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Empowering Nurses to Lead Every Nurse in Every Setting North Dakota Action Coalition Leadership Program Copyright ND Center for Nursing 2014

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The North Dakota Action Coalition is a member of the Campaign for Action that was established in response to Institute of Medicine Future of Nursing Recommendations. Website: www.campaignforaction.org

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High-quality, patient-centered health care for all will require a transformation of the health care delivery system Institute of Medicine Report 3

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Campaign for Action Areas of Focus Leadership Practice & Care Education Interprofessional Collaboration Diversity 4

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The North Dakota Action Coalition is focused on the leadership development area of focus from the National Campaign. We have been working in groups over the last two years to develop leadership training customized to the needs of North Dakota nurses. www.ndcenterfornursing.org/nd-action-coalition/

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Every Nurse in Every Setting

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Nationally, it has been shown that when nurses are positioned to influence system practice and policies it leads to improvements in quality of care, wellness, and reduced medical errors. Nurse-led initiatives have: Reduced falls with harm Reduced code blue calls Reduced 30-day re-admissions Improved care transitions. 7

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What Can You Do as a Nurse Leader? Volunteer Speak up at workplace Pursue lifelong learning Serve on boards and enter policy debates Mentor Seek out committees Share the Institute of Medicine report Support academic progression Teach the next generation Join the North Dakota Action Coalition 8

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The North Dakota Action Coalition is co-lead by: the ND Action Coalition North Dakota Center for Nursing Patricia Moulton, PhD Executive Director Established in 2011 501c3 non-profit organization Vision: A unified voice for nursing excellence Mission: Guide the ongoing development of a well-prepared and diverse nursing workforce to meet the needs of the citizens of North Dakota through research, education, recruitment and retention, advocacy and public policy. www.ndcenterfornursing.org University of Mary Harold Schaefer Emerging Leaders Academy Cheryl Kalberer, MED, Coordinator, Emerging Leaders Academy Coordinator at the University of Mary Established in 1998 Experiential leadership development program for select students Mission: To identify and develop servant leaders of moral courage Guided by an external advisory board of representatives from across the health care profession http://www.umary.edu/academics/e mergingleadersacademy/ela_tab1.p hp http://www.umary.edu/academics/e mergingleadersacademy/ela_tab1.p hp

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Leadership Is. Everybodys business Relational Learned Self-development An ongoing process Is not. A title A right A job In your genetic makeup A means for power

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Leaders and Managers : Change Agents LEADER: Innovates Develops Investigates reality Focuses on people Challenges status quo Asks what and why Does the right thing MANAGER: Administers Maintains Accepts reality Focuses on system and structure Accepts status quo Asks how and when Does things right

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The North Dakota Action Coalition Leadership Program is divided into 4 modules. Communication is foundational for learning and understanding about 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.

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North Dakota Action Coalition Leadership Module Authorship Module Chair(s): Module Consultant: Module Committee Members:

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14 The learning module begins with the next slide.

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EC HO ECHO Essential Communication Hearing Ourselves Presented by the North Dakota Action Coalition Communication Group 15

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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 16

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To successfully complete this learning activity and be awarded contact hours: The learner must Complete the module and the additional 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. To earn a certificate of Achievement in Leadership Development you will need to complete the additional project as described at the end of this learning activity. 17

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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. 18

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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. 19

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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 20

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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. 21

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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 listenmeaninghearspeak 22

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Meaning making requires we reflect on the way we process and store the stories of our experiencesdepending on ones world view and adult development level shared experiences may end up being a different story to another person. 23

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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 and eventually wisdom. 24

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We need to HEAR what we say to others. We need to HEAR what others say to us. 25

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Most people talk so they wont hear May Sarton, Belgian American writer 26

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Communication is often filtered, we need to inspect, clean and sometimes replace our filters. 27

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There are a number of strategies and tools to help you practice reflection 28

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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. Bulman, C., & Schutz, S. (2013). Reflective Practice in Nursing, 5 th ed. Hoboken, NJ: Wiley-Black. 29

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What is the benefit of reflective practice in nursing? Helps you learn from experiences Opens up your practice for others to examine - requires open- mindedness and courage. Requires you to take on and act on criticism. Is intermingled with feelings and emotions. These feelings and emotions lead to deeper reflection. Fuels motivation to improve ones practice. Bulman, C., & Schutz, S. (2013). Reflective Practice in Nursing, 5 th ed. Hoboken, NJ: Wiley-Black. 30

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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 31

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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 32

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Skills involved in reflection (cont.) 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 33

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Reflective thinking is a process that grows knowledge, skills, attitudes, and judgment 34

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Reflection is meant to grow and challenge our thinking.. 35

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Frameworks are maps to help guide us in reflection. 36

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Frameworks ask a common set of questions that can guide our thinking. Gibbs Reflective Cycle 37

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There are many frameworks to choose from or you can create your own. 38

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One framework used in nursing is Tanners Clinical Judgment Model 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), 513- 516. Consider how it compares to the Nursing Process Assessment Diagnosis Outcomes identification Planning Implementation Evaluation ANAs Nursing Scope and Standards, 2 nd Edition, 2010 39

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The Nursing Process & Tanners 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) 40

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The Nursing Process & Tanners 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) 41

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The Nursing Process & Tanners 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 42

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You are strongly encouraged to utilize these frameworks for self care in becoming a skilled communicator. 43

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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? 44

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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? 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. 45 Reflective Exercise

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Authentic Are you the real deal? 46

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Over the next several slides Nursings 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 47

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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 48

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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 49

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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 50

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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 51

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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 52

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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? 53 Reflective Exercise

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Authentic Leadership Acknowledge your strengths and weaknesses List both your strengths and your weaknesses Consider your weaknesses your initial 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. Bulman, C., & Schutz, S. (2013). Reflective Practice in Nursing, 5 th ed. Hoboken, NJ: Wiley-Black. 54 Reflective Exercise

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Brief side track on the topic 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/emotionalintell. htm http://psychology.about.com/od/personalitydevelopment/a/emotionalintell. htm http://www.mindtools.com/pages/article/newLDR_45.htm http://www.ei-nurses.com/2e.php 55

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Becoming Mindful... Paying attention in a non-judgmental manner... 56

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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 Http://www.mayoclinic.org/mindfulness-exercises/ART-20046356 57

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The art of reflection instead of reaction PBR 3 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 (dont jump to conclusions, instead strive to cleanse deceptions, what is the real story?) www.americannursetoday.com/.../11a8ce23-ea5c-4cff-b7ea-9a4fb5ca17 58

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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. 59

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Becoming 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. 60

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An approach for becoming candid... Carefronting ends the blame game. 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? 61 Reflective Exercise

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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/ANAPeriodic als/OJIN/TableofContents/Volume112006/No2May06/tpc30_316075.html 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. http://www.emergingrnleader.com/carefronting/ 62

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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. 63

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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 when developing your plan. Becoming aware of self-deception Becoming reflective Becoming authentic Becoming mindful Becoming candid Implement your plan and evaluate the outcome. 64

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Leadership Development

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To earn your certificate of achievement in leadership development you will need to submit the following: Evidence of completion of Communication Module Document one additional instance of applying the 5 factor model for skilled communication in your practice. Document one instance of using Carefronting and the outcome of using this technique. While the 5 factor model will no doubt be helpful in all aspects of you life, we ask your examples be from interactions as a nurse. You may compile all the additional requirements in a portfolio and submit all the project requirements at the end of Module 4.

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Additional Recommended Reading Bulman, C., & Schutz, S. (2013). Reflective Practice in Nursing, 5 th 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/ http://www.vitalsmarts.com/resource-center/ 67