Sunday, January 22, 2012

Carrots, Incentives, and Wisdom

We return, once again, to the matters of childhood and character.

As surely as Pavlov's pack of canines, we are wired from childhood to chase the carrot. As adults, we glorify the root vegetable as an "incentive" or, worse, the multisyllabic "incentivize."
In his provocative question on the discussion board last week, Dr. Artino asked about the design of the reward system, behaviors leadership hopes to get, and types of behaviors it actually rewards.
No “one” designed the system; it evolved out of and for our human natures. In the discussion board, I referred to Erik Erikson (Erikson, Erik H. (1950). Childhood and society. New York: Norton) who wrote a psychosocial theory of development. I suggested organizations can be thought of as “parents” and employees as the “children” of the parent. Erikson believed (and made a good case for) how people meet the challenges of the life tasks (he postulated eight developmental stages throughout a lifetime) formed their competencies, values, emotional attitudes, and sense of self.

I believe that lack of trust on both sides (leader to employee, and employee to leader) creates an excess use of rules. Yes, some rules are essential, but overuse of rules stifles the use of professional judgment. Leadership may claim to want folks who will innovate and “think outside of the box” yet typically the reward (the perks, the bonus, or the promotion) is bestowed on those who conform.

I came across Michael MacCoby who writes about social character and organizations. I like that he used Erikson’s theory of development as a framework for understanding the difference – and similarity – between bureaucratic and interactive characters. The chart below lists the eight developmental stages on the far left, and in the corresponding row, character traits you might expect to see:


He writes, “[in the '80s] . . . organizations began to redesign work. New modes of work required not only new skills but also new values. A new organizational ideology emphasized innovation, interactive networks, customer responsiveness, teamwork, and flexibility. The economic organizations creating the greatest wealth had to become interactive instead of bureaucratic. They had to manage intelligence rather than energy. Instead of the paternalistic bureaucratic manager, the interactive managers were expected to be coaches of empowered individuals and teams.”

So, we have paternalistic, rule-laden bureaucracies which periodically dole out incentives and reward based not on innovation but on “not stirring up trouble.” Remarks by mid-level managers years back exemplify the attitude. The first, at the time of the annual performance review, remarked, “Well, I have not had any complaints, so you must be doing a good job.” Seriously. Since when does not logging complaints equate with a good job?

The second remark pertained to ensuring a task was accomplished not because it was the right thing (morally, humanly) to do, but because “we wouldn’t want to end up on the front page of The [Washington] Post.” (We ended up on the front page anyway.) Such remarks made me feel demoralized, relegated to the bottom rung of expectations (not just me, but my colleagues as well), as if scraping by without complaints or above-the-fold headlines was all I had to do to collect a paycheck. The driving motivation was to stay out of the news rather than doing the right thing.

I want to know other’s thoughts on expectations in the workplace, and was pleased to find a wise soul who put words on my own experience. Here’s how TED describes Barry Schwartz, a psychologist: “. . . makes a passionate call for "practical wisdom" as an antidote to a society gone mad with bureaucracy. He argues powerfully that rules often fail us, incentives backfire, and practical, everyday wisdom will help rebuild our world. He studies the link between economics and psychology, offering startling insights into modern life.” From his 20 minute video I took away these insightful bits:

A wise person knows when and how to make the exception to every rule. A wise person is like a jazz musician, using the notes on a page but dancing around them, knowing how to invent combinations for the situation and people at hand.”
When things go wrong, we reach for incentives. Neither rules nor incentives are enough. Over reliance on rules and incentives chip away at moral skill. Moral will is undermined by impulsive appeal to incentives that destroy our desire to do the right thing.”

Incentives lead us to not what is my responsibility, but what serves my interests? Any incentive system can be diverted by bad will. Excessive reliance on incentives demoralizes professional activity: workers lose morale, and causes the activity itself to lose morality. Employers should encourage virtue, wanting to the right thing, the right way, for the right reason."

Thank you, Barry Schwartz, for putting into words what I struggled to express!

Comment, question, thought? Go to it.
~ Carol 


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Sunday, January 8, 2012

Unfixed: Let's Deal with It

Suppose the nursing and primary care physician shortage is not fixed. Just suppose.
That, despite addressing the issue as we are now, despite the economic and market models and calculations, the heated negotiations in health insurance conference rooms, and the contemplative considerations of academia, we are in the same predicament twenty, thirty years from now (it could happen). What, then, must we do? (Billy Kwan's, played by Linda Hunt, repeated question, "The Year of Living Dangerously".)
While reviewing the discussion board for our class in healthcare management, you may have come across the post in which I wrote of substituting NPs for physicians in primary care, in order – my argument – to free them for the practice of geriatrics. Geriatrics is my “thing” so any time I can find a way in which to weave it into the conversation, I do so. My read of the healthcare tea leaves is we are to expect shortages of nurses, primary care physicians, and geriatricians. An accidental realist, this likely state of affairs compels me to suggest we prepare ourselves – and our children, our families, our patients – to know how the shortages will be manifested in the quest for healthcare. We might expect:
1. increased frustration scheduling a timely appointment in primary care
2. ailing parents whose multiple medical conditions are not addressed
3. anguish and regret that we did not “fix” the problem when we had the chance
I do not have “the” answer to the shortages. I do, however, practice and teach resilience to patients, families, and caregivers. We live in a privileged country where a demanding population has high expectations and relishes a good crisis. We will discover, however, no quantity of prosperity or urgency will solve personal demands involving public crises.
Nursing education programs have turned away 30,000 qualified applicants annually?

Here’s Chris Fleming, June 14, 2010 in Health Affairs blog:
“[although these projections represent a smaller shortfall than earlier estimates] the magnitude of the 2025 deficit would still be more than twice as large as any nurse shortage experienced since the introduction of Medicare and Medicaid in the mid-1960s. Avoiding this shortfall would require expanding the capacity of nursing education programs, which since 2002 have turned away 30,000 or more qualified applicants annually.”

Stats on geriatricians:

Matt Sedensky, Nov 11, 2011, The Huffington Post:
* 70 million American members of the baby-boom generation (those now 46–65) reach their senior years over the next few decades
* 2011 - one geriatrician for every 2,600 (1:2600) people 75 and older
* 2030 - one geriatrician for every 3,800 (1:3800)
* compared to pediatricians, 1: 1300 < 18 years old
* geriatricians rank among the lowest-paid medical specialties (median salary $183,523).

How are you planning to cope with the shortage when it directly affects your 1) practice, 2) family, and 3) well being?

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