The Hunterdon Medical Center: Critical Mass and Emergence of the Goddess

"Kind words can be short and easy to speak, but their echoes are truly endless."

--Mother Theresa

A Story From: The Hunterdon Medical Center Told by: Birute Regine Illustration of:

• good enough vision
• multiple actions
• metaphor
• tune to the edge
• complexity lens
• reflection
• generative relationships
• paradox
• min specs
• tension
• shadow system
• from life cycle to ecocycle

Miracle in a Cornfield

Inside the bright and spacious office of Linda Rusch, VP of Patient Care at Hunterdon Medical Center in Flemington, New Jersey, is a wide, neat desk with a jar of hard candy on it, pictures of family and friends scattered about, framed degree diplomas lining a wall. In addition to the diplomas is the Governor of New Jersey's nursing merit award for outstanding leadership; Linda, was the recipient of the award in 1996. There is also a plaque from the Johnson & Johnson-Wharton Fellows program in Management for Nurse Executives which says "We solemnly pledge that we will be guardians of human compassion within our organization. And we will be courageous, foster patient care that treats the bodies and cares for the soul of the patients we serve, so help us God." As a leader, Linda not only embodies these sentiments but also expands them to include the staff and the community. It seems fitting that she has found herself at Hunterdon, whose logo is a heart and whose claim is "caring from the heart."

Principles
Good enough vision

Forty-five years ago, Flemington was a rural county of 46,000 people with 25 general practitioners. The vision of Hunterdon Medical Center, inspired by Dr. E. Corwin, was to be not just a hospital, but a model medical center that would be an integrated system of health care services. A unique relationship was forged with local doctors to actualize this vision. General practitioners would be automatically admitted to the attending staff of the hospital, specialists would be chosen based on community need, and an affiliation with a medical school would be established.

A massive volunteer effort ensued, which raised more than $1.2 million. Seventy-five percent of Flemington's citizens contributed to the fundraising campaign, at a time when the average annual income was about $3500. From this collective community effort, the medical center manifested, and was what many considered to be a "miracle in the cornfield." With such beginnings, it is no wonder that Hunterdon would focus on caring for its community--by providing health education and activities designed to meet its physical and emotional needs; and by providing preventive as well as curative services. It would be, it promised, the best community hospital in the region. Karen Simms, who has been a nurse at the medical center for about 30 years, reminisces:

"We used to get up in the morning, and we'd see deer in the field out there. Some of my patients were farmers then. I remember one of the nurses that I worked with used to milk the cows before she came to work in the morning. Now the world has changed a lot and is constantly changing, and the town of Flemington has changed drastically as well. We're getting built up and the farmland is not what it was. Now you see a great big parking lot and a lot of new construction where fields once were. The medical center has changed with managed care; we've had to drastically change how we do our nursing care. But the nice thing is that this hospital, despite the changes, still maintains that community feeling. "This is a family-oriented hospital. We know these people when they come in the door. It isn't just "Patient in Room 425." It's Mr. Blue down the street, and from whom you buy vegetables. I see people that I helped deliver into the world come in having their own children. I can't tell you the number of people that I have seen in Shop-Rite that come up to me and say, "Hi, Mrs. Simms. Do you remember me?" It's a really great feeling. We know the people here because we live here; it's our community. It's not only me as a nurse, it's me as a person who lives on Hill Hollow Court.

Today Hunterdon Medical Center, a not-for-profit, 176-bed facility and part of the Hunterdon Healthcare System, continues to demonstrate its care for the patient and community. For the past several years, Hunterdon has consistently topped the charts in patient satisfaction regarding nursing care. In 1998 they averaged 95 percent and in 1999, 97 percent.

Community Focus: The difference between wanting to and having to

As is Hunterdon's mission, creating wellness and community health is also very much Linda's focus as a leader, and for her, at the heart of reframing health care itself. As she told us:

"When you think about it, we make money from the illness and disease of our community. When you look at the hospital census and the beds are filled, you think, we're making money. Now, that gets stuck in my throat; we can't think that way anymore. We need to make money, of course, but I wonder if there are different ways of doing that. If people are sick, you certainly want them to come to your hospital, but the essence for me is, wouldn't it be wonderful if we could survive as a medical center by keeping our community healthy? Not just physically, but emotionally and psychologically as well.
"That's what I'm striving toward: how do we embrace this community of ours and give them services that they want, so that they have a higher level of functioning? That's why, seven years ago, when I came on board, we started with these questions: How do the Medical Center nurses care about their community? What would it look like? How would we behave? We then made a banner that we took to all our community programs that said, HMC nurses care about their community.

Principles
Multiple actions

Aides
Metaphor

Principle
Tune to the edge

The thinking behind this for Linda, who is a big proponent of the principles of complexity science and their relevance to a new way of working, is to encourage people to make changes in places that they feel they can make changes, recognizing the power of small changes in complex systems. Small changes have two pathways in a system. One is like a drop of rain falling on a still pond--a small change can create a ripple effect; that is, it replicates and spreads throughout the system. Qualitatively, the newly introduced behavior is the same, but it is now to be found throughout the organization. The second is like the grain of sand that falls on a sand pile, causing large avalanches of sand. That small change initiated the emergence of something qualitatively different, and much bigger than the original change, as pent up energy in the system gets released: something old collapses, and something new emerges. In the first case, the rippling of a new change throughout the organization leads toward the building of a critical mass, leads towards the system being poised at the edge of chaos, the edge of great change. The second case represents the release of energy simmering in the critical mass, leading to large change. The two combined represent the pathway to creative adaptation for an organization. Linda's genius is in building a critical mass in the organization, the essential first step to eventual, though often unpredictable, great change. The importance of small changes in Linda's thinking is immediately evident on her office door where a quote of Ghandi's is taped saying, "What ever you do may seem insignificant, but it is most important that you do it."

The result of Linda's question and challenge to her nurses--'How do the Medical Center nurses care about their community?'--was a sprouting of many community projects, all initiated by the nurses, many small changes in the hospital's relationship with the community. A critical mass of reaching outward into the community was building energy. As Linda puts it, AThe hospital is like the hub with spokes going out into the community in different strategic areas."

One of the most astounding aspects of these ongoing, evolving projects is not just that they are outcomes of nurses seeing something that needed to be done and then doing it, but that they are on a completely volunteer basis. The time spent is their time; the money spent is their money. As Linda says, "We're not making anyone do community work. You can't make people do that, saying it's a condition of your employment." The nurses do this not because they have to but because they want to. This volunteerism, when translated into monetary community benefit, has been on the rise since 1995. In that year, the volunteer dollar was $112,570. In 1999, it was $424,034.

What these nurses have wanted to do is participate in many health fairs, which started with the local Shad Festival and now includes the Lanape Health Fair. At the Shad Festival, which takes place over two days each year, volunteer nurses, wearing blue t-shirts saying 'Hunterdon Medical Center nurses care about our Community,' provide free blood pressure tests, and educational material, such as on Lyme disease. At the Lanape Fair, every nursing unit sends a representative to educate the community, on concerns such as managing stress, identifying depression, preventing falls.

Several nurses wanted to volunteer for training in March of Dimes, and are now going out on engagements, speaking about maternal/child health topics. One nursing unit adopted a homeless family during Christmas, and all the nurses personally donated money. A group of OR nurses created a community forum for people to become familiar with laparoscopic and orthopedic instruments, and to meet "Aesop" the robot who holds these instruments in OR. In this way community people could become familiar with surgical procedures, and would be less frightened should they one day undergo these procedures. Children are brought to the OR before their surgery for the same purpose-to familiarize them with the area and to ease anxiety about surgery. The maternity ward set up a infant car seat program in collaboration with police and car dealerships in order to teach people how to put a car seat in properly.

Although Flemington, being an affluent community, may appear to be the idyllic life, it is not exempt from drug use and domestic violence. In response to this community need, the maternity unit set up a domestic violence program in collaboration with the Women's Crisis Center and the Prosecutor's office. Inspired by nurse Karen Simms, this program in many ways reflects the changing needs of the community. Karen explains:

"I think the growth and the population and the clientele has changed and has opened our eyes to things we were not exposed to before. Our job is to be responsive to these issues. What questions should we be asking patients to identify them as victims of violence? How do we keep people from falling through the cracks? How can we inform people about what to do and what can be done?"

In response to these questions, the domestic violence program provides seminars open to the community. Some nurses wanted to involve schools, so the nurses went out to the schools and talked about things such date rape drugs. Others collected money for women's shelters at Christmas time. Still others took on the responsibility of decorating and maintaining one of the rooms in a new shelter for women.

Principles
Complexity lens

Nurses are experimenting with more effective ways of training nurse graduates. As part of their orientation, new nurses personally experience what it might be like to be a patient-they're put in johnnies and into beds, sometimes even restrained. They are also taught complexity ideas as part of their orientation, as a biological model for thinking about the workplace and the insights it lends to areas such as risk management.

These efforts also went beyond Hunterdon, and included collaboration with other health care centers. For instance, Linda and nurse executive Mary Anne Keyes of the nearby Muhlenberg Regional Medical Center joined forces and have gathered their staff together in order to cross pollinate ideas and to collaborate in and explore changes that can be made within the next three years, with a goal no less daunting than transforming health care itself.
All these initiatives have been enormously successful. All these efforts, without anyone getting paid. All this, because they wanted to.

A Critical Mass

When health care is in crisis, and most nursing staff are disgruntled, anxious, stressed, and morale is generally low, how is it that Hunterdon nurses are doing such incredible things above and beyond their job? This might be thought to be related to the fact that Hunterdon is economically in the black. Should there be layoffs, one might speculate, people might be less interested in volunteering. Even so, not all hospitals that are economically sound get such a burst of creative giving and such a commitment to improving health and wellness in the community. In fact, CEO Bob Wise believes there is a correlation between the hospital's success and its nurses' efforts at participation in the community:

"I can't avoid seeing the relationship between the hospital and the community as a reason for our financial success. We extend ourselves beyond the walls of the hospital and into the community, and community responds to that. The people see the commitment and the nursing care in the community, and then they want to go to our hospital for care because they know they will get good care. It's a positive feedback loop that's driven by the nurses' care and their commitment to the community. It's not just their professional skills, but the relationships they create and the philosophy they live by, which is to extend yourself beyond your job and make a difference in the community.

Linda explains the nurses's community commitment and involvement in this way: Debbie Summers, a clinical nurse specialist;

"They somehow embrace it; there is an expectation that we should be doing this. It's like, here's the buffet, and if you want to come to it you can. I was at an Education Council meeting and all the nurses were talking about volunteering for all these great projects, and a new nurse from ICU came over to me and said, "What should we do in ICU?' And I said, 'What do you mean?' 'What project should we be doing?' she asked. I said, You don't have to do a project. All the nurses did it because it was their own thing, it was their creativity and what they wanted to do.' But she felt compelled--like she should be doing this. And that's the critical mass."

And that's the small changes rippling through the system, replicating themselves throughout the organization, and growing exponentially. As this critical mass builds, one of the small changes has the potential for having a huge effect on the health care system. And as the principles of complexity science indicate, we can't know what or when that major change will be, but the conditions are ripening at the Medical Center.

The conditions are ripening, largely because of Linda. Linda is a charismatic leader, a petite powerhouse of positivism, who invites and inspires the best in people. It is easy to see how people would want to please her, not disappoint her. Here is someone who sincerely looks you in the eyes and really wants to know how you are and who you are. Here is someone who will hold your hand as you walk together down the hospital corridor. Here is someone to contend with.

It is through Linda's efforts that she evokes the notion of the goddess: a collective feminine energy--complex, powerful, and wise.

The Goddess

You may wonder how the goddess might be relevant to health care and to a complexity style of management. First, it is relevant to be considering the most effective use of feminine power in hospitals, simply because they are predominantly staffed by women. At Hunterdon, women comprise 85 percent of the staff. In Linda's case, the 350 people and 18 departments she oversees, are 96 percent women Secondly, the creative power in complex adaptive systems--that is the rich interactions among its agents--is largely a feminine (but not necessarily female) power; that is, generating connections and cultivating relationships.

CEO Bob Wise recognizes what many others may overlook-the importance of appreciating and supporting the feminine side in health care. Perhaps his understanding can be traced back to his days in high school and college when he worked as a nurse=s aide or as an orderly, and personally felt the challenge and satisfaction of this kind of work. Or perhaps like many masculine men, he also has what he admits, "a strong feminine side." As Bob said,

"I just talked at an orientation of new employees. All but two were women. There were a number of nurses joining us who I especially appreciated. Many nurses today are beginning to feel they are undervalued or even devalued for the work they do and the responsibilities and pressures that they have to deal with. If organizations don't respect them and provide a nurturing environment, they choose to go elsewhere or leave the profession all together. Nursing takes so much energy-there are no days off from compassion and this needs to be seen, listened to, and respected.

"I mentioned to this group that health care has always been dominated by women because of their compassion and commitment to care. And women like Florence Nightingale, and more currently, Mother Theresa, have had dominant roles in changing health care. And that holds true today.

"Since the 50's and into the 90's, the masculine side has been in charge, a testosterone driven model that generated hierarchy and kept men at the top and in positions of leadership. It's the feminine power of health careBthe sensitivity, the compassion and its expression, the care and personal relationshipsBthat we value here. And I believe those hospitals who value the feminine side and support it will be the hospitals that will succeed."

To embrace feminine divinity, the Mother Goddess, who embodies the cyclic mystery of life, death, and regeneration, is to recognize its obvious pertinence to a female population as bearers of life, and especially to the nursing profession who partake in and are witness to all these mysteries daily. Embracing the goddess and feminine power is a way for nurses to reclaim nursing care in their own terms. This is what is happening at Hunterdon.

Images of the Great Mother Goddess, who gives birth to all creation and also takes it away, goes back to prehistory. In Neolithic times, she reigned supreme, where maternal power emphasized union and interaction rather than strife and competition. In this way, the feminine perspective is more akin to a complexity science way of thinking, because of their common focus on the importance of interactions among individuals rather than on individuals themselves.

Over the ages, various manifestations of this primordial force unfolded and diversified. In the Iron Age in Babylon, the goddess was put aside as the mythology of war came to dominate, and the hero became a mighty warrior. But she reemerged in Greece in the eighth century, not the same supreme power she once was, but nevertheless a powerful presence. Among the Greek goddesses, one who could be regarded as the patroness goddess of complexity science is Gaia. Gaia, the last goddess of earth and born from chaos, still evokes the image of the mother of all. The name Gaia has had a recent revival as people are becoming aware of the global ecosystem, and the physical system of which it is part, and are beginning to recognize the strains we are putting on it. The Gaia Hypothesis of physicist James Lovelock proposed that the planet Earth itself is a self-regulating system, a whole organism, the ultimate complex adaptive system. A Gaia-inspired way of thinking thus urges that we consider the earth and her creatures as one whole--interwoven, interacting, and interdependent; that we are a part of rather than apart from each other. Once considered on the fringe of science, Gaia-inspired thinking has now been brought into the mainstream, and it brings with it the mystery and a reverence for the planet as being alive and on whom all life depends.

Like the Mother Goddess, Linda has put her primary energy into cultivating positive interactions, knowing that trying to eliminate negativism in the work place is the way to influence a positive critical mass and a constructive emergence. She creates unity of purpose by setting an expectation of cooperation, rather than negative competition, and by posing questions of connection to her managers: Who do you need to make connections with? Are you checking with your people to see if they feel connected and safe? What are you connecting to in terms of the whole organization? These strategies cultivate varied, rich connections that are the key to an adaptable and innovative organization. As Linda says, "You have to really collaborate with other departments and the communityBhospitals are not silos. In complex systems, you can't make a decision and expect it not to effect somebody else, either directly or indirectly. So collaboration is so important. Everyone talking to one another." Linda engages feminine power by encouraging plentiful connections and experimentation, which in turn generates a dynamic connectedness and a burgeoning critical mass.

In league with Athena, set your hand to work

From these rich interactions, another goddess energy has emerged at Hunterdon Medical Center, one that is more complex--Athena, the goddess of wisdom. The goddess Athena is often overly simplified and depicted as a severe, helmeted and girdled goddess, the unvanquished warrior and guardian of the city Athens, which was likely named after her. But there is an older and less known image of her as a wild and awesome goddess wreathed in snakes, that wind around her head as hair and as a crown. The head of a serpent, the symbol of life and death, is held firmly in her left hand.

It is this central polarity between the serpent and the helmet, that creates a fundamental inner tension and makes Athena a complex goddess--where the feminine, matriarchal character is in relation to patriarchal ideals, where feminine and masculine meet. And from this tension, Athena comes to embody a new relation to instinct--a self-discipline and a way of organizing that can make civil order possible. She is the emblem of lucid intelligence that can see beyond the immediate satisfaction. Her wisdom is practical foresight and counsel, and the capacity to reflect before impulsively acting.

Because of this merging of masculine and feminine, Athena has many divergent spheres of influence. She teaches weaving, and all manner of handicrafts, such as building, whose success depends upon holding in mind an image of the end. She embodies civilized action as a balance between expressing an impulse and restraining it. Instead of Amight is right" and demonstrations of power that defined the territory of the gods, she is reflective, creative, and adaptive. Where Poseidon provides a horse, she invents a bridle and builds a chariot. Where Poseidon rules the waves, she builds the first ship and rides them. Where Poseidon's gift to Athens is a salt spring gushing upwards from the depths of the earth, hers is a carefully cultivated olive tree, whose oil was the prize.

Linda too engages in similar activities. Like Athena who cultivates groves which renders the gold of olive oil, Linda cultivates and organizes her environment so that a human, caring, and complex order is possible. Like a weaver, she holds the image of a positive environment and weaves this image throughout the organization. And like a warrior, she protects her organization and people with masculine analytic skillfulness and with the ferocity of the maternal instinct.

In this section, we discuss these aspects of Linda=s leadership, largely in her own words. In our experience of work environments, we found Hunterdon to be among the most evolved as a connected and robust culture. The connection and care among staff was palpable, visible, and very present. This atmosphere can be largely attributed to Linda, who started these efforts alone, and has since gathered a critical mass of change agents, eighteen to date, who promote the complexity way of management, a way that also evokes the goddess.

This is not to say that Hunterdon, like other hospitals, doesn=t have its struggles and difficulties, which of course it does. When Linda joined Hunterdon, the staff was suspicious and disheartened, and developing trust and a new way of working was a struggle, and at times painful. And even today Hunterdon is not utopia. Nevertheless, we will focus on the positive behaviors evident at Hunterdon, the collective endeavor, evolution and effort of all the strong women which has led to what we believe to be a new point of reference for what is possible in hospital environments, for what health care can be, and Hunterdon nurses shows a way of getting there.

The Cultivator

Linda, who calls herself a "cultivator" rather than a leader, has thoughtfully and carefully cultivated a critical mass--of people wanting to participate and contribute, and thus plentiful interactions-from which an environment of a higher order and a greater depth emerges. Essentially Linda cultivates an environment where people want to come to work, "where," as Linda says, "people can have fun and laugh and feel secure and can be very creative." And it's happening; you can feel it in the hallways, on the units.

Setting High Expectations

Linda cultivates a higher level of functioning by appealing to a higher self in people and speaking to the health, that is the desire to grow and learn, within a person. She cultivates the higher self by setting a standard of high expectations. High expectations become a form of guidance, and like a simple rule from which new patterns can emerge, people recognize the paradox of expectations, at once pushing and letting go, as nurse manager Carol Fiorino observed, "Linda's very hands off, but the expectations are way up there. The status quo is not okay." This is how Linda sees it:

"A cultivator puts out expectations. I have this part of my personality that we have to be the best-the best nursing care, the best hospital, the best manager. It's taking pride in your work. Every year, I keep raising the bar, and I think the staff likes that. I have very high standards and I don't tolerate mediocrity. I can be real tough. There's nothing wishy-washy about me. I can love you to death, but you know what? You've got to do your job. I'll work with my people when they're having difficulties, but if they can't do the job, they'll have to start looking elsewhere. It's a very strong message. You better do your job.

"As a cultivator you have certain things that you like to have happen. One of the things I want to see happen generally is a lot of interaction, people talking to each other. For example, I said to the nurse managers that one of my expectations was that they would have a nurse/physician collaborative breakfast or lunch once a year. The idea was for them to come together as a unit and talk about how they together can make things better. That's all I said. Well, you should see what they did with that. It's not once a year. It's three or four times a year, and it's not just doctors now. They have other departments coming in. As a cultivator, it's important to keep reminding people why they are here-to improve things and to take care of the patients. Isn't that the higher order of life, to know we can make a difference in someone's life?"

Freedom and Responsibility:

Linda cultivates a higher level of functioning by giving people freedom and responsibility. This context was formally established through a process called shared governance, which allows each staff nurse to be involved in the creation, design and implementation of their practice and systems that effect their patients. Shared governance values participation, cooperation and accountability as a way of building a strong social network system. These democratic ways are also a way to engage the nonlinear dynamics in a system because they encourage diversity and again lots of interaction in the system, which is the stuff of a critical mass. As Pat Steingell, director of patient care services, says, "I have the freedom to be able to do what I want to do. Linda may want to know why it makes sense to do that, but as long as I'm prepared, she's going to go with what it is that I want."

Everything is Relationship

"Everything is relationship," says Linda, and cultivating relationships is one of the greatest strengths that she brings to the Medical Center. Linda explains:

"My job is to bring all the relationships together, and help people learn about relationships, like teaching conflict resolution. When people are afraid of hurting people, they don't resolve conflicts, and that's very dysfunctional. The relationship gets deeper and more meaningful when you can resolve the conflict. It's about staying in conversation with someone when a problem comes up. Pick up the phone and say, 'Can we talk about this?' You don't have to go through your manager."

Developing the world of relationships gives access to non-linear processes in complex adaptive systems, from which come unexpected results; but it also requires an enormous skill-both intellectually and emotionally. The world of relationships is messy, and many leaders and manager's shy away from fully engaging this dimension. Linda, who is also a trained family therapist, recounts a story which reveals not only her powerful insight into relationships but also the depth and the level of attunement that she has cultivated in her work relationships:

"One of the nursing units have staff that goes away together every year-it's the girl's soul trip.' This one year they were going to Bermuda. There's always nurses to cover for them, but I feel that the manager and the assistant manager shouldn't both be gone-it puts too much responsibility on the office if problems crop up. It turned out that on this occasion they were both planning to go. I was upset about it when I found out. I hadn't expected that. The manager, realizing I didn't know the plan, said to me, You decide. Tell me what to do. And I said, 'No. I'm not going to tell you; you make your own decision. In other words, I was saying you're a grown up. But she knew how I felt. When I came to work on Monday, I found out that they had both gone. The manager made her decision and I wasn't going to demand that she not go.

"What happened was, as the manager was splashing away in the water in Bermuda with everyone else, she realized she wasn't having fun. She couldn't stay in the water. Everybody saw her leap out, crying, and no one knew why. She couldn't wait to get back to her room and call the hospital. I was pulled out of a meeting and was told that the manager sounded terrible and to call her right away. I thought something terrible had happened. When I got on the phone, she was crying. She said, I can't believe I did this. I can't believe I disappointed you. I can't stand knowing you don't think highly of me.

"For me, that's all it took. What mattered to me was that she felt bad enough to call me, and cared enough about how I felt. I said, 'It doesn't matter. What matters is our relationship and, you know, our relationship has just grown--it's on another level because this happened to us.

Bringing Out the Best

As a cultivator, Linda works at seeing and bringing out the best in people. "All you need are seedlings," she says, "and they're there. They just need a little water. That's how you cultivate." In the following example, Linda brings out Athena, the reflective warrior, in director Pat Steingall by redefining Pat's relationship to her impulse. This is how Pat recalls it:

"I was one of those people who thought they were going to change the world, but I did it all wrong. I would be in a meeting and I would always see the other side of the story; I would always go for the underdog. Then Linda said to me one day, 'I love your enthusiasm. But think about this for a minute. You need to learn to pick your battles. If you're going to have to stand up all the time and really make everybody else see the other side with such force, pretty soon you're just going to be seen as, not somebody with great ideas or of seeing the other side, but as somebody nobody wants to listen to because--there she goes again.'

Her telling me that changed me greatly. Now before I open my mouth, I think about how passionate I am about this particular topic before I decide to step in and whether it's worth sticking my neck out for. If so, then I really need to look at this more carefully. Linda's given me that ability to have a different focus on what I'm doing. She helps me as I change, stumble and grow."

The Weaver

Weaving Stories As we said, weavers need to have the ability to hold an image to the end, but as in complex systems, you don't know exactly how that image will manifest itself. The image Linda holds is a creative and caring workplace. And she keeps this image alive by amplifying all the positive things that occur in the workplace which in turn becomes a way of perpetuating positive energy. Positive interactions generate positive feedback loops, which affect the quality of the energy in the system as a whole.

Linda weaves a web of stories, and through her actions she teaches others to weave. Webs are built from the center out, and it is a never ending process. As Sally Helgesen states about social webs in the workplace in her book, The Web of Inclusion, "The architect of the web works as the spider does, by ceaselessly spinning new tendrils of connection, while also continually strengthening those that already exist." The image of weaving is one of the most ancient associated with the female domain. The spinning goddesses of Germanic and Greek myths are also the goddesses of fate. From a complexity view, interweaving the past with the future forges new connections and strengthens existing connections which ultimately influence the direction and the health and yes, the fate, of the whole system. Following is a story of Linda, at the center the web, holding to her vision of the workplace and keeping it alive by weaving stories that strengthen and create relationships. A never ending process.

"I parked my car the other day and this doctor pulled right behind me. I didn't know who he was; all I knew was that he had to be a doctor because he parked in the doctor's parking lot. I said 'Hi, you're a doctor, aren't you?' And he says, 'Yes, I'm Doctor Pizzi.' 'Oh, my goodness,' I said. 'I heard so many wonderful things about you.' He said, 'You did?' I said, 'Yeah, I've heard that you do the most incredible cervical fusion in no time at all and these great laminectomies.' I knew this from Donna Cole in the OR. He said, 'Thank you very much. This is a wonderful hospital.' 'What do you mean?' I asked. 'The environment, the staff, they're just so great.' 'That's really nice to hear.' I said. 'Don't you do most of your work at another hospital?' 'Well, I used to, but I pretty much do all my cases here now.'

"So what do you think I did with that information? I called Donna Cole right away. See, that's the thing I do. Anytime I hear a compliment or information about somebody, I make that phone call almost immediately. Then Donna gets the information that the OR staff's work is appreciated, and she feels good and she tells her staff and then they feel good, too. That's the flow. That afternoon I had a shared governance meeting with 12 staff nurses and I said, 'Do you want to hear a great story I heard this morning?' So that's the kind of story telling that goes on. Anytime you hear something wonderful like that you go right away to that person and tell them, by phone, by notes, whatever it takes. You look for those morsels, those flows of positive energy and spread them around, like milkweed. You have to name this stuff because otherwise it gets lost.

"My whole thing with the doctors is servant/leadership. Doctors are one of our biggest customers, and so it's important to find out what makes them happy and if they feel supported. OR is notorious as being a horrible place to work-very temperamental and volatile, even abusive. But that's not tolerated here because these is too much care in that place. They literally hug each other. The doctors bring in food almost every morning and sit with the nurses in a big kitchen. And they just hang out together. They'll never give up that room because they need that room for everybody to sit around and talk. Donna Cole did a survey of surgeons in our OR. Of the 70 percent of doctors who returned the surveys, 100 percent rated the OR staff as 10, the tops."

The Protector

By being Selective In order to protect and sustain the emerging culture, Linda and her managers are careful about who they include when they hire, and as Linda says, "prune those who are not the best fit in the culture. The most dangerous trait in people to this environment, says nurse manager Carol Fiorino, Aare people who don't care. If I see that in someone, I don't want them here."

"Pruning is important for setting those expectations," Linda says. "I meet with the nurse managers and we call it "liberation"--its giving ourselves permission to prune. When we see dead branches on a tree, we cut them off so that it doesn't take the nutrients out of the whole tree. It's the same with organizations--people who take away from and drain rather than contribute to the whole need to be pruned. Some managers have difficulty with pruning, but it's easier when you think of the whole and what benefits the whole. And here again, a critical mass is building in their way of thinking, which is-->It's alright to prune because we have to be the best in nursing care and we have to be the best hospital. 'So there's a critical mass of pride."

By being Supportive

Although Linda may be tough and set high standards and expectations, she is equally as supportive of her people and their efforts. Without support, an environment of high expectations could easily tyrannize rather than inspire staff. Through support, Linda creates an ambiance not only of excellence but also of care. Linda sets an example through her own behavior and asks nothing more of others than she expects from herself:

"When problems come up, my staff knows that I am there for them. That my door is always open for them, and that I will really extend myself to them. They know I would go to bat for them and defend them to the hilt. I support them because I want them to look wonderful; I want them to really succeed. "For example, the first two quarters of this year [1999] our census was full and the nurses were doing a lot of extra shifts to care for all the additional patients. We asked them if they wanted to go on divert; we would support whatever they decided. They decided they didn't want to divert, that they would figure it out because they didn't want to let the community down, despite being as tired as they were. Some would even stay overnight at the hospital. So we brought in massage therapists for them; we'd bring in pizza when they didn't have time to eat. The Human Resource person and the Information Systems person would make rounds with me, asking them what they needed and how we could help. It's a way of showing them that managers support them and that we care about them. In the end, it's the little things that matter. And it was those little things that nurtured them, that kept them going.

By being Sustainable

Although in non-linear systems, leaders/protectors can't predict, they can anticipate. The sustainability of a hospital rests partly on the leader's capacity for foresight, on their level of sensitivity to and awareness of external forces that can affect the system. And then to have the agility to act quickly. Here is an example of Linda protecting the organization, like Athena protecting Athens, which ultimately influences the organization's sustainability:

"I was meeting with my managers, and I told them this incredible story I was hearing about these national surgery chains coming and trying to lure the physicians away. The only thing I said to them was, 'Look, take the notes you've made, read them, and just think about these barracudas coming.' I don't know why this metaphor of the barracuda came in, but they laughed. I view this hospital as this wonderful sanctuary and these barracudas are swimming all around us. 'They smell blood,' I said, 'and they are out for the attack. What can you do? How would you create your product line to insure that the barracuda wasn't coming in? Now go do it.' That was all I said. And they laughed, but they knew exactly what to do. I told them to come back in three months.

"The story is about survival. We have to position ourselves so that we are competitive and so that we can survive as a hospital and create the greatest environment for the physicians so that they want to stay. So my role is to protect us. I'm the protector of the organization, because these barracudas might come in. So I want to make sure that we keep our docs happy and that we're doing the right thing by the patients."

The Wild West Women

The complexity-science message of building a critical mass through small changes has spread through the hospital as a fundamental strategy, whether people know about the science or not--the ripple effect. And from this critical mass the power of Athena has emerged as a fractal phenomenon at Hunterdon Medical Center. All the elements of cultivating, protecting, and weaving, set into motion by Linda, have replicated and are manifested in their own unique way in different departments. In particular, the unit headed by Carol Fiorino, the nurse manager of the 48 bed medical/oncology unit, known as Three West, has taken the wisdom and complexity of Athena and evolved it further. They are like Athena in her restrained wildness-boisterous, flexible, women, strong women with strong personalities, who under these conditions are discovering themselves and coming into their own. As Carol says, "We're rough around the edges; we're kind of loud; we laugh loud, like the Wild West. And when chaos comes, and chaos is always rearing its head, we know we can get through it. I feel sorry for our husbands because we are not the same peopleBnone of us. I was a homebody before, and now with this independence and freedom, along comes this mouth. The sweet little shy girl my husband married doesn't exist anymore." The goddess rises.

Cultivating

Like Linda, Carol deplores the status quo, because as she says, "it gets boring." Here is how Linda's message of cultivating freedom and responsibility comes forth in Carol:

Principles
Tune to the edge

"As a leader, I need to go out on all kinds of limbs. The expectation is to get out there. It's okay to make a mistake, but you've got to recognize what you're doing and look back and determine what you could have done better. The fear that an idea won't be accepted is taken out of the equation, so it makes us very bold. Women are untapped, I think. I just feel that we can be more, but a lot of time people put their thumbs on us, and it's whether we allow it to happen. I feel very free here. Free is my word; I love it, and I encourage it. Before I was pressured to be somebody other than myself, to be on this cow path, and stay exactly on the line. Now I can do what feels right to me. Now, I'm so far out there, there's no way back"

The standard of high expectations manifests itself in a unique way in Three West. The women have created a positive feedback loop, in which they are pushing each other to be more, and do more. By way of Carol's example, for instance, they push each other to go to school to increase their education. And this has become infectious throughout the floor.

As nurse Mary Balut says, "We push each other and say, 'Come on, why don't you do this? We'll do it together. We do a lot of things together and that makes it fun to be creative and innovative. One nurse who left and had come back to our floor said to me, 'I haven't thought about going to school, and I don't even want to go to school, but coming down here, you people drive me crazy. Now I feel I have to go back.' She went with us for a semester. It's that you start to want to keep learning and when everyone is doing it together-you don't want to miss out on anything." Another critical mass builds.

Weaving

Carol, like Linda, has a strong instinct to be in the right place at the right time. As Mary told us, "She's knows where to be at what time, for her staff and for the floor itself, because she keeps circulating to see what's going on. She keeps informed, so that when there's something that needs to be done, she'll know about it." This behavior keeps the lines of communication open, so vital to adaptability in complex adaptive systems. Her instinct lends itself to her being privy to stories that she then weaves among her staff. As Mary says, "If somebody is doing something good, and somebody always is, Carol makes sure that everyone knows that person is doing something good. So it's constantly keeping something positive going. It's a rollover effect." That rollover effect is positive energy that feeds on itself.

In a similar spirit, the nurses weave patients'= story as a way to take better care of them. "It's more important to the patient that we listen to them and learn their story," says Mary, Arather than just do the daily routine, like baths or whatever. Sometimes they want to call their daughter, for instance, and we help them do that."

From this focus on stories, the nursing staff tell each other "stories from the heart,"of giving and nurturing. Here people's stories of going the extra mile for a patient are circulated so that more people are aware of the positive and powerful things that occur daily. Following is a Wild West Women's story of the heart and of feminine power, a story where the goddess surrounds and abounds.

Endless Journey

A woman from England was admitted to Three West several times after being diagnosed with a terminal disease. She had no family in America and often seemed to take comfort in being admitted to the unit, whose nurses had become like family members to her. On the last admission, it was evident that she would soon die. Carol and other nurses were sitting on her bed, marveling at her courage and faith as she told them she was going on another endless journey. They asked how they could make things better for her. She had two requests. Although her family was in England, she didn't want them to come see her; she did, however, want to talk to them on the phone. The nurses helped her do that. The second request was that she didn't want to die alone. She told Carol she wanted to be held. Carol thought about how silly she would look if someone saw her, but nevertheless, she lifted the covers and lay next to her in bed and held her for a long time. The English women fell asleep shaking because even though she was courageous, she was also afraid. Call bells went off, and Carol recognized that one of them was hers. As she began to climb out of the bed, a nurse coworker appeared at the door. She came close and whispered, "Move over, I'll take your place. I love her too." That began a period of two days when their dying friend was never left alone. Nurses stayed over time to hold her, others came in early. At the end of two days, when she had completed her calls to her family, they could feel her spirit leaving them. They had fulfilled their promise; she was never alone. She passed on to her "endless journey" held by each and everyone one of them.

Protecting

A sense that "we're somehow united," as Mary put it, and as the above story illustrates, emerges as a collective identity from an openness and trust and a deep connection. This unity of values and purpose is well protected by the Wild West Women. Perhaps because it was hard earned, as Carol points out:

"We've weathered storms together, gone through a lot of different changes together, we've grown together. We went from a 32 to a 48 bed unit, which was horrendous. We took in new staff from other units, and that was difficult, too. I think that out of that chaos has come this nice adaptive system. Of course, when something has to change there are those little ripples of fear here and there. But we all know that we're going to get through it okay. Good or bad we're still going to get through it together. It's 'our' problem and it's 'we'll' deal with it.

"In a sense, our trust is born out of necessity. You have to be that way on a unit with that many people, that size, and that freedom, or else you're dead in the water. I know they care and they have good character, that's when the trust comes in. You can't tell somebody or force somebody to be a certain way. But I think when you realize that you can really develop on your own, and have the freedom to do whatever you wantBof course there will be ups and owns, mistakes and regressions--but in a freer environment things do grow. And people's abilities and strengths, when loved and nurtured, really emerge."

Having this freedom to grow together in their own terms, the community of nurses at Three West have developed a level of attunement to each other that is palpable, visible, and visceral, not only to them but to observers as well. This is how nurse Gladys Nay describes it:

"There's a lot of watching that goes on between us. There's a lot of communication that's unsaid, as well as said; we're close enough that we can do that. So if I come in and I look tired, Mary will pick up on it right away. It's weird because some of us have been together for ten years or longer, but even some of the new people, when they come in, they feel it, and they go right along with it. It's infectious, this attunement, this doing good deeds. If someone comes in and has a negative attitude, they're not keeping it for very long. Either they can't handle the atmosphere and leave or their attitude will start to change. The expectation is high, both with how you interact and what you give. If you're not a giver, you won't survive."

That feeling

In a complex adaptive system, a sign of a healthy system is that it is adaptable and robust. An important source of this adaptability and robustness is diverse interactions. In human systems, an aspect of these interactions are lively conversations, which Linda so fervently nurtures. What initially were efforts to create more interactions, have become a cultural need. As Carol says, AI noticed while visiting another hospital there were no nursing stations. I asked where the nurses went to talk to each other. 'They don't,' I was told. My group would die if they couldn't talk to each other. They could not survive. They socialize, they care, they get together. They need that interaction on the floor and off the floor. And they fight hard. If there's a disagreement, we've always encouraged them to go talk this out one to one. You can't triangulate and pull somebody else in. It's three years since I've had anybody in my office with an argument that couldn't be resolved like this."

A robust human system, then, is characterized as people engaged in many conversations that are energizing and stimulating. What does it feel like? "It's a feeling of being more alive. I just feel so much more passionate about what I do," says Linda. "We''re very alive," says Gladys. "It's not just that we've got to do our job. It's more we want to be able to do this. I think this aliveness carries over from the way we treat each other, onto the floor and the patients. It's that same feeling. It's a more female energy, a more female environment that is totally non competitive. I don't compete with her to do a better job, and she doesn't compete with me. It's not just being task oriented but paying attention to the quality of interaction. We're just more alive being together."

And that feeling is spilling over into other parts of the hospital, as Bob Wise says:

"The nurses carry that culture wherever they go, within and outside the hospital. It spills out into other departments, and people in the community feel it. I don't need to do a patient satisfaction measure. I get it on the street-someone will come and say something appreciative.

"Being in this feminine environment has its effect on me-it keeps me young. I've learned to lean on othersBwe lean on each other. It's a completely bottom up system-no, bottom out! I support them, listen, and they have a chance to lead and participate. And I see an organization where people can handle demands-that takes pressure off me and lightens my load. It also keeps me in a positive mode. Rather than seeing barriers and limits, what I see are people coming up with solutions, sharing ideas, offering time and energy and that makes it easier for me."

"That feeling," which some called a deep resonance, others called attunement, and still others a connectedness, fuels another critical mass, and, as is to be expected in complex systems, the unexpected happens. In this connection-rich world, separateness and separation wanes--thought from feeling, hospital from community, people from people, nature from our nature. The line of demarcation is getting "more and more smudged,"as Carol puts it. And from this interrelated reality, another goddess emerges; unexpectedly Aphrodite awakens.

Dare we say Love?

Like Athena, Aphrodite has been oversimplified as the goddess of love and desire. She is that, of course, but she is more than that. Aphrodite is there wherever life sparkles with beauty and joy. She is the golden one, the lover of laughter. Her presence is evident in a playful affection and joy mixed with awe and respect. She is attended by the Graces--Joyous, Brilliance and Flowering, all that makes for sweetness in life. Aphrodite is "born" when people joyfully remember the sacred reality, that bonds exist between human beings and the whole of nature. Unlike the Great Mother goddess, the origin of all things, Aphrodite is the child of the beginning of creation, the first fruit of the separation of Heaven and Earth, and thus she carries the memory of their union. It is through love that union is possible and so Union is then reunion. And love resounds with the mystery of life itself.

At Hunterdon, there are places blessed with Aphrodite's presence, where there is laughter, unity, bonds, where love emerges unexpectedly and inspires awe. Gladys says, "It's the emotional support and the love that somehow happens." And as Carol adds, A I love them and I think they love me. I think you can feel that when you come to our floor. I don't know how it got there. It just happened. It wasn't planned. I get really teary eyed about them. Each person is very different and very unique, as all human beings are, but I'm very proud of them. People often tell us they can't believe that we care so much for each other and do so much for our patients."

Love in the work place is not a common phenomenon, and in some ways it takes courage, a certain kind of stamina to allow oneself to really acknowledge its presence. As Linda states:

"It's letting yourself feel the love and being in the love. And that feeling is this incredible connectedness with other human beings at that very moment. I feel many moments like that throughout the day. Because my door is open, there are managers that will come in and just say, 'I need to hug you.' Sometimes I walk through the hospital, and the amount of love I feel is unbelievable. Sometimes I go up to Bob Wise, our CEO, and say, 'Do you realize what a great place this is? Do you realized the amount of love that is in this hospital?'

"And you know, it starts with you as an individual. You've got to love yourself first, and then it can spread. It seemed the more I could love myself, the more I could love other people, then the more they loved me back. It's that feedback loop. And it's just happening all over this hospital. Managers feel more loved, so they're loving their staff more, and the staff is probably making an impact on their families. Who knows? A critical mass for a loving and respectful environment is growing exponentially. You touch somebody, they touch somebody, and it keeps spreading."

The milieu of love at Hunterdon is a big change that resulted from many small actions. At a time when few resources are being spent for health-care reform and experimentation, and money is largely invested in technology rather than people, the nurses at Hunterdon have taken it upon themselves to do something. And they do this in a context where they love their work and love the people they work with. Is this not what everyone wants?

At Hunterdon, the women have already brought back the "care" in health care and in a deeper way, in a way that is essentially guided by feminine wisdom and the evocation of love. And so it is not surprising to hear, immersed as they are in goddess energy, that many of the nurses from the hospital's Education Council are now committed to creating a spiritual milieu in the hospital and want to leave that as their legacy. This perspective expands the meaning of care as not only having bodies treated with respect, but also, and perhaps more important, to care for the spirit by empowering the patient--by focusing on their strengths and wishes--and to have nurse's actions and decisions for care be guided by love as well as knowledge. For example, a patient, who has always wanted to go to Hawaii, is dying and knows they will never go. Nurses respond to the patient's spiritual need by bringing in Hawaiian music and posters, even leis. Bringing Hawaii to the patient they tend to the spirit. Again, small changes. Again, Hunterdon nurses are explorers and fellow travelers on a journey towards greater healing.

In this environment where a critical mass of love is gathering and where women are on a mission, anything can happen. At anytime, one small action, one grain of sand, and the nurses will have irrevocably changed the face of health care at Hunterdon. The promise for a healthy community lies immanently at Hunterdon, like a new growth of bamboo. For five years, nothing happens when a bamboo is planted. In the fifth year, it grows eighty feet.

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