Nursing Leadership and Management of Bedside Nursing Care
Nurses providing care at the bedside do not hold the title of manager, yet they are the manager of their patients care. Leadership skills are imperative within the role of the bedside nurse. There are numerous healthcare settings in which nurses exhibit and share their leadership capacities; acute care, home-care, primary care offices, hospice, public health, schools, long-term care and many more. Although Registered Nurses (RNs) work autonomously, RNs work as part of team that encompasses and overlaps into numerous aspects of various healthcare settings. Utilizing new leadership skills learned through advanced education and striving towards proficiency of team management exemplifies an unyielding commitment to successful bedside nursing.
Collaboration
The American Nurses Association (ANA) defines collaboration as “recognition of the expertise of others within and outside the profession, and referral to those other providers when appropriate. Collaboration involves some shared functions and a common focus on the same overall mission” (ANA, as cited in Finkelman, 2012, p. 353). The aspect of team members working together towards a common goal is the key to the success of the team and a positive outcome for the patient. The ANA states that collaboration is in the scope of the RN and is an expectation of the RNs practice. Collaboration is a vital competency across the array of teams within healthcare (Finkelman, 2012). Equally significant is collaboration between the RN and the patient. This element guides patient-centered care.
Patient-Centered Care
The Institute of Medicine (IOM) endorses patient-centered care as one of the foundational competencies for medical professionals (Finkelman, 2012). The IOM states patient-centered care is "respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions." (Epstein, Fiscella, Lesser & Strange, 2010, p. 1490). Patient-centered care is not a concept that is not new in nursing, although it has become a more widely used idiom within health care since the IOM initiated it in 2001 (Epstein et al. 2010). Promoting a role of leadership by managing ones nursing practice within the values of each individual patient can inspire other healthcare workers to do the same (Epstein et al. 2010). To facilitate patient-centered care, clear communication is essential.
Communication
Learning methods to improve communication with all healthcare members is the basis for an effective team (Finkelman, 2012). An example of a system to improve communication between healthcare team members, namely nurse to doctor and nurse to nurse, is the Situation, Background, Assessment and Recommendation (SBAR) format for communication. SBAR is recommended by the Institute for Healthcare Improvement (IHI) (IHI, 2012). SBAR is utilized to prompt communiqué between healthcare professionals, as a means for more effective exchange of clinical information. SBAR was originally created by clinical staff at Kaiser Permanente. When used methodically, SBAR is a focused communication style that stimulates teamwork and promotes patient safety (IHI, 2012).
Nurses are the center of the communication that occurs between patients and doctors, doctors and families and virtually between all members of the healthcare team. Because of the nurse’s central role, there are also increased chances of miscommunications, information becoming lost in translation. Communication errors can lead to clinical errors. Competent communication requires more than simply talking and hearing. Communication is an active process that ensures patient safety and fulfillment of a medical plan (Finkelman, 2012). Communication also requires feedback, especially during delegation within a team.
Delegation
Collaboration, communication and sharing of a common goal are the foundation of bedside nursing in a team (Finkelman, 2012). The RN is frequently the team leader of other nursing staff and ancillary staff that provide direct and indirect patient care. The success of the team relies on effective delegation as well as frequent evaluation. Delegating requires confidence in one’s own decisions, as well as confidence in the experience of others on the team. Without this confidence, the nurse may believe that it is easier to do the task themselves. Providing care in teams can cause issues with accountability and loss of control related to the lack of trust in others (Finkelman). Similar to the nursing process, where each process is interdependent on the other, delegation is also a cyclical practice-the outcomes influence each other (Hansten and Jackson, as cited in Finkelman, 2012). Determining the effectiveness of delegation requires the RN to utilize critical thinking.
Critical Thinking
Critical thinking is done though self-assessment, when one evaluates from within. Extensive critical thinking occurs throughout the entire scope of a nurse’s daily clinical practice, not just at the bedside. Critical thinking is used while physically assessing the patient, monitoring vital signs, labs, fluid volumes, and reading medical histories. Nurses also utilize critical thinking while on the phone with the patient’s family, conferring with a fellow healthcare team member, in the medication room and even on a break or when driving home after their shift, contemplating prior decisions and evaluation of outcomes. Thinking critically is continually seeking to improve outcomes (Finkelman, 2012). The role of the RN as a leader utilizes multiple skills to think critically: judgment, evaluation, interpretation, active listening, reasoning, analysis and utilizing an awareness of oneself to continually seek to improve one’s practice, especially when mistakes occur (Finkelman). Improving patient outcomes is also done through advocating.
Advocacy and Interventions
All members of the team are involved in implementation of a patient’s plan of care. The accountability for interventions and proper evaluation of outcomes is largely the role of the bedside RN. As the quarterback of the medical team, the RN is taking orders from the Coach (the physician). The RN is then orchestrating the execution of the team’s plays (interventions) on the field (at the bedside). As the leader, the RN is the advocate for their patient across all the various healthcare settings. Situations arise when the RN must “change the call at the line of scrimmage” and advocate that adjustments be made to interventions that have been ordered, or request an intervention that has not been ordered. The ANA endorses that the nurse is an advocate for the patient as well as the nurse educating their patient to become their own advocate (Finkelman, 2012). Also supported by the ANA and the American Organization of Nurse Executives is the practice of the nurse administrator as an advocate for fellow nurses and the working environment of nurses (Finkelman). Advocacy and interventions are not static, yet fluid and ever-changing. This requires bedside nurses to assume the role as a leader in the constant evaluation of the patients care.
Evaluation
Evaluation of the team’s management of a patients care must be incorporated into every step of the nursing process for the bedside nurse (Finkelman, 2012). Evaluation is the process that is most often left out (NCSBN, 2012). Evaluation is an opportunity to prevent problems from reoccurring. Evaluation involves seeking the rationale and appropriateness of the management of a patients care. Does the team’s plan of care reflect the best interest and safety of the patient? Is the patient and families wishes incorporated into that plan of care? If not, what adjustments need to be made? Is the team’s communication effective with adequate feedback? The reality of answering these questions is for the RN to assess the outcomes of the patients (NCSBN).
Conclusion
Nurses at the bedside are often thought of as being on the front lines of health care. Through continued education, RNs can learn and more fully appreciate the importance of leadership skills, especially at the bedside. This is particularly more relevant as the healthcare system has been changing to more managed care. Patient care decisions are often based more on finance than patient’s needs (Finkelman, 2012). The role of the bedside RN has become even more diverse. The nurse must empower patients by teaching self-advocacy as well as the ever-increasing importance of prevention of illness and management of chronic diseases. As healthcare becomes more focused on regulatory compliance, quality measures and consumerism, the nurse must remain open and flexible to this change, while standing tall and firm on the foundation of patient safety, patient-centered care and the nursing process.
