The Future of Nursing
LEADING 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 Setting
North Dakota Action Coalition
Leadership Program
Communication
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North Dakota Action Coalition
The 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 Education
During 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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ECHO
Essential Communication
Hearing Ourselves
Presented 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 selfreflection 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 is
far 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-andYou.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.
listen
speak
communication
meaning
hear
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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 openmindedness 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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Reflection is meant to grow and challenge our thinking…..
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?
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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
Consider how it compares
to the Nursing Process
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•
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•
•
•
•
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Introduction
Background
Noticing
Interpreting
Responding
Reflection-in-action
Reflection-on-Action
Nielsen, A., Stragnell, S., & Jester, P. (2007).
Guide for reflecting using the clinical judgment
model. Journal of Nursing Education, 4(11), 513516.
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/thinkinglikea
nurse.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-deception
 Do 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 Nurses
http://nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/E
thicsStandards/CodeofEthics.aspx
Review the International Code of Ethics for Nurses
http://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 intelligence
Emotional 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/emotional
intell.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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Candid
The 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 candid
Carefronting 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/tpc3
0_316075.html
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Bringing the Five Factors together – your
action plan, first a reminder. . .
Becoming reflective exposes selfdeception, 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.
61
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.
63
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/
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