Kennedy:
We're all familiar with nurses rounding on their team members, nurse managers rounding on their team members. And typically, there's a list of prescribed questions that are asked and we just think it would be so awesome for the leader to ask in addition to whatever things they're asking to also ask how are you taking care of yourself? When was the last time you had a vacation and what do you have coming up? We've heard so many nurses say that I guess because of their sincere dedication to their job, they feel like they have to get permission to take a vacation, I guess I'm primarily talking about leaders here. They feel like that it would be looked down upon in some organizations for them to take their vacation. And I just think that is something that definitely needs to change because people need their time off to reenergize and refresh themselves. So it's just I think important that that is kind of sprinkled through the culture.

Dan:
Especially with the frontline leaders, I think there's a stigma that if I take vacation my staff is going to get mad at me, the people above me are going to get mad at me, we're in this crazy crisis I can't take time off. And I think that just it's not helping anybody to have that mindset.

Lucy Leclerc:
That's exactly right.

Dan:
And not just vacation, but just any break, even cutting out at noon on a day when you're just not able to focus. I think those types of behaviors, and then helping facilitate your team members, your nurses, your frontline nurses to do the same thing, I think if we could have that culture in nursing, that would be amazing.

Kay Kennedy:
Absolutely. You sound like a true human-centered leader, Dan.

Dan:
I've just lived through all the not human-centered leadership and so I on a mission to stop that stuff.

Kay Kennedy:
We're with you.

Dan:
And you guys were talking about outcomes to it, and that's a big focus. And there is evidence that says that bad leadership can impact not only staff outcomes with burnout and that kind of stuff, but also patient outcomes are impacted by poor leadership. Can you talk about a little bit of the outcomes positive or negative that you've found as you've worked with teams on this?

Kay Kennedy:
Sure. Well, we like to say behavior drives culture and culture drives outcomes. One of the things that we're able to see an impact with is the healthy work environment. And like most nurses, we like to refer to the healthy work environment description by AACN. And there's really behaviors that are described there and those behaviors drive a culture. And what we found is we can crosswalk human-centered leadership with these specific behaviors. And it's just a really nice marriage and it produces a healthy work environment. So the components of healthy work environment, skill, communication, true collaboration, effective decision-making, appropriate staffing, recognition and authentic leadership. We are seeing an improvement in these things.

Kay Kennedy:
And there's a test and tool that you can use online that AACN provides to get a reading on the staff perception of the environment. And so we kind of like to use that tool to help determine before and after the improvements. But then when we go from culture to outcomes, we really expect to see with our program and our approach improvements in quality, patient safety because of the work of the awakener, the dimension on what I spoke about that focuses on developing the people. And then another important outcome is engagement, which really comes about from the connector, bringing together the team around the common mission, vision, and values, and brings in engagement, which then results in improved retention.

Kay Kennedy:
And then lastly, the upholder who's recognizing the humanity and self and others. The culture created there as one of caring. And caring really relates to an outcome of RN satisfaction, which has one of the magnet required outcomes through assessment tool. And then lastly, patient experience. I mean, we've all heard forever never happy nurses make happy patients. So these are the outcomes that we really want to impact through human-centered leadership. They line up exactly with the outcomes that magnet requires for magnet recognition.

Dan:
I think there's so much opportunity to just continue to link that. And then you talk about the upholder and the word that comes to mind, and maybe it's Tim Porter Grady like running around in the back of their but is accountability too. And accountability for these behaviors to actually occur and accountability to not do the negative stuff as well. How do you support that accountability piece?

Kay Kennedy:
I think mainly through ownership. It's about the engagement that comes from being trusted to come up with solutions to problems and being trusted to be one who owns their practice. I mean, accountability comes from that direction, not from a hierarchal direction.

Lucy Leclerc:
And I would add to that. It really has to do with the leader being comfortable in handing over some of the work that goes into not just identifying the problems, but the solutions and then allowing the people who are closest to the work to own the solutions. And one thing we've seen over and over again is that when leaders are able to give up that power they're astounded when more work gets accomplished with less of their input. Because no leader or that's where I think we kind of set our nursing leaders up for failures, that we expect them to know all the answers or they expect that of themselves. And that's where we have to start to give permission to leaders to say it's not humanly possible for one person to know the answer, solution and action that will bring about every possible solution to a problem.

Dan:
In long-term in a chronic kind of leader solving all the problems, eventually the team doesn't solve any more problems, they throw them up to the leaders. It actually creates a cycle of more stress and misaligned expectations and all that kind of stuff. So pushing it back down and facilitating the people closest to the problem to solve it, it gives them confidence to do it more and more. But also the leader isn't seen as this all-knowing person and also the blame and the accountability is shared now instead of on the shoulders of someone who isn't always equipped to solve the problems that are coming up every day. They're more facilitating how it happens and how people come together and connect and have trust rather than actually solving the actual problem.

Kay Kennedy:
Very true.

Dan:
I mean, we could go deep all day long on this stuff and I'm going to start pulling out all kinds of references and stuff. And at the end of the day, we all know the nurse leaders are stressed and are dealing with a lot right now. In our podcasts, we'd like to end the show with what would you like to hand off to them? So maybe I'll start with Lucy first. Lucy, what would you like to hand off to healthcare leaders and how can they tomorrow kind of enable the human-centered leadership concept?

Lucy Leclerc:
I would ask them to consider being part of what we think is this revolution in healthcare because we want to shift that tide from being completely numbers-focused to being human-centered again. And my ask would simply be for nurse leaders to embrace and live those attributes that the awakener, the connector and the upholder. And does that mean you have to go out tomorrow and make a lot of changes in your life? No, we believe if you start by recognizing the humanity in yourself and in others, you'll make a difference in the lives of those entrusted in your care. And if each of the four million nurses in the United States embrace this concept, just imagine the impact we could have on our patients, in ourselves, in our teams?

Dan:
I love that. Kay, how about you?

Kay Kennedy:
I guess I would just ask people to remember that it does start with you taking care of yourself and the impact as a leader you can have by modeling self care and prioritizing it through the organization? And then it's not about you, it's about empowering others. And so that's kind of the theory, in a nutshell, it starts with you, but it's not about you.

Dan:
I think that's a great mantra for leaders as well, it's not about you. Kathy Valic would say that a ton to me when I was doing my dissertation, Dan is not about you, it's bigger. I don't know if that's PTSD or just the group?

Kay Kennedy:
You've remembered it.

Dan:
Yeah, totally, totally. I remember them, oh, man, I still talk to them, but they're ingrained in my brain. You have a lot of great resources, you have the book coming out. Where can people find you and learn more about this concept and get more resources?

Kay Kennedy:
Well, thank you, Dan. We have a website, youleadership.com. And our book is coming out December 14th, you can go ahead and pre-order on Amazon. But we also have a reflective journal for bedside nurses that is called Shifts, and it is formatted in the S bar format. And the idea behind that is for bedside nurses to become more resilient through the practice of self-care and self-compassion and use the tool of journaling as a way to accomplish resilience. We just feel like it's a really important thing right now, especially right now, always, but the pandemic has just heightened the awareness of the need. So we have those two resources. And, of course, there's articles that we've written that you can find on the website as well. But the main thing is we could not be more thankful for the opportunity to get to speak with you today, Dan. So thank you so much.

Dan:
Well, thank you for being on the show. It's always awesome to talk to people and dive deep on stuff that I'm very passionate about too. And I think there's a lot of resources out there for nurse leaders to check out. We'll post the website and some of those resource links in the book pre-order on our show notes, so check those out. Kay and Lucy, thank you so much for being on the show. And look forward to a shifting and changing healthcare for the better in the future.

Kay Kennedy:
Fantastic. Thank you so much.

Lucy Leclerc:
Thanks, Dan.