Preparation for professional practice.

Introduction

The aim of this essay is to critically analyse the professional roles of qualified nurses, their accountability, collaboration and their responsibilities when taking leadership and managerial roles at all points in their career. This essay will be structured in two parts;Part 1 will focus on the process of the service improvement plan during one of the author’s practice placements in an acute ward and refers to the recommended “change” which the author intends to implement. The plan for change is based on protecting patients’ mealtimes. First, brief definitions will be given and an exploration of the concepts of management and leadership will be undertaken. Part 2 of this easy will focus on the professional development of the author upon qualification as a staff nurse within a few months which will be discussed under the section on “delegation”. SMARTER theory has been identified in this easy as learning needs. In accordance with the Nursing and Midwifery Council Code of Professional Conduct (NMC, 2008) all names and places in this essay will be replaced with pseudonyms.

According to Huber (2010) management in the context of nursing has been identified as involving the use of delegated authority within formal organisational, settings, to co-ordinate, organise, direct and control responsible subordinates. In the same context, Mckimm and Held (2009) described management as the process of bringing together or working with individuals, groups and other resources to accomplish organisational goals. Scott and Caress (2005) view management as directing and controlling a group of individuals for the purpose of co-ordinating and harmonising those groups towards achieving goals. Tormey (2009) illustrated the distinguishing characteristics of management and leadership. (Cheery and Jacobs, 2005) state that a manager is one who is appointed to formal positions of organisational authority and uses legitimatised power to command, reward or punish the workforce. On the other hand, a leader is one who will be able to communicate, gain commitment, facilitate change and achieve results through efficient and creative means, with his/her followers despite the absence of the formal position of power (Huber, 2010).

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Leaders seek the active involvement of those around them to achieve mutually agreed goals; leaders also seek the collective will of all involved, establishing contact with leading other clinicians (Hersey et al., 2001). Crevani et al. (2010) suggest that leadership is an adventure requiring a pioneering spirit and leadership skills and interpersonal skill which differs from person to person; Yoder-Wise (2011) states that the work of nurses is based on management; therefore, nurses require better leadership skills and management skills which are considered to be a major factor in improving direct person-centred interventions, achieve goals, objectives and decision making for quality care provision. In order to achieve the goals and objectives, managers of the organisation must be involved in the activities which include being able to analyse matters, establish objectives, formulate goals, plan strategies, communicate effectively, efficiently handle change, conflict, as well as evaluate the ever-changing situation situation (McCrimmon, 2011) . Rosener (1990) cited in Barker, 2009) identified two types of leadership which include transactional and transformational leadership.

Bass (2008) suggests that transactional leader focuses on management tasks and will not identify the shared values of the team; however, the transactional approach is orientated and can be effective when meeting deadlines or in an emergency. Cummings et al. (2008) concluded that the transformational leader recognises her/his followers’ potential and takes active interest in them and their development. The transformational leader inspires, promotes excellence beyond mere task, encourages employees to become autonomous and solution focused, stimulates interest among followers to view work from a fresh perspective, generates an awareness of vision towards which the team is headed, develops followers to higher levels of ability and potential ((Rolfe, 2011).

Hersey et al. (2001) on the other hand identified different leadership styles; however, for the purpose of this easy the author here will focus on three styles which include autocratic, democratic and laissez-faire. Hersey et al. further state that some people are able to combine the three styles of leadership and adopt a style to match the situation at hand. The autocratic leader is likely to make decisions on his or her own and give orders; this style can create antagonism and reliance which might hold back originality and advancement (Bass, 2008). Democratic leaders are more drawn towards relationships; they encourage group discussions and seek consensus where every decision made is agreed by the whole group (Hersey et al., 2001). This style of leadership may be slow because of every member of the group being considered; however, it is a favourite leadership style among the nursing profession (Grint, 2005). According to Hersey et al. (2001) the laissez-faire leadership style promotes complete freedom and is known to allow events to take their own course; this is because there may never be a clear decision. Again Hersey et al. further state that there is no one style which is better than the others as they all have their own advantages and disadvantages. As specified previously, the situation will determine the styles to be used to achieve the goals (Hersey et al., 2001).

Improvement Plan

The improvement plan was formulated during the author’s recent practice placement in the Psychiatric Intensive Care Unit (PICU) which provides intensive care management service for individuals who are disturbed and exhibiting extremely violent and aggressive behaviour. According to Allan (1988), any patient brought to this unit must be on section of the Mental Health Act (MHA, 1983), apart from the severity of an individual’s illness, in order to qualify for admission to the ward. During this placement, the author of this essay discovered that there had numerous and ongoing interruptions and arguments between some patients and staff during mealtimes. In addition, staff members who were supposed to assist during mealtimes frequently claimed to be “very busy”.

This untenable situation prompted the author to suggest introducing “Protected Mealtimes” to the team. The rationale for choosing this improvement plan was because some of the patients on that ward were not encouraged or supported by staff member during mealtimes, mainly those elderly patients who were finding it very difficult to eat and drink unassisted. Many patients were on medication that was causing them serious side-effects such as dehydration and constipation, so they needed to be encouraged to have adequate and healthy dietary intake. The author therefore had a discussion with their mentor and other multidisciplinary team members regarding this issue and they all supported the need for a meeting to resolve the above issue.

Initially, the author felt very nervous about introducing this new approach to the team members, due to lack of confidence and knowledge. The key point of the change was explained to all the patients. A proposal was put forward after the meeting regarding and defining the topic, namely “Protected Mealtimes” and the patients on the ward were given the opportunity to voice their own opinions on what they thought about the new proposal. The patients gave a positive verdict on the proposal. The National Catering and Nutrition Specification (2008) defined protected mealtimes as a period when all non-imperative activities and treatments must stop, in order to allow patients to eat and enjoy meals without being interrupted by any other activity on the ward. It should be a period during which staff members need to encourage the adequate consumption of dietary intake and provide an environment which is very conducive to eating and is friendly and hygienic. It is also a time when staff members need to ensure that mealtimes are a pleasant and relaxing social experience for all patients (Royal College of Nursing, 2007).

The author took on the role of a democratic leader which according to Hersey et al. (2001) looks more towards relationships which encourage group discussion, consensus and group decisions, rather than the leader alone making the decision when introducing change. According to Greenhalgh and Heath, 2010) therapeutic relationship, engagement, listening skills and effective communication skills played an important role during the meeting detailed above, because the team members, as well as the patients were all equally convinced that the issues raised by the author were pertinent and essential, in terms of the patients’ satisfaction.

It was agreed in the meeting that, during mealtimes, there would be no drug round, no activities by occupational therapy staff, no visitors allowed on the ward during mealtimes, and no domestic work carried out. All the televisions would be switched off, dormitories, day rooms, shower rooms and activity rooms should be locked. All the staff members and patients on the ward must be present in the dinning area during mealtimes, in order to avoid distraction as advised by (RCN, 2007). The change was implemented within a few days of the meeting. Initially, it was not easy, but within a few days everybody on the ward adjusted. Moreover, some patients who normally isolated themselves from group activities on the ward now began to interact and engage well in conversation during mealtimes. Staff members were supporting/encouraging and showing compassion to all the patients, mainly some of the elderly patients, with good dietary intake which showed appropriate care for patients. Such changes had a significant effect on the provision of ward services. According to Age UK (2010), appropriate nutritional care for patients in the hospital is very important, because it decreases the risk of malnutrition, obesity and its associated complications.

Change Management

According to Christie and Robinson (2009), it is essential to have a plan for how things will be accomplished when implementing a change in any clinical setting. Change management in a nursing setting means observing things that happen or are done differently for the benefit of the patients. Braine (2006) stressed that for a change to be implemented successfully, there must be an awareness of the need to change, a desire to support and participate in the change, the knowledge to change, the ability to implement the change and the resources to maintain the change. O’Connell et al. (2008) advised that as a change management model for protected mealtimes, simple implementation would focus on the need for nurses to engage, motivate and participate in the change. Allan (2007) identified three stages for the change process which include unfreeze, change and refreeze. Allan emphasised that during the unfreeze stage, a proposed change needs a clear aim, so that the individuals planning it will have no doubt why, know the rationale and the benefit will be explained to others.

The National Institute of Clinical Excellence (2007b) has identified some barriers that hinder change management within the multidisciplinary team, many of which were evident in this particular example. These include the financial and political environment which can affect a professional’s ability and motivation to change. Garon (2012) concluded that a lack of awareness and understanding in an organisation’s nursing management theories have shown that the way in which an organisation is managed can affect nurses’ confidence to communicate the need for change. Maddock (2002) argued that the approaches to change and the proposal thereof may be ineffective unless individuals’ management strategies are put in place to develop leaders.

Accountability/ Responsibility

According to Marquis et al. (2009) one of the legal requirements of a registered nurse is accountability. Scrivener et al. (2011) identified that accountability involves the ability of the nurse to define every action he/she carries out. The (NMC, 2008) emphasised that accountability is seen as being of great importance and a qualified nurse is accountable for his/her own actions such as supervision, delegation, creative acts, intervention, assessing a situation or follow-up concerns. NMC (2008) further explained that the entire health care professionals are accountable and responsible for any action, error or omission made in practice. Huber (2006) states that as members of a multidisciplinary team, nurses must maintain their professional accountability. Nurses should also be able to use their communication skills to make complicated information understandable, explain choices, offer reassurance, look out for side-effects and liaise with medical colleagues about the subsequent progress of individuals with mental health problems (Garon, 2012). This was seen as a critical aspect of the operation here with regular reviews being planned to evaluate the success of the change and to amend the program where appropriate.

Furthermore, if a nurse is meant to delegate care to another professional or support worker, she/he must delegate effectively and should be accountable for the appropriateness of the delegation. During one of the author’s practice placements in the acute ward, a newly qualified nurse delegated the task of security nurse to an agency staff who was very new on the ward. This agency staff let one of the patients out of the ward, not knowing that the patient was on level 1 observation restricted to the ward and the patient absconded from the unit. This resulted in an investigation which revealed that the newly qualified nurse did not delegate the task properly and did not communicate effectively. This raised the question of accountability and responsibility.

The specifics of the nurse’s role are identified as being responsible for assessment, planning, the delivery of care and the evaluation of nursing care for their patients (NMC, 2008). According to RCN, 2011), nurses are accountable and responsible, on a daily basis, carrying out patient care most of the time and acting as care provider. Nurses have the responsibility for communicating the relevant information necessary for the patient to receive their full nursing care provision (NMC, 2008).(RCN, 1992) also states that with an increase in the level of responsibility and accountability, nurses need adequate training and competence to develop these changes. It is the responsibility of the nurses to make sure that patients are suitably dressed and eat their meals, while also managing their welfare rights and dealing with individuals’ psychological distresses; theses roles have to be carried out in conjunction with running organisational demands (RCN, 2011).

Orchard et al. (2005) described inter-professional collaboration as a combination of different professionals working together in a partnership in order to achieve common goals, establish a therapeutic relationship, showing respect for others and the skilled therapeutic use of self. On the other hand, inter-professional collaboration means the adoption of multi-disciplinary and multi-agency working as the most effective route towards comprehensive mental healthcare (Audrey, 2003). However, Garon (2012) states that when talking about change in inter-professional collaborative team work, it is important to consider how staff members would need to be motivated to accept and welcome this change. It is also very important to select the right leader, which was a key advantage of this approach, to implement the change and involve all team members in the change process, as well as considering the safety of the patients, their comprehensive care and the stress the change might cause (NICE, 2007b).

During this implementation of “Protected Mealtimes”, all the team members on the ward worked collaboratively, demonstrated excellent communication skills, showed motivation and were very enthusiastic and committed to the plan.

The Professional Development Plan (PDP)

The purpose of writing this professional development plan is to think and reflect on a facet of the professional development experienced by the author during their three-year course. It will also enable the author to work efficiently and effectively in their areas of weakness and help to sustain areas of strength, as well as developing delegation skills in the nursing environment, upon qualification. In order to accomplish these goals, a plan utilising SMARTER theory (Specific, Measurable, Realistic, Timely, Ethical and Recorded/ Reflective (Appendix 1) is proposed. During the three years of nursing training, the author of this essay has utilised Gibbs Reflective Cycle (1988), as a framework for reflection on day-to-day actions, strengths and weaknesses. According to Brechin (2000), reflection means not only thinking about a situation, but also using it as a form of systematic appraisal of the events that have occurred and as an examination of an individual’s ability to learn from the experience and influence future practice.

During this placement in the acute ward, the author discovered that delegating duties to staff when co-ordinating shifts was a far more complex issue than originally anticipated. The RCN (2006) described delegation in nursing as a process of entrusting or allocating responsibility to another person who is seen as being able to carry out such a task. The Nursing and Midwifery Council (2008) states that a nurse’s job cannot be completed or carried out without delegating some part of the care functions to others, as it is highly impossible to deliver total care for different patients with different care needs. Barr and Dowding (2008) in their research emphasised that delegation is a critical leadership skill that must be learned.

This became evident when considering a situation which emerged when dealing with a violent patient in a ward environment. In order to delegate tasks relating to this individual it was necessary to use confidence, communication, courate, compassion, competence and care. On the whole this was doen relatively well by myself however it was found that the newly qualified staff nurse is more likely to be unfamiliar with the procedure delegated to him and this made communication a more vital so that guidance could be obtained. Having identified a weakness in the authors ability to delegate, this communication between the two parties in the case mentioned above was used as a clear example of how greater comfort from the process of delegation could be obtained. This would in turn improve confidence.

By watching delegations within the ward environment it became apparent to the author that there were greater difficulties when the manager used the autocratic style and this often created hostility amongst other staff and may hinder creativity and improvement. This brought the manager’s delegation skills into question. There was also an increased danger that the more junior member of staff would find themselves unsupervised in an inappropriate and unacceptable way according to RCN (2011). This leadership style as described by Bass 2008 as creating difficulties. Where better delegation communication were used the author was much more comfortable with the delegation process as they were aware that the process would be used appropriately and would be successful. With this in mind the PDP going forward would focus on risk management and controlling the process without following an autocratic style which would lead to loss of control when delegating.

The author of this essay has learned from undertaking this assignment that delegation not only saves time, but is also an essential skill which a registered nurse must posses; it is also requires good leadership and is an important role for every nurse involved in health care delivery. Through this Personal Development Plan (PDP), personal areas of weakness have been identified which the author is currently striving very hard to correct.

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