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When a situation is "not black or white": Using adaptive leadership to address complex challenges in nursing home care.

Do you ever have days when you feel as though there is a steady parade of staff, supervisors, and corporate consultants looking to you to generate solutions to the ‘problem of the moment?’ Although Directors of Nursing (DONs), as leaders of nursing services, have the administrative authority and skills to be a natural source of help, this reveals the widely held assumption that the leader is the person in charge and that the person is charge is the one with the most knowledge to solve problems. This approach does not acknowledge what many DONs already know---most problems in nursing homes are complex, are difficult to resolve, and usually cannot be solved by any one leader. 
 
The adaptive leadership framework provides a novel way to think about leadership by differentiating between technical and adaptive challenges that arise in an organization (1). Technical challenges are problems or issues that are easily defined and can be solved with the right expertise, skill, or resources. Managers often solve these technical challenges by matching the technical challenge with the right policy, procedure, or finding the correct expertise. Leadership behaviors and skills needed to address technical challenges are those with which DONs are most familiar and comfortable. For example, if a DON aims to reduce adverse drug events, she or he could work with the nursing home administrator to implement a high risk drug alert system within the pharmacy ordering system (2). The technical challenge is identifying inappropriate medications or interactions, and is addressed with health information technology. The DON uses administrative skills to partner with the Nursing Home Administrator (NHA) to advocate for the new system and to balance the budget for the home. 
 
However, problems in nursing homes are rarely purely technical and typically include adaptive challenges (3). Problems in complex environments such as nursing homes usually fall on a continuum, ranging from those with more technical elements to those with more adaptive elements (see Figure 1). Adaptive challenges are problems for which there are no known solutions; they require brainstorming and innovating new ways of accomplishing care and often require a change in attitudes, values or beliefs (3–6). 
 
 
 
Figure 1 
 
The Continuum of Technical versus Adaptive Challenges. 
 
 
 
Drawing upon our previous example, adverse drug events do not occur solely because of the lack of clinical support decision tools to alert providers to potentially inappropriate medications or interactions. Clinical trials of these systems in nursing homes indicate adaptive challenges such as providers not using the system for certain conditions, or even ignoring system alerts (2). Rather, new solutions are needed and the best ideas are created by involving a variety of people such as providers, administrators and direct caregivers. By interacting with each other, these staff will exchange information about the various contributing factors, identify areas for new skill development, and learn new ways to provide care. 
 
Implementing these new ways to provide routines—referred to as doing the ‘adaptive work’—can be accomplished only by those involved. For example, only the provider can change his or her attitude and learn new behaviors to use the drug alert system (3). The DON or NHA cannot do the actual work of changing attitudes, behaviors and learning, all of which are needed to accomplish new care to reduce adverse drug events. Therefore, adaptive challenges are owned by the person(s) with the challenge and only that person or group can do the necessary adaptive work. Adaptive leadership requires having the attitudes and skills necessary to distinguish between technical and adaptive challenges and appropriately aligning the solutions, using expertise where appropriate for the technical aspects and using adaptive approaches where necessary (6). Adaptive approaches are behaviors and strategies used to facilitate and support the adaptive work that others need to do to address their adaptive challenges. Developing adaptive leadership and approaches is difficult in a system replete with rules and regulations and a highly structured chain-of-command. The purpose of this study, therefore, was to describe examples of DONs using adaptive leadership to facilitate assessment, care planning, supervision and delegation.