As part of the @BloggerNurse November challenge ‘The Newly Qualified Journey’ I thought it would be a good idea to share with you the reflective assignment I recently wrote for my preceptorship program at GHNST. This is a rather lengthy (non-blog) read, however, if it can help people better understand the ups and downs of being a newly registered nurse then I’m happy to share my journey with you the reader.
During the preceptorship, we had a focused session on decision-making through leadership and management. The aim was to help us recognise key features of effective decision making and delegation in the clinical setting. Therefore, this paper will critically reflect on experiences that have influenced my professional development against the four domains of the NMC, (2010) Standards in nursing education, using the Rolfe et al, (2001) reflective model ‘What? So, what? what now?’ template as a guide. I will specifically explore my professional limitations, conflicts in communication, problem-solving through initiative, and delegation in leadership. I will then set an action plan using SMART goals tool to support my development.
Modern scholars of leadership discuss various definitions of what leadership is, consequently, there is no concise definition of what leadership means. Nonetheless, despite these many definitions, certain traits can be recognised by most theorists as to what it is to be a leader. This derives from the fact that each leader will bring individual talents, for example, some leaders are decisive and self-assured while others are sociable and outgoing (Northouse, 2017). The Kings Fund (2015) discuss that leadership within healthcare must ensure direction and priority in an organisation shared vision, values and strategy to ensure that responsibility and commitment are established successfully within a team.
I worked a particularly stressful and understaffed shift only 10 weeks after starting my job as a newly registered nurse, it was a night shift and due to sickness, the staffing levels for that night shift included myself, an agency nurse and one bank HCA to manage twenty-four acutely unwell patients. The shift involved multiple medical emergencies, alongside a complex patient load. This proved very difficult, as I was a junior level nurse left in charge of a night shift for the first time. Some of the complex patients at the start of the shift included an elderly patient with chest pain and palpitations, a patient who had a Vasovagal-syncope in the toilet followed by a fall and head injury, and a patient with a NEWS (National early warning score) of 10. My participation in managing the situation as a coordinator escalated quickly, as a small team we prioritised the patient’s needs and the roles and responsibilities between the three of us were quickly decided within our individual competence level. I called the site manager to insist that the level of safety on the ward was not acceptable, we negotiated that a permanent staff nurse from the trust would come from a better-staffed ward to help support us.
The main significance of this issue was the potential in compromising patient safety and my own abilities in clinical competencies as a newly qualified nurse. The NMC, (2015) code of conduct requires me to preserve the safety of the patients and public while working within the limitations of my competency. Evidence suggests it is vital that I take responsibility in recognising and maintaining my junior status (Schober and Ash, 2012). Self-analysis and critical reflection in understanding my limitations are fundamental to provide a high standard of care to service users, also helping me to develop my practice and leadership (Reading and Webster, 2014). Although I am a junior level staff nurse I was still able to contribute to patient care as the nurse-in-charge under the supervision and guidance of the site manager and substantive staff nurse who came to support the shift. Upon reflection, I can now recognise that because of my forward-thinking in asking for help we could provide a safer service during that shift. Understanding my own limitations based on my professional boundaries and values is what enabled me to complete tasks autonomously while remaining aware of when to seek advice or refer to more senior professionals (Black, 2013). In addition, I showed leadership potential by recognising my own limitations by being open and honest and identify how to manage the situation. Siviter (2013) deliberates that regardless of how much experience you may or may not have, you have a responsibility and a duty of care to accept the limitations of your role as a staff nurse in charge, only working within safe parameters of care. Although colleagues were impressed and complimentary of my abilities to ‘step-up’ and act as a shift leader, this could cause implications for my role as a leader in the future and I must make certain people are aware of my junior status at all time, as the role of an experienced nurse is different (Wheeler, 2013). In contrast to Siviter’s discussion Gopee and Galloway (2017) converses that leadership can be utilised at all levels of competency, suggesting that leadership and management situations can be demonstrated by all members of staff in health and social care and not be limited to those in management roles, suggesting that good leadership comes from your priority and focus to provide patient-centred care and to deliver this with the best outcomes intended. However, Gopee and Galloway, (2017) continue to discuss that some leaders are reluctant to delegate tasks below their level of leadership, believing that juniors are unlikely to be able to perform them competently. The site manager saw me as a safe member of the team asking for help when it was needed, this showed good integrity, which has enabled me to take the lead of my own abilities to support my colleagues during the busy shift. Drawing all this information together, I refer to Belbin’s, (1981) philosophy of nine team roles. Belbin’s theory suggests a good balance of roles based on different characteristics determines the success of a team as it allows individuals to work to their personal strengths, creating high performances within the group. This can be linked to Gopee and Galloway, (2017) suggestion that everyone has a role to play in leadership based on the group’s situational needs.
My Specific aim is to understand the changes in my limitations, transitioning from a newly qualified nurse to a more experienced nurse. I will measure my progress through discussions and documentation with the senior nurses on the ward, attaining this by dedicating time to research literature around differences in limitations from novice to expert nurse, whilst using resources, like my preceptor and new registrant review meeting to reflect on my development. Thomas et al, (2015) suggest now is appropriate to begin understanding my professional limitations as both a qualified nurse and clinical leader- This is relevant because I am already approaching my first six months of being a registered nurse. I aim to review this goal during my appraisal.
Communication and Interpersonal Skills
I have recently cared for an overseas visitor who was a non-NHS funded patient, this situation has reminded me of some of the barriers we face in communication through different languages, after all, do we need words to express what care we require? I would like to take this opportunity to reflect on an incident I experienced as a student nurse during my elective placement in Sri Lanka last year, this helped shape the way I deal with language barriers today as a staff nurse. I attended an operation in Kandy teaching hospital in Sri Lanka, the patient was having a total vaginal-hysterectomy. The patient, Mrs X, had a regional spinal anaesthesia, no pre-operative tests were carried out to gauge the patient’s lower limb sensation. The operation began, and the patient was screaming in agony. Staff continued the operation, ignoring the patient’s cries for help. At first, I hesitated, but then quickly recognised the need to advocate the patient’s welfare and dignity. I was met with challenging and conflicting interests in the patient’s well-being when questioning what the staff were doing. Because I was working in a foreign environment, English was not the spoken language, and this created a communication barrier.
The significance of this issue was to recognise that the distressed patient’s well-being and dignity were being compromised, it was necessary for me to advocate for the patient’s best interests and safety. Not only did this challenge my professional values, ethics and morals. I had a duty of care to protect the patient’s dignity and human rights by negotiating effective communication strategies to find resolution (Management Association, 2017). This is underpinned by the NMC, (2015) code of conduct requiring nurses to communicate clearly. On reflection, a positive outcome to this experience was my application of the 6C’s, all six elements were pragmatic in reaching the success of the patient’s welfare. This was a pivotal point during my development as a nurse, this was the first time I used my courage to speak up and do the right thing when I had concerns; this can represent personal strength and vision to provide patient-centred care and new ways of thinking (Department of Health, 2012). Meuter et al, (2015) suggest it is vital as a leader that you adapt communication styles to suit the situation. Regardless of the language barrier, I recognised the importance of providing Mrs X with compassionate, non-verbal communication, such as when I held her hand in support. An aspect to take forward for development would be my approach in delivering communication, avoiding conflict. My communication during that situation could have been perceived as abrupt and defensive. To help me assess my communication skills, I recently completed a communication questionnaire, which suggesting my preferred communication style is assertive and aggressive. Sully and Dallas, (2010) propose assertive communicators are clear and focused on communicating important messages, enhancing the quality and efficiency of the professional relationship. Whereas Riley, (2015) found that assertiveness is not always an appropriate response, bringing higher risks of personal injury and possibly creating a conflicting response. Though conflict is healthy and inevitable within healthcare, open conflict and vigorous discussions can be useful, as it creates self-criticism, change and innovation (Phillips, 2013). Nevertheless, the questionnaire suggests I also have an aggressive side in communication and although a healthy balance can be found between assertiveness and aggression, it is important to recognise that an aggressive style may distance people, provoking anger and resentfulness, perhaps leading to failures in communication and good patient outcomes (McIntosh and Rima, 2007). An example of a failure to tackle challenges of conflict was the Francis Report, (2013) for Mid-Staffordshire hospital where standards became unacceptable, leading to a public enquiry. As nurses, we must recognise our contribution to the service and health improvement initiatives to better our practice through effective communication and conflict resolution.
Specifically, I would like to further develop my resilience in confronting challenging situations, and in addition, develop my emotional intelligence to have awareness of emotional motivation, understanding others’ views to create effective communication, avoiding conflict (Carragher and Gormley, 2017). I can see now how much this situation affected me and that I am still progressing from this learning experience through continually reflecting my current practice. I can measure my progression by reviewing and reassessing my communication style through the questionnaire discussed above. In addition, I can compare qualitative evidence from patient feedback that I received during my training and now as a newly qualified nurse. This goal has great relevance because I must continue to develop these capabilities in communication, so they become a part of who I am and my behaviour as a registered nurse, as I am entrusted with the management and leadership of delivering safe care (Ellis and Bach, 2015). This progression will change as a gain more experience and therefore, I would like to set incremental times to review my communication.
Nursing Practice and Decision-Making
Looking back to another challenging shift, I was looking after a patient who had become aggressive towards other patients, relatives and staff. Whilst trying to problem-solve and help my colleagues defuse the situation, I ended up being punched in the face by the patient. Although I was shocked by this incident, I remained professional and instead of being angry, I had concerns about the deteriorating mental state of the patient. This was abnormal behaviour from the patient and my reaction was to recognise and interpret why he had acted in this way. After investigations and nursing assessments, the patient was diagnosed with vascular dementia. With the correct diagnosis, we could provide person-centred care to meet the full range of essential physical and mental health needs of the patient.
The significance of this was my ability to problem-solve by using my intuition to recognise and interpret signs of deterioration within the patients mental and physical health, in addition ensuring that the rights of the patient are at the centre of my decision-making process (NICE, 2016). The NMC, (2015) code of conduct requires me to recognise and assess signs of normal and or worsening mental and physical health of patients. Despite the aggression shown towards me, I could use my intuition and knowledge to recognise the deterioration of the patient’s mental health. Evidence suggests that good leaders use their intuition to enhance their decision-making (Marquis and Huston, 2009). The seminal work of Klein, (1999) discusses naturalistic decision-making, recognising the importance of making quick decisions based on intuition. It looks at the three-step process of experiencing and analysing the situation, then implementing the decision. Part of my decision-making during the situation was recognising that this behaviour was abnormal for the patient based on my previous experiences, and my priority was to maintain the safety of the patients, my colleagues and the public. Similarities can be found in Benner’s, (1984) pioneering decision-making theory, the intuitive-humanist model, exploring how clinical decisions can be enriched as the development of knowledge is gained through increased experiences and leadership. Consequently, both theories suggest this decision-making process enhances over time, it should be noted that I was still a novice in recognising and interpreting accurate assessments of the patient’s mental health needs. The implications of this experience were my naïveté in managing aggression through problem-solving and thus, the avoidable event occurred. (Dahlkemper, 2017). Evidence recommends nurses develop an awareness and ability to measure potential risks of aggressive behaviour. Aggressive behaviour rarely occurs without normal signs of impending hostility (Dolan and Holt, 2013). During this event I demonstrated my ability to assess the patient’s anxiety and confusion, consequently, I took lead of the situation by trying to move the patient to a safer environment. Nonetheless, due to a lack of leadership experience and confidence in my ability to problem-solve, I was unable to de-escalate the patient’s aggression and therefore my self-esteem and physical safety were at risk (Standing, 2017). Now I am becoming more experienced in dealing with violence and aggression in confused patients, I am further able to notice early signs of deterioration, acting proactively to be ahead in my assessments and thinking, thus enhancing problem-solving techniques and broadening my leadership potential (Thomas, 2012).
Specifically, I want to gain the skills and experience necessary to apply effective problem-solving to enhance my leadership in decision-making. I will measure my personal development through my own critical reflections, acknowledging my growth as a leader and my ability to accept responsibility for making mistakes and learning from them (Aston et al, 2010). I can attain this by attending a problem-solving and decision-making workshop. In addition, I can consider using the Plan-Do-Study-Act (PDSA) cycle to create an action orientated plan for future situations based on my past experiences (IfHI, 2016). This is relevant because nursing encompasses lifelong learning and this area of development comes with knowledge and experience (Jeffreys, 2010). A realistic time frame is hard to set, due to the ongoing nature of this skill and therefore, I will review my understanding and application of problem-solving once I have gained further clinical experience.
Leadership, Management and Team Working
I recently took part in the South-West NHS Military challenge which included a major incident simulation. My role during this simulation was to act as a nurse in a deployed medical team, working in collaboration with paramedics and doctors. During the simulation, I was observed by senior military medical staff in my ability to take lead in coordinating and delegating tasks to manage risk, executing patient care safely and effectively.
The significance of this issue is recognising my responsibility as a leader to delegate and support safe care to be carried out by appropriate members of the team to achieve good and time effective health outcomes. The RCN (2015) states nurses have a duty of care and a legal obligation to delegate tasks appropriately to the most suitable trained member of staff. This is underpinned by the NMC, (2015) code of conduct which states registrants must be accountable for their decisions to delegate tasks. Stanhope and Lancaster (2014) suggest the skill of effective delegation is becoming increasingly significant because it safeguards competency and improves time management. NHS England (2017) suggest this could be because of falling numbers of nurses, and changes to healthcare policies and practice. Covey (2015) proposes delegation is both for individuals and organisations; we accomplish all tasks through either delegation of time or tasks set to people, suggesting transferring a task to another skilled professional enables us to focus on other complex activities. Moreover, delegation helps develop growth for personal and organisational leadership (Motacki and Burke, 2016). During the debrief sessions the military medical staff discussed my ability to safely co-ordinate, lead and delegate appropriate tasks to my team during the simulation. A core concept of management and leadership is the allocation of delegation to another person to carry out a specific activity (Karssiens et al, 2013). The seminal work of Kotter (1988) details that although leadership and management are distinctive and complementary in their application, leadership goes beyond the routine of following managerial processes, moreover leadership delegation drives the collaborative vision for people to act to fulfil tasks. Both are essential to ensure safe and successful delegation is implemented, the implications of a lack of delegation in a health care setting could impose a negative effect on patient safety (Künzle et al, 2010). New evidence by Horton et al (2017) suggests that nurses have different styles of delegation based on personality and levels of confidence. The most common style found through analysis was the ‘do-it-all nurse’ the study indicates that newly qualified nurses actively avoid delegation, due to a lack of confidence. The study concludes the importance of preceptorship education in communication skills, self-awareness and emotional intelligence to enhance junior nurse’s confidence from the start of their careers as registered professionals. Although my confidence was noted in my ability to lead and delegate tasks during the situations, I am aware that I fear failure and have a lack of self-belief, which could impede on my ability to lead effectively. To prepare myself to be a better leader, I must firstly enhance my self-discipline and confidence to manage my own abilities (Barr and Dowding 2015). Leaders that are self-assured can delegate better because they are comfortable in recognising other team members’ skills and knowledge. If you believe in yourself and your capabilities, other people will recognise your confidence and feel able to follow your lead, making delegation easier and more successful (Maxwell, 2007).
Specifically, I would like to enhance my self-belief in my abilities to lead and competently delegate. I will measure this by reflecting on the comments made from this experience, and moreover my practice as a staff nurse on an acute medical unit. I must continue to re-evaluate my own strengths and weaknesses in my self-belief. I can achieve this by using the tool SWOT analysis which focuses on my strengths, weaknesses, opportunities and threats. This allows me to analyse the core issues of my self-belief (Cottrell, 2015). This is relevant because evidence proposes to be a leader, it is crucial to have a strong sense of self-belief which will enable people to follow my lead, making it easier for me to delegate tasks (Ellis and Bach, 2015). I aim to improve my confidence and self-belief through further experience in taking on the responsibly of coordinating more shifts at work.
In conclusion, this paper critically analysed my leadership development from my time as a student nurse to becoming a newly qualified nurse. We have explored and discussed my professional limitations, conflicts in communication, problem-solving through initiative, and delegation in leadership. I have set myself SMART goals to forward my development in each of these areas. From exploring theories of leadership to researching evidence in what makes an effective leader, I have discovered the importance of continually developing in my knowledge and expertise (Gopee and Galloway, 2017). The preceptorship has helped me recognise that the transition from student to newly qualified nurse is only the first step in my career; my abilities as a leader will depend on my willingness to learn and reflect on my experiences (Aston et al, 2010).
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