1. Cox, Sharon MSN, BSN

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Q I'm replacing a unit manager who operated in a "mama manager" style by making top-down decisions and micromanaging. How do I set the tone of ownership and accountability rather than dependency?

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With the pressures inherent in healthcare, all too often managers regress under stress and get caught up in a hyper sense of responsibility, with the need to control making it difficult to move decisions out to those who must make them work. Your question reflects the insight that a manager's effectiveness is measured by what happens in his or her absence. The better you do your job, the less staff members need you; it's all about developing people rather than controlling people. Start by sharing your perspectives on management in the context of improving teamwork, morale and, ultimately, patient care.


To be transparent about your intent, use the 4 Ps as a visual framework:1


* Purpose-the why behind the what to develop a high-performing team and provide quality care


* Picture-key initiatives, systems, and structures to foster ownership of practice, such as unit-based councils or task forces, routine staff meetings with reports, behavior norms, and goal setting


* Plan-steps and time frames to develop team agreements or ground rules, skill set training around problem-solving and teamwork, accountability partners, bedside report, and progress toward unit goals


* Part to play-individual commitments to adhere to ground rules, use skill sets offered, assess personal learning needs, develop a network of peers from high-performing units to learn best practices, and attend specialty organization meetings.



Begin setting expectations by sharing three things you need from staff members and eliciting three things they need from you to work as a team. You might ask that when they bring you a problem, they offer an idea for how to solve it. They may ask you to share real-time feedback or advocate for needed system changes. Use this same approach at a peer level to develop three to four team agreements around what staff members need from each other to improve their teamwork. Examples include assuming positive intent; talking to each other, not about each other; and zero tolerance for chronic negativity. Discuss progress in staff meetings, focusing on what's going well.


Your value of teamwork will also be clarified by having the team read The Five Dysfunctions of a Team, which highlights key themes of trust, healthy conflict, commitment, accountability, and skill set development.2 It's worthwhile to perform a team assessment so staff members can decide which of these areas to prioritize.


Relative to the unit council, start with their "felt need" rather than assigning issues because this promotes ownership. Use a four-part process for problem-solving. State the problem on a flip chart and then ask, "How do we help this happen?" Follow this by brainstorming options to deal with the issue and creating an action plan. The action plan should include who will do what by when, the expected outcome, and who needs to know. This process takes less than an hour and should be shared in staff meetings. It highlights how to go from problem processing to being proactive and offers a good mental model for all.


Speaking of mental models, keep in mind that the overall effort in culture change is to move from dependence (a reactive victim mindset) to independence (ownership of practice) to interdependence in which staff members effectively collaborate with other departments, build networks, and take part in professional organizations. When you defer to your staff members' expertise on an issue, provide teamwork training, or fund a trip to a professional meeting, you're creating experiences that change what people believe. When their beliefs change, their actions change and when actions change, you get better outcomes. This is the nitty gritty of culture change.


Most important, model the behaviors you expect, pace yourself, and trust the process. Remember the adage "don't push the river, it flows by itself." When you see a light in your staff members' eyes, you'll know you're doing the right thing.




1. Bridges W. Managing Transitions: Making the Most of Change. Boston, MA: Nicholas Brealey Publishing; 2017. [Context Link]


2. Lencioni P. The Five Dysfunctions of a Team: A Leadership Fable. San Francisco, CA: Jossey-Bass; 2002. [Context Link]