Nursing Leadership and Managerial Qualities - Term Paper Example

Serious injury can occur for a patient that falls from the bed due to a nurse not putting the side-rails of the patient's bed into the up position. Such an incident can lead to the patient, and /or their family lodging a complaint against both the nurse involved and the hospital who is the employer Capezuti, Maislin, Strumpf & Evans, 2002). In general, the testimony of an expert is required to establish the standard of care that has been breached, in order for a patient or their family can sue for medical malpractice or nursing negligence. In the current scenario, an elderly patient with dementia was left to sleep with the side-rails down. As the patient fell from the bed and broke his arm, the nurse and hospital were liable for damages. This paper aims to identify nursing policies that were not followed so as to prevent such a scenario from occurring. Firstly, nursing leadership and managerial qualities in regards to the present situation shall be outlined. Secondly, issues of nursing accountability shall be detailed. Next, the concept of team-work as pertains to the scenario shall be highlighted. Following, the topics of clinical governance, as well as teaching and facilitating of nurses in general, shall be outlined as relevant to the present scenario. 1. Leadership and Management Leadership and management issues are of critical importance to the discipline of nursing. Some of the areas that leadership and management incorporate are finances, business focus, information management, and marketing (Baker, 2000a; Kelly-Hayes, 2003). When a patient falls from a bed because procedures have not been followed, it is clear that nursing leadership and management training is lacking. In the current scenario, additional costs were created within the hospital to care for the patient, in regards to the broken limb, as well as consultation with attorney's to establish their legal obligations, and in administration costs to report the incident, and to process ongoing documentation relevant to the complaint made by the family. From the point of view of nursing being a business, the scenario is an example of poor management, in that protocols were not in place to ensure that an incident did not occur (e.g., having checklists available so that the nurse could be sure she had followed all necessary procedures). The information management that was lacking was that the nurse did not have available protocols to compare her patient care to. In regards to marketing, the hospital as well as the nurse has provisioned the patient and family with an image of being incompetent and neglectful in their care for the patient. Recent studies point to a distinct lack of leadership qualities amongst nurses in general, and attribute this to a lack of training in the area (Laukkanen, 2005). Unfortunately, this is a waste of resources as nurses are in key position to influence hospital care policies, as well as state and national legislation (Sullivan, 2001). It is contended that student nurses need to be encouraged to develop their leadership and managerial skills, as well as their clinical skills (Baker, 200b). For example, a more salient awareness of cost-containment issues could have motivated the hospital to have set protocols for the bed-care of elderly patients (Antrobus, 1999). Additionally, the use of job re-design amongst the nursing staff could have provided the hospital with a critical evaluation of the sequential tasks of each job a nurse undertakes, and provided solutions for combining tasks to improve patient care (e.g., saying goodnight/see you later to a patient also includes the action of the hands checking the bed-rail is up) (Sullivan, 2001). Quality management important to nursing as it allows for an evaluation of the outcomes of practices. In turn, this style of management provides for a preventative approach to nursing that identifies potential problems quickly, and facilitates research into viable alternative solutions (Belcher, 2000; Hendel & Steinmann, 2002). As such, the hospital working environment should be one that facilitates the nurse to carry out good practice. This requires support from more senior nurses to ensure that student nurses have been briefed and assessed on their understanding and practical demonstration of knowledge of known potential problems (Hendel & Steinmann, 2002), in this case, a patient falling from the bed due to rails not being in an position. However, nursing management that is over-controlling does not contribute to the nurse developing self-directed learning and concrete understanding of why protocols are undertaken as they are (Kelly-Hayes, 2003). Efficient and effective patient care practices in regards to bed-rails will only occur with flexible clinical leadership that recognizes and encourages good practice (Capezuti et al., 2002). 2. Accountability The practice of nursing necessitates scientific and technical knowledge of clinical practice, but it is also essential that the nurse be aware of, and to be motivated to, practice ethical codes of conduct as defined by the Nursing and Midwifery Council (NMC), as well as their employer (NMC, 2004). Ethical codes of conduct make the nurse accountable for their decisions and actions in their delivery of patient care. As such, abiding with ethics enables the nurse to be guided through value-based judgments (General Medical Council, 2001; Thompson, Melia & Boyd, 2000). Furthermore, these value judgments need to be evaluated in a critical manner in the same way that scientific information is critically analysed. Ethics is a generic word that reflects a set of standards for analyzing and understanding moral life. Hence, ethics requires that the nurse to go beyond the individual patient and to apply assumed universal laws (General Medical Council, 2001). The NMCs code of conduct is based on four general principles: 1) patient autonomy; 2) beneficence for the patient; 3) avoidance of harm to the patient (non-maleficence); and 4) justice (NMC, 2004). In the present scenario, the nurse allowing the patient to lower the bedside-rails during their brief interaction was an example of the nurse acknowledging the patient's right to choose her level of comfort. It is of benefit to the nurse in question that she explained to the patient the dangers of having the side-rails in the down position, such as the risk of the patient falling from the bed, as this allowed the patient to make an informed choice. However, the nurse, by virtue of her profession, must maintain the principle of beneficence in that she was not to carry out an activity that would affect the mind or body of the patient (Thompson, Melia & Boyd, 2000). Her remiss at raising the side-rails once the patient had fallen asleep, and before she herself had left the patient's room, means that she did not align her practice with the stipulated ethical code. Also, the Hippocratic Oath of, "First do no harm" (i.e., non- maleficence) was not followed by the nurse as her actions did bring harm to the patient in the form of a broken limb, as well as initiating feelings of mistrust in the patient and his family that the nurse and the hospital could provide adequate care. This may lead the patient or his family to not trust others in the medical community, which could seriously inhibit their motivation to seek medical assistance when it is required, or to disclose necessary information to ensure optimum treatment. Additionally, in the present scenario, the nurse and the hospital's determination to honestly represent their case through proper legal channels, so as to maintain the patient's human rights, as well as the credibility of their profession, demonstrates their attention to the ethical standard of justice. Furthermore, the British Medical Association (BMA) would be able to provide further legislative support for the nurse in the current scenario (BMA, 1999). The BMA would encourage the nurse to draw on past experience that demonstrates her; respect for the patient in question as an individual, such as having asked for their consent before delivering a procedure; her pattern of maintaining the patient's confidentiality in regards to their medical information; and her trustworthiness in her past interactions with the patient. The BMA advice would also encourage the nurse to highlight other interactions with the patient that demonstrated her tendency to maintain her professional knowledge and competence at clinical care, as well as circumstances in which she identified and minimized risk for the patient. Ultimately, mistakes occur during the provision of nursing care to patients. However, the aim of ethical codes of conduct is to guide nurses and other health professionals so as those mistakes are made infrequently (Kelly-Hayes, 2003; Thompson, Melia & Boyd, 2000). 3. Team-Work A key feature of nursing practices is to work within a team environment. The nurse may find themselves working in a team environment comprised of other nurses, doctors, volunteers, chaplains, social workers and other health and human service workers (Martin, 2000). Team-work has been a traditional practice that is supported by nursing philosophy and is demonstrated in a variety of its practices. It is well recognized within the nursing literature of the interdependence of the physical, functional, psychosocial and spiritual dimensions of the workplace account for team member well being, as well as facilitating a multidisciplinary and so comprehensive approach to patient care Cronenwett & Redman, 2003). The overlap of roles and services in the provision of patent care has been indicated to extend and multiply the resources available to a patient (Crawford & Price, 2003). In the present scenario, had the hospital been more attentive to the development of a team-culture within their organization, it may be that the incident would not have occurred. This is argued, because an overlapping of nurses checking on patients would have enabled another to notice that the rails were down (Crawford & Price, 2003). It has been shown that cross-functional teams are much more flexible, and that when team members are able to 'cover' each other in general patient care duties, the patient is afforded more comprehensive and careful care (Baileff & Suite, 2000). Perhaps this is due to a sense of responsibility instilled in each team member, as they are aware that they can rely on others to recognize their strengths and to provide support for their weaknesses. Also, collaboration is an important element of team-work. It has been found that nurses, who work alone for a great deal of their time in delivering care, are more likely to feel rushed (Baileff & Suite, 2000). It appears that team-work is the key to effective and efficient patient care, as the team tends to be more structured and organised. Due to an assumed lack of a team-work approach in the present example, it is likely that the patient will experience anxiety and distress during future interactions with that nurse or hospital. Research shows that by sharing the responsibilities of care across nurses on duty, that the sum of their competencies as a whole team is greater than each nurse as an individual. Although, for team-work to be enacted and productive, it is necessary that each member have a common purpose, and that each member is aware of the role's of others as well as themselves, and that they have the ability to pool their resources (Baileff & Suite, 2000). Overall, it is the workplace dynamics that can provide the nurse and in turn the patient with a sense of care and well being (Crawford & Price, 2003). 4. Clinical Governance Clinical governance is the way in which an organization ensures the quality of care service that they provide to patients, by way of making the individual employees accountable for determining, maintaining and evaluating standards of performance (Henderson, 2002). Another way to define clinical governance is that it is a set of guidelines by which NHS organizations accept accountability to continuously enhance their quality of care provision, and take action to safeguard these standards by developing a work environment which excels (Department of Health, 1993). As such, for the present scenario, the responsibility for the quality of care the patient received is equally divided between the hospital and the nurse involved. As clinical care is becoming more complicated in regards to potential for litigation, it is necessary for medical professionals to develop extended networks of professional relationships (Department of Health, 1994). This enables a person such as the nurse in the scenario to put into practice her clinical responsibilities across a broad range of contexts. In the 21st century, where patients and their families are more informed of their rights than in previous years, and a time when the fallibility of the medical profession is well documented, a nurses' awareness of their accountability is essential. In general, provision of high quality care requires that the nurse and hospital demonstrate its seriousness toward this issue by way of putting in place, and constantly evaluating, these standards (Department of Health, 1998). Importantly, in the present scenario, it is the responsibility of the hospital to ensure that the individual nurses was aware of the services that she was to provide, and to have monitored her activities to ensure that the high standards of quality care were actually being met (Department of Public Health, 1998). In this way, there is a formal link between the individual nurse and the hospital, in the form of the model of clinical governance. It is also the hospitals responsibility to be sure that the nurse in question has access to appropriate supervision to ensure that such an incident does not occur (Department of Public Health, 1998). 5. Teaching/facilitating Communication and critical thinking ability is vital to the teaching/facilitating process of student nurses (Butterworth et al., 1997). For example, in the form of coaching, the nurse can be provided with improved patient care insights at both the individual and the team level. The practice of teaching by way of coaching and mentoring has been shown to decrease incidences of error in clinical practices of nurses (Demeter, 2002). Importantly, teaching/facilitating would have enabled the hospital in this scenario to apply learning theories to plan the learning activities of its nurses in regards to side-bars on patient's beds. Additionally, the hospital could have incorporated knowledge of different learning styles to deliver learning in a multiple of ways to ensure that the nurse was able to engage in the learning activity to the best of her ability (Demeter, 2002). Also, the hospital could have practices specific instructional activities pertaining to side-bars within the classroom, as well as in patient rooms themselves. In conclusion, it is evident that the present scenario of leaving down the side-bars on a patient's bed can have serious repercussions, for the patient and their family, as well as the nurse and the hospital. Leadership and management required that the nurse tend to her duties as she would in a business environment, being constantly aware of the financial, informational and marketing consequences of her care practices. The nurse's accountability in the present scenario meant that she had a set of ethical obligations to adhere to, and these are in place to guide her delivery of care. In particular, the nurse in question did not practice non- maleficence, the practice of not placing the patient in a situation of risk of injury. Team-work has been shown to be essential to nursing practices. In regards to the scenario it has been assumed that the hospital does not have a strong team orientated work culture. Clinical governance makes both the hospital and the nurse responsible to set, maintain and monitor high standards of quality care to the patient. Also, teaching/facilitating, such as coaching or mentoring, has been found to enhance the quality of service delivery of nurses, and so decrease the incidences of medical errors. Ultimately, the practice of nursing is a complex activity, which requires the nurse to extend their awareness and knowledge of business, ethics and legalities, governance and teaching. References Antrobus, S. (1999) Nursing Leadership: influencing and shaping Health Policy & Nursing Practice, in Journal of Advanced Nursing, 43(1):19-27. Baileff, A. & Suite, B. (2000) Integrated nursing teams in primary care. Nursing Standards, 14(48): 41-44. Baker, C. M. (2000a) Problem-based learning for nursing: integrating lessons from other disciplines with nursing experiences. Journal of Professional Nursing, 16(5): 258-266. Baker, C. M. (2000b) Using problem-based learning to redesign nursing administration masters programs. Journal of Nursing Administration, 30(1): 41-47. Belcher, J. V. (2000) Improving managers' critical thinking skills: student-generated case studies. Journal of Nursing Administration, 30(7): 351-353. British Medical Association [BMA] (1999) "Confidentiality and disclosure of health information", Retrieved June 3, 2006, from: http://www.bma.org.uk/ap.nsf/Content/Confidentialitydisclosure Butterworth T. et al (1997) It is good to talk. An evaluation study of clinical supervision in 23 sites in England and Scotland. Retrieved June 3, 2006 from the University of Manchester website: http://www.mu.com.edu.uk Capezuti, E., Maislin, G., Strumpf, N., & Evans, L. K. (2002) Side rail use and bed-related fall outcomes among nursing home residents. Journal of the American Geriatrics Society, 50(1): 90-96. Crawford, G. & Price, S. D. (2003) Team working: palliative care as a model of interdisciplinary practice. The Medical Journal of Australian Palliative Care, 179(6): S32-S34. Cronenwett, L.R. & Redman, R. (2003). Partners in action: nursing education and nursing practice. Nursing Education, 28(4): 153-155. Demeter, S. S. (2002) Coaching your unit team for results. Seminars on Nursing Management, 10(3): 189-195. Department of Health (1993) A Vision for the Future Report of the Chief Nursing Officer. NHS Health Services Circular, 38. Department of Health (1994) CNO Letter, 94(5). NHS Health Services Circular, 115. Department of Health (1998) A First Class Service Quality in the New. NHS Health Services Circular, 113. Department of Public Health (1998) Clinical Governance in North Thames. NHSE North Thames Region Office, London. General Medical Council (2001) "Good medical practice", Retrieved June 3, 2006, from: http://www.gmc-uk.org/guidance/good_medical_practice/index.asp Hendel, T. & Steinmann, M. (2002) Graduate students learn effective management. Journal of Nurses Staff Development, 18(4): 203-209. Henderson, E. (2002) Managing quality in services: Part 2. Nursing Management, 9(8): 30-33. Kelly-Hayes, P. (2003) Nursing Leadership & Management. Thomson Delmar Learning. Laukkanen C. (2005) Leadership in health care--orchestrating change. Cancer Operating Room Nursing Journal, 23(2): 37-38. Martin, V. (2000) Developing team effectiveness. Nursing Management, 7(2): 26-29. Nursing and Midwifery Council (2004) The NMC Code of Professional Conduct: Standards for Conduct, Performance and Ethics. London NMC. Sullivan, D. J. (2001) Effective Leadership and Management in Nursing, 5th Ed. Prentice Hall. Thompson, I., Melia, K. & Boyd, K. (2000) Nursing Ethics 4th ed. Churchill. Read More