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The Future of NursingLEADING CHANGE,

ADVANCING HEALTH

The report from the Future of Nursing can be found at the following link.http://www.thefutureofnursing.org/IOM-Report

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Transforming leadership • Strong leadership is critical if the vision of a transformed health care

system is to be realized. Yet not all nurses begin their career with thoughts of becoming a leader. The nursing profession must produce leaders throughout the health care system, from the bedside to the boardroom, who can serve as full partners with other health professionals and be accountable for their own contributions to delivering high-quality care while working collaboratively with leaders from other health professions.

• FROM: Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine; Institute of Medicine

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• What is needed is a style of leadership that involves working with others as full partners in a context of mutual respect and collaboration.

• The new style of leadership that is needed flows in all directions at all levels. Everyone from the bedside to the boardroom must engage colleagues, subordinates, and executives so that together they can identify and achieve common goals (Bradford and Cohen, 1998).

• FROM: Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine; Institute of Medicine

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Empowering Nurses to Lead

Every Nurse in Every SettingNorth Dakota Action Coalition

Leadership Program

Communication

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North Dakota Action CoalitionThe North Dakota Action Coalition (NDAC) is focused on the development of statewide leadership programming for “Every nurse, in every setting” This includes nursing students, front-line nurses, community nurses, advanced practice nurses, chief nursing officers and nurse researchers.

The ND Action Coalition is co-led by the ND Center for Nursing and the University of Mary Harold Schafer Emerging Leaders Academy and is part of the National Campaign for Action. To learn more click on the links below:http://www.thefutureofnursing.org/content/action-coalitions

http://www.thefutureofnursing.org/

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Leadership Program is divided into 4 main areas.

Communication is foundational for learning about and understanding first yourself and then systems.

Knowledge of how systems function is necessary to institute change.

The ability to accept and engage in change is necessary to be an advocate for health policy.

All nurses are expected to lead!

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Evaluation of learning: Applying the IOM Core Competencies in Nursing EducationDuring this learning activity you will be asked to evaluate if and how you meet the learning objectives. Take a few minutes now to review the evaluation form found at the end of this module. Part of learning the art of reflection is to be able to compare yourself against set standards and/or objectives. To better facilitate the reflective process you are strongly encouraged to read and understand the expected outcomes so you can measure your progress while you are learning. One standardized set of capabilities is the IOM Core Competencies in Nursing Education. We provide a review on the next slide.

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• Providing patient-centered care: I will be able to Identify, respect, and care about patients' differences, values, preferences, and expressed needs; listen to, clearly inform, communicate with, and educate patients; share decision making and management; and continuously advocate disease prevention, wellness, and promotion of healthy lifestyles, including a focus on population health.

• Working in interdisciplinary teams: I will be able to Cooperate, collaborate, communicate, and integrate care in teams to ensure that care is continuous and reliable.

• Employing evidence based practice: I will be able to Integrate best research with clinical expertise and patient values for optimum care, and participate in learning and research activities to the extent feasible.

• Applying quality improvement: I will be able to Identify errors and hazards in care; understand and implement basic safety design principles, such as standardization and simplification; continually understand and measure quality of care in terms of structure, process, and outcomes in relation to patient and community needs; and design and test interventions to change processes and systems of care, with the objective of improving quality.

• Utilizing informatics: I will be able to Communicate, manage knowledge, mitigate error, and support decision making using information technology.

--From Health Professions Education: A Bridge to Quality. Institute of Medicine, 2003

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In addition to evaluating whether or not you have met the learning activity objectives, you will be asked to evaluate whether or not this learning activity has helped you to meet the IOM’s core competencies.You will also be asked to respond to the following 3 questions. They are provided here to help you reflect on your learning experience while you proceed with this learning activity.

Tell us what you have learned about communication.

Describe one scenario where you have used the material learned in this continuing nursing education activity.

How do you predict you will use this material in the future?

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ECHOEssential Communication

Hearing OurselvesPresented by the North Dakota Action Coalition

Communication Group

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The purpose for this learning activity is to introduce the 5 factor model for becoming a skilled communicator and to provide reflective practice tools that grow your communication skills. Objectives 1. Define communication.2. Review the 5 factor model for becoming a skilled communicator. 3. Review the use of self-reflection.4. Review frameworks/ standards/ codes that inform the practice of self-

reflection in nursing. 5. Use self-reflection to develop expertise for becoming a skilled

communicator.6. Develop your personal action plan to become a skilled communicator

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Communication isfar more than speaking ….It is about HEARING not only what others say to us but HEARING what we say to others.

To become a skilled communicator we must learn to hear ourselves.

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Becoming a skilled communicator requires 5 factors: Becoming aware of self-deception Becoming reflective Becoming authentic Becoming mindful Becoming candid

The foundation for this learning activity is based on the Five Factor Model of Becoming a Skilled Communicator (Kupperschmidt, Kientz, Ward, and Reinholz, 2010). http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol152010/No1Jan2010/A-Healthy-Work-Environment-and-You.html

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Becoming reflective exposes self-deception, which leads to discovering your authentic self.

The act of reflection leads to heightened awareness / alertness to verbal and nonverbal communication (emotional intelligence) which is being mindful.

These states of becoming prepare one to speak purposefully, to express and listen truthfully also known as being candid.

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To successfully complete this learning activity and be awarded contact hours: • The learner must• Complete the reading assignments.• Complete the learning activities.

• You will need to write in a journal during this learning activity, you may do so either on paper or by using your computer. Save your work so you can access it and re-read your thoughts.

• Complete course and self evaluations.

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Opportunities for further learning are presented through-out this learning activity.

You are urged to take time to engage in these extra learning activities.

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When we speak we count on others to

listen and hear our meaning… When we

listen others count on us to hear their

meaning…

Communication is about meaning

making.

communication

listen

meaning

hear

speak

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Meaning making requires we reflect on the way we process and store the stories of our experiences…depending on one’s world view and adult development level shared experiences may end up being a different story to another person.

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As we process the bits of data we constantly receive during the act of communicating, we translate those bits into streams of information, it is in reflecting/ thinking that we turn all those bits into knowledge.

Leadership requires we process those bits of data in a way that fosters development of wisdom.

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We need to HEAR what we say to others….We need to HEAR what others say to us.

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“Most people talk so they won’t hear”May Sarton, Belgian American writer

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Communication is often filtered, we need to inspect, clean and sometimes replace our filters.

Reflection is a way to inspect, clean and if necessary replace our filters…

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As nurses we need to elevate our communication to a level that fosters professionalism.

We have a standard of professional performance to meet.

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There are a number of strategies and tools to help you practice reflection

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Becoming reflective is. . . • The process of pondering, carefully and persistently, the MEANING of

an experience.• Creating meaning from past or current events that guide future

behavior.• Self-questioning so situations become more clear and coherent.• Systematically examining the past and the present to inform the

future.

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What is the benefit of reflective practice in nursing?• Learn from experiences • Opening up one’s practice for others to examine requires open-

mindedness and courage. • Requires one to take on and act on criticism.• Is intermingled with feelings and emotions.• Fuels motivation to improve one’s practice.

Bulman, C., & Schutz, S. (2013). Reflective Practice in Nursing, 5th ed. Hoboken, NJ: Wiley-Black.

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What specific skills are involved in reflection?• Self-awareness • Aware of character, beliefs, values, qualities, strengths, and limitations

• Description• Ability to state characteristics or appearance WITHOUT expressing judgment

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Skills involved in reflection (cont.)• Critical analysis

• Separation of the whole into its component parts• Undertake a detailed examination of structure, elements, or parts.• Understand the nature of, how parts relate to, and influence other parts.• Include the manner ways of knowing (empirical, aesthetic, personal, ethical)• Challenge assumptions

• Synthesis (opposite of analysis)• The process of result of building up separate elements, ideas, into a connected and

coherent whole

• Evaluation• Make a judgment about the value of something • Use of predefined criteria or standards

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Reflective thinking is a process that grows knowledge, skills, attitudes, and judgment

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We have all heard the saying…”think outside the box”…. Do we mean we wish others would think more like what is in our box?

Or are we ready to examine our own thinking, behavior, worldview, values, and respect where others are in this process as well?

Reflection is meant to grow and challenge our thinking…..

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Frameworks are maps to help guide us in reflection.

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Frameworks ask a common set of questions that can guide our thinking.

Gibbs Reflective Cycle

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Modified Gibbs Reflection Cycle

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There are many frameworks to choose from or you can create

your own.

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One framework used in nursing is Tanner’s Clinical Judgment Model • Introduction • Background• Noticing• Interpreting• Responding• Reflection-in-action• Reflection-on-ActionNielsen, A., Stragnell, S., & Jester, P. (2007). Guide for reflecting using the clinical judgment model. Journal of Nursing Education, 4(11), 513-516.

Consider how it compares to the Nursing Process

• Assessment• Diagnosis• Outcomes identification• Planning• Implementation• Evaluation ANA’s Nursing Scope and Standards, 2nd Edition, 2010

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The Nursing Process & Tanner’s Clinical Judgment Model

Introduction (Assessment)Your view of the situation

(Be aware of your viewpoint)

Background (Assessment)Relationship, experiences, formal knowledge

(Be aware of the factors that create your background)

Noticing (Assessment)Initial and later

(Be aware of your patterns for sensing situations)

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The Nursing Process & Tanner’s Clinical Judgment Model

Interpreting (Diagnosis)Cause, patterns, similarities, differences, observations, data

(Be aware of your viewpoint, how does it impact your meaning making)

Responding (Outcome planning, Implementation)Actions, stressors, feelings(Be aware of your patterns)

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The Nursing Process & Tanner’s Clinical Judgment Model

Reflection-in-Action (Evaluation)Think about practice while doing it

(This takes practice)

Reflection-on-Action (Evaluation)Thinking back on what we have done to discover how we may have contributed

to the outcome or unexpected outcome. (Consider working with someone you trust to help clarify your point of view)

http://simulation.laerdal.com/forum/forums/storage/14/4049/thinkinglikeanurse.pdf

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You are strongly encouraged to utilize these frameworks for self care in becoming a skilled communicator.

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For the reflective process to be effective, we must reflect on how we see ourselves in any situation.

What self-deceptions do we hold?

Have you examined your role and perceptions about miscommunications that have occurred?

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Reflective exercise to become aware of self-deceptionDo I fully appreciate the work of nursing and the environment in which that work takes place?

Do I base my practice on the Code of Ethics for Nurses? (See next slide for link to review Code of Ethics for Nurses)

Do I assume responsibility for attaining and maintaining my work environment? What is my definition of my work environment? Is my definition complete? How would others describe the workplace? Is that description how all members feel? If there is collective unhappiness what is my responsibility in perpetuating the perceived shortcomings?

Am I open and trustworthy?

Do I acknowledge and change routines and behaviors that have hindered communication?

Commit at least 10 minutes to each question, write your reflections in your journal.

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Authentic – Are you the real deal?

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Over the next several slides Nursing’s Standards of Professional Performance are briefly reviewed. These standards describe a competent level of behavior in the professional role.

Standard 7. Ethics Standard 8. Education Standard 9. Evidence-Based Practice and Research Standard 10. Quality of Practice Standard 11. Communication Standard 12. Leadership Standard 13. Collaboration Standard 14. Professional Practice Evaluation Standard 15. Resource Utilization Standard 16. Environmental Health

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• Standard 7. Ethics • Practices ethically

Review the ANA Code of Ethics for Nurseshttp://nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/EthicsStandards/CodeofEthics.aspx

Review the International Code of Ethics for Nurseshttp://www.icn.ch/about-icn/code-of-ethics-for-nurses/

• Standard 8. Education• Attains knowledge and competencies that reflect current nursing practice

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• Standard 9. Evidence-Based Practice and Research • Integrates evidence and research findings into practice

• Standard 10. Quality of Practice• Contributes to quality nursing practice

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• Standard 11. Communication • Communicates effectively in all areas of practice

• Standard 12. Leadership • Demonstrates leadership in the professional practice

setting and the profession

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• Standard 13. Collaboration• Collaborates with the healthcare consumer, family, and

others in the conduct of nursing practice

• Standard 14. Professional Practice Evaluation • Evaluates her or his own nursing practice in relation to

professional practice standards and guidelines, relevant statutes, rules, and regulations

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• Standard 15. Resource Utilization • Utilizes appropriate resources to plan and provide nursing

services that are safe, effective, and financially responsible

• Standard 16. Environmental Health • Practices in an environmentally safe and healthy manner

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Reflective exercise: Your performance as a nurse?

• Do you practice ethically?• Do you attain knowledge and competencies that reflect current nursing practice?• Do you integrate evidence and research findings into practice?• Do you contribute to quality nursing practice?• Do you communicate effectively in all areas of practice?• Do you demonstrate leadership?• Do you collaborate with the health care team, patient, family, and others in

conducting your practice?• Do you evaluate your practice in relation to professional standards?• Do you use appropriate resources and provide safe, effective, and financially

responsible nursing service? • Do you practice in an environment that is safe and healthy?

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Reflective exercise: Authentic leadership • Acknowledge your strengths and weaknesses

• List both your strengths and your weaknesses• Consider your weaknesses your guide for self-development

• What is your purpose?• Do you hold and practice professional values?

• Do you role model professional behaviors?

• Do you practice through your heart as well as your mind?• Do you have enduring relationships?

• Do you treat others with respect?

• Do you practice self discipline?• Do you seek out and act on feedback?

• How do you behave when you receive feedback?

• Commit one hour to writing your responses in your reflective journal.

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Brief overview of emotional intelligenceEmotional intelligence (EI) refers to the ability to perceive, control and evaluate emotions.The subset of social intelligence that involves the ability to monitor one's own and others' feelings and emotions, to discriminate among them and to use this information to guide one's thinking and actions.(Peter Salovey and John D. Mayer, 1990)

To read more http://psychology.about.com/od/personalitydevelopment/a/emotionalintell.htm

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Becoming Mindful

Paying attention in a non-judgmental manner

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Exercise for becoming mindful• What is mindfulness?

Mindfulness is the act of being intensely aware of what you're sensing and feeling at every moment — without interpretation or judgment. Spending too much time planning, problem-solving, daydreaming, or thinking negative or random thoughts can be draining. It can also make you more likely to experience stress, anxiety and symptoms of depression. Practicing mindfulness exercises, on the other hand, can help you direct your attention away from this kind of thinking and engage with the world around you. Http://www.mayoclinic.org/mindfulness-exercises/ART-20046356

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The art of reflection instead of reaction…• PBR3

• Pause (stop your negative thinking, your habitual response)• Breath (slow deep breathes, to trigger your parasympathetic nervous system)• Relax (comes with breathing)• Reflect (instead of reacting)• Re-write your story (don’t jump to conclusions, instead strive to cleanse

deceptions, what is the real story?)

• In a nutshell: when you feel your fear/ anger button being pushed…mentally and physically stop what you are doing, take slow deep breaths until you feel relaxed. Reflect on what just happened, then record an authentic story in your brain.

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CandidThe ability to speak frankly, free from bias, a willingness to risk speaking/ hearing the truth.Happens in environments where there is sufficient trust. Must be willing to suspend judgment while listening to others. Must be willing to hear what you are thinking and quiet your mind.It is ok if we hold diverse points of views. It does not necessarily mean we disagree. We have simply chosen a different meaning.

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Each person brings their own unique ways of speaking and listening to communication.

Practice suspending judgment while listening to others.

Be fully present.

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An approach for becoming candidCarefronting ends the blame game.Below are reflective questions for this approach for becoming candid. You may ask yourself these questions when you find yourself in a situation where communication has failed. Stop and ask yourself: What is the respectful thing to do now? (Respect for both yourself and others)Where do we go from here? When do we begin to discuss the conflict- if not now, when?Who will end the blame and help work toward the professional practice environment we all deserve?

For more on Carefronting follow the link below. http://www.emergingrnleader.com/carefronting/ Dr. Betty Kupperschmidt an Associate Professor of Nursing at the University of Oklahoma, has been a pioneer in bringing the concept of carefronting to nursing practice.

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More resources for Carefronting• Carefronting: An innovative approach to managing conflict• October 2012 Vol. 7 No. 10

Author: Rose O. Sherman, EdD, RN, NEA-BC, FAAN http://www.americannursetoday.com/article.aspx?id=9584&fid=9534

Addressing Multigenerational Conflict: Mutual Respect and Carefronting as Strategy (Kupperschimidt, 2006)http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume112006/No2May06/tpc30_316075.html

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Bringing the Five Factors together – your action plan, first a reminder. . . Becoming reflective exposes self-

deception, which leads to discovering your authentic self.

The act of reflection leads to heightened awareness / alertness to verbal and nonverbal communication (emotional intelligence) which is being mindful.

These states of becoming prepare one to speak purposefully, to speak and listen truthfully also known as being candid.

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Skilled communicator action plan• Based on your responses to the reflective exercises, develop a personal

action plan to increase communication skills. • Enlist trusted others to help you meet your goals. • Consider the 5 factors Becoming aware of self-deception Becoming reflective Becoming authentic Becoming mindful Becoming candid• Implement your plan and evaluate the outcome.

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To successfully complete this learning activity and be awarded contact hours: • The learner must• Complete the reading assignments.• Complete the learning activities.

• You will need to write in a journal during this learning activity, you may do so either on paper or by using your computer. Save your work so you can access it and re-read your thoughts.

• Complete course and self evaluations.

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Additional Recommended Reading Bulman, C., & Schutz, S. (2013). Reflective Practice in Nursing, 5th ed. Hoboken, NJ: Wiley-Black.Prather, H. (2000). The little book of letting go. Berkeley, CA: Conari Press. Senge, P., Scharmer, C.O., Jaworski, J., & Flowers, B.S. (2004). Presence: Human purpose and the field of the future. New York: Crown Publishing Group. Vital Smarts (Crucial Conversations) http://www.vitalsmarts.com/resource-center/