Enrolling Others in Change

There are nearly 4,000 of us who work in the GBMC HealthCare System as employees, volunteers or physicians in private practice. When I think of all the improvements that we have made on our way to our vision, I am amazed at how many of them started with only one or two of our people in action and then spread to many more people. A fantastic example of this is the work that has been done by our nurses at reducing pressure ulcers.

It has now been more than seven months since the last pressure ulcer at GBMC! Those of us who don’t have to turn debilitated patients every two hours to prevent these can only imagine how hard our nurses and nursing technicians have been working to prevent them. Our people have always understood that they needed to help patients avoid pressure ulcers but only after a few folks started the movement to guarantee standard work in assessing who was at risk for skin breakdown and then delivering the measures shown to prevent it reliably, have we improved our performance.

Why is it that some change initiatives achieve great results and others don’t? There are a number of reasons but I think the single biggest reason is failed enrollment. We often hear: “People don’t like change.” Doug Krug, the author of the book Enlightened Leadership, makes the point that this is not true. Krug says that people change all the time; just think of all of the people that got rid of their flip phones and Blackberries to get iPhones, for example. The true statement according to Krug is: “People don’t like to be changed.”  We humans need to see and accept the need for the change and we need to feel that we have played a part in the design of the change or at least have chosen to make the change and have not had it forced upon us.

We have achieved zero pressure ulcers at GBMC because the overwhelming majority of our nurses and nursing technicians have been enrolled in the change. They understand the reason for the standard work, they now know what the work is and they have accepted that it must be done to prevent harm to their patients.

It is hard to get everyone enrolled in any change initiative in a large complex organization. The GBMC System is not presently making the same degree of progress on some of our other goals. From me on down the line we need to do a better job of enrolling others to achieve these goals. The enrollment starts with a conversation about the need for the change – what we are trying to accomplish. It continues with a discussion of what is expected of the person being enrolled. Then the enrollee must have some time to ask questions, voice any concerns, and be heard. Finally, the person doing the enrolling needs to hear from the enrollee that they have understood and that they are in!

I am very grateful for everyone’s hard work and particularly for everyone that enrolls others in change.

Finally, I'd like to congratulate two of GBMC's nurse leaders on recent accomplishments: Jody Porter, RN, DNP, Senior Vice President, Patient Care Services and GBMC’s Chief Nursing Officer, has been re-elected to the board of directors position of Treasurer of the Maryland Organization of Nurse Executives and CJ Marbley, RN, has been named to the same organization’s board of directors as a Member-at-Large. These individuals are certainly enrolled in creating positive change right here at GBMC and throughout the nursing community. Thank you for your commitment to excellence!

How Yoga Affects Breathing

by Baxter

Jellies by Melina Meza

As I was reading an interview in my latest yogauonline.com newsletter with physician and yoga therapist Loren Fishman, MD and his collaborator Ellen Saltonstall called Can Yoga Preserve Freedom of Movement? (hell, yeah!), a short statement from Dr. Fishman about how physical movement and the breath are connected caught my eye:

“…something that is really very poorly recognized in the medical or the yoga literature: that moving your joints is one of the strongest stimuli to breathing properly and deeply. There are little movement receptors inside all of our joints, and they send signals that go directly and indirectly to the apneustic center, one of the centers in the brain that regulate breathing.”

You may remember that a while back Nina and I wrote a post Falling for Yoga Myths about some of the things that really do stimulate and regulate our breath, and that I also did a post How Breath Affects Your Nervous System detailing the relationship between the Autonomic Nervous System and the breath. Part of my purpose for writing these posts was to correct some common misconceptions about breathing that continue to exist in the yoga community. You may recall that I mentioned that the levels of carbon dioxide (NOT oxygen) in the blood stream are monitored by the deep brain structures, and it is the CO2 levels that have some of the greatest influence on changes in breathing moment by moment. In addition, the brain and the periphery of the body are also assessing the acid/base balance of the blood, or the pH.

But now, Dr. Fishman adds in a new twist to our understanding of breath! Turns out that the same nerve receptors we have talked about in relationship to balance, called proprioceptors, which are located in the muscles, tendons and joints, affect breathing, too. Not only do they tell the brain where you are in space, how fast you are moving and in which direction, but also the movement of joints, tendons and muscles stimulate part of the brainstem that regulates breath called the apneustic center. Located in the part of the brainstem called the pons, the apneustic center is involved in stimulating our inspiration or “in breath.” Movement—physical movement—stimulates increased depth of breathing, known technically as “hyperpnea.” In a serious, life-threatening situation in which the breathing was slowing and shallow, moving someone’s limbs could stimulate the breath back to healthier levels. Cold water and pain can have a similar effect on breathing.

This connection between bodily movement and improved depth of breathing is helpful news, especially when it comes to people who have been previously inactive, have become stiff, suffered a loss of vitality and notice that their breathing does not respond well to physical stresses such as an increase in work load for their body. By beginning to move the joints and limbs systematically, as we would do in a beginning level yoga class, we are (without even mentioning how to breath) going to stimulate an increase in the depth of breathing. I am sure many of you have had this experience: at the start of class, during an initial sitting meditation or centering practice, the breath and chest feel slightly tight and restricted, but when your attention is brought to the breath at the end of a balanced yoga asana practice, the breath seems to have greater freedom and depth with less effort. This body-to-brain connection of the proprioceptors and the pons of the brainstem are likely at work. Just one more reason to keep moving your body!

To read all kinds of nerdy details on the physiology of breathing, check out the article Regulation of Breathing.