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PROactive Management of Integrated

Services & Environments


Empower: Fixers to Enablers

In a complex health care setting transforming the nature of day to day interactions at the frontline takes time and patience. Unfortunately results orientation that is expected of middle and senior management puts an unhealthy premium on targets. Delivering results at speed often supersedes longevity and sustainability of a change initiative. It is thus not surprising that the focus becomes behavioural modification rather than shifting the culture in which a behaviour is entrenched. Hitting the target and missing the point is what plagues such change programmes.

As soon as one area of practice is addressed another pops up, and while fixing the second or the third, the first goes back to square one. In this approach when the spotlight is on, staff emulate the new behaviour, but might revert back to the norm as the focus shifts to something else. Sustained focus on behavioural modification to change the interactions at the frontline would be akin to playing whack a mole in a games arcade. As you hammer one down many more will pop up. This is not a sustainable approach to work and often underlies burnout in middle and senior management / leadership.

Within PROMISE we have found that the answer lies in tackling the mindsets that underlie the behaviour we are trying to address. It is the intangible soft stuff that dictates how we make sense of the world and what and how we do stuff in our microcosm. If we don’t make a conscious decision to grapple with it we will invariably go from crisis to crisis, reacting and fixing stuff (in health care fixing staff or patients as the case may be) and any proactive aspirations we have will remain as such – aspirations.

 ‘Aoccdrnig to rsceearh at an Elingsh uinervtisy, it deosn’t mttaer what order the ltteers of a word are in so lnog as the frist and lsat ltteers are in the rghit pcleas.  The rset can be a total mses and you can still raed wuothit a porbelm.’ SOURCE: Scott Keller and Colin Price, ‘Performance and Health: An evidence-based approach to transforming your organisation’, 2010.

Just a bit of context enables us to make sense of writing that is full of errors. So our mindsets tend to interpret the huge amounts of information available to us by filtering out some things and magnifying others, especially those that reinforce our existing beliefs.

As part of enquire and explore in the previous phase, our frontline ward staff were looking in a forensic way as to what they do now and asked themselves what should they stop, start and continue. For example when going through the therapeutic day they looked at how patients were woken up in the morning. Generally this happened just before the morning medication round when patients were asked to wake up and attend the clinic room for their medication. A suggestion was put forward regarding waking the patients up 10 minutes earlier with a cup of tea giving them the chance to get dressed and start the day on a positive note. The first reaction of the staff was quite telling about the underlying mindset. It varied from why did we not think of this before to this is not my job. Bit of exploration brings the mindsets to the forefront which went from ‘we can make a difference’ to ‘this is not a hotel’.

Through the technique of laddering one can trace out the thoughts the latter minset will give rise to – this is not a hotel – I am not a waiter – I am a nurse and they are a patient – we are blurring the boundaries and so on. Similarly we can make a difference gives rise to – they will start the day on a good footing – we will form a connection – this will help in therapeutic alliance and so on.

Now imagine a mindset that says ‘I am the professional I know how to fix you’ and contrast that with ‘I bring professional expertise, I value your lived in experience, I can help you help yourself’. Whether it be an interaction between staff and patients or between the leadership and the frontline, the interaction that stems from an enabling mindset will be quite different from a fixing one. Needless to mention that frontline staff will mirror the behaviour of the leadership in their interactions with patients thus leaderships actions set up a self-perpetuating cycle of mindsets and behaviour.


An old dog can learn new tricks, but it is very difficult for the old dog to forget their old tricks. It is often helpful in organisations like those in health care where staff might work a life time, to think of time in terms of eras, a practice that might have been acceptable in a previous era may be unacceptable in the next.