NUR 213 Comprehensive Study Notes: Professional Identity, Leadership, and Practice

Professional Identity Formation in Nursing

• Core ideas around forming a professional identity within nursing: collaboration, compassion, longevity, evidence-based practice (EBP), respect for roles, civility, cultural care, and safety/quality care.
• Key attributes and dispositions described:
  • Respect for roles and diversity; nurses as nurturers of roles and advocates for professional pride, excellence, confidence, leadership, and presence.
  • Clinical judgment, education and practice integrated together; community engagement and an inquiring mindset.
  • Ethical comportment, humility, moral courage, patient-centered self-care, and a growth mindset.
  • Self-awareness, accountability, life-long honesty, and a commitment to learning and resilience.
  • Emotional intelligence, empathy, and relatability; capacity to grow and reflect; psychological safety and supportive workplace cultures.
• Emphasis on creating a healthy workplace that fosters integrity, learning, and inclusion.
• Visual metaphor elements referenced: Tree of Impact, Growth Mindset, and a dynamic capacity to grow through reflection and resilience.

Nursing in the 21st Century: Challenges

• Main challenges facing the North American health care system:
  • Increasing older patient population.
  • Changing consumer desires and expectations.
  • Expanding information technologies and data availability.
  • Focus on improving quality and safety of care.
• Foundational citation: Institute of Medicine Committee of Quality of Health Care in America, 2001, Crossing the Quality Chasm: A New Health System for the 21st Century.

Nursing Settings

• Typical settings where nursing practice occurs:
  • Hospice
  • Home care
  • School clinics
  • Public health
  • Hospitals

Nursing Role in Health Care: Lead, Manage, Follow

• Leaders interpret rapidly changing environments, improvise solutions, help others cope, and establish vision.
• Leaders accept responsibility, identify needs of individuals/groups/organizations, coach, motivate, communicate, counsel.
• Leaders serve as a symbol for staff and the organization; they practice clinical judgment and foster education and practice together; community engagement and inquiry mindsets are integral.

Leadership Styles

• Autocratic (Authoritative):
  • Communications flow down the chain of command, direct decisions, coercive motivation.
  • Often high output, effective in crises or bureaucratic settings.
• Democratic:
  • Decisions involve group input, communication flows up and down; staff achievements are supported.
  • Quality of work tends to be good; collaboration and cooperation are emphasized.
• Laissez-faire:
  • Few decisions, minimal planning; employees take most responsibility; communication among team members.
  • Often lower output; informal leaders may emerge.

Types of Leadership

• Three broad styles: Autocratic, Democratic, Laissez-faire (as depicted in lecture visuals).

Characteristics of Leaders

• Key traits:
  • Bring energy, take initiative, inspire and motivate
  • Positive attitude and effective communication
  • Respectful, problem-solvers, critical thinkers
  • Able to set boundaries and demonstrate trustworthiness

Transformational vs. Transactional Leadership

• Transformational Leaders:
  • Empower followers to assume responsibility for a common vision; personal development is a secondary outcome.
• Transactional Leaders:
  • Focus on immediate problems, maintain status quo, use rewards to motivate followers

Leadership Theories and Approaches

• Leadership is developed over time and draws from multiple theories.
• Theories help address important questions, contribute to evidence-based care, and guide organizational work; no single theory fits all healthcare settings.
• Approaches to leadership styles include critical thinking, decision making, and problem solving.
• Decision making styles include paternalistic, informative, and shared decision making.
• Influencing factors: physical/emotional state, biases/values, knowledge/experience, attitudes, time constraints, and willingness to change.

Phases of Decision Making

• Six phases (from most to least action-oriented):
  1. Defining objectives
  2. Generating options
  3. Ranking options
  4. Selecting the option most likely to meet objectives
  5. Implementing the option
  6. Evaluating the result

Problem Solving in Nursing Leadership

• Effective leaders anticipate problems and develop methods to deal with them.
• Emphasizes identifying and selecting the best available option given the context.

Emotional Intelligence in Nursing

• Definition (Daniel Goleman, 1998): the capacity for recognizing one’s own feelings and those of others, for motivating ourselves, and for managing emotions well in ourselves and in our relationships.
• EI is distinct from, but complements, academic intelligence; includes social skills, interpersonal competence, psychological maturity, and emotional awareness.
• Goals of EI: balance emotions and reason to maximize long-term effectiveness and mitigate stress.
• Core EI components (per nursing literature):
  • Self-awareness and self-management
  • Empathy and relationship management
  • Motivation and social skills
• The Quick Emotional Intelligence Self-Assessment (resource): used to gauge EI strengths; not a definitive tool, but a learning aid.

Self-Awareness and Emotional Intelligence in Practice

• Self-Awareness practices:
  • Do not change the subject; connect feelings to events; be curious about feelings
  • Reflect on feelings and their sources; diary or journaling as a common method
  • Seek feedback (e.g., ask colleagues how you come across)
• Emotional Intelligence in practice:
  • Self-awareness leads to better self-management and adaptability
  • Relationship management involves collaboration, conflict management, and catalyzing change
  • Empathy and understanding differences in others contribute to more effective teamwork

Prioritization, Delegation, and Assignment

• Definition of prioritization: deciding which needs require immediate action and which can be delayed; four Ps framework:
  • PURPOSE for the care
  • PICTURE of the current clinical status
  • PLAN for care
  • PART who will deliver this care
• Prioritization principles:
  • Systemic before local; life before limb
  • Acute problems before chronic; actual before potential problems
• Priority levels:
  • 1st Level: ABCs plus -V (Airway, Breathing, Circulation and cardiac status, Vital signs/pain)
  • 2nd Level: Mental status changes, untreated medical issues, acute pain, acute elimination problems, abnormal labs, safety risks
  • 3rd Level: Health problems beyond first two levels; long-term issues like education, coping, rest; chronic, nonurgent, stable
• Questions to guide prioritization: life-threatening risk, impact on other patients, essential to safety and plan of care, patient age, admission timing, multi-system involvement, surgical status

Critical Thinking and Prioritization Scenarios

• Example questions used in exams to test prioritization and critical thinking in clinical settings (illustrative):
  • Emergency room or clinical room scenarios involving safety and priority assessment, such as a patient on precautions or a post-op patient, or an outpatient clinic triage call.
  • Correct responses typically emphasize early assessment and identification of life-threatening issues before other tasks.

Delegation in Nursing

• Definition and purpose:
  • The transfer of responsibility for performing a task while retaining accountability for outcomes; an art and science requiring judgement
• Roles:
  • Delegator: RN who assigns tasks
  • Delegatee: person receiving assignment; must be reliable and competent
• Five Rights of Delegation:
  • The right task
  • The right circumstances
  • The right person
  • The right direction/communication
  • The right supervision
• Safe delegation practices:
  • Show respect, prioritize patient safety, two-way communication, positive reinforcement
  • Identify strengths and areas for improvement; clarify purpose; ensure training and competencies are current
• Scope of practice considerations:
  • RNs can delegate to RNs, LPNs/LVNs, and UAPs within scope and institutional policy
  • Some tasks are exclusively RN responsibilities (e.g., initial assessments, certain medication administration, complex patient education, IV medications, central lines, etc.)
• Span of control and authority:
  • Span of Control: number of individuals an RN is responsible for
  • Appropriate Authority: authority to perform specific functions per Nurse Practice Act and institutional policies

Scope of Practice: RN vs LPN/LVN

• LPN tasks within scope may include data collection, basic assessments, implementing care steps as directed, and basic patient care activities.
• RN tasks exclusive or higher-level include: initial assessments, care planning, medication reconciliation, discharge teaching, complex IV/central line tasks, analytics, and professional communication with other units.
• Examples from practice scenarios highlight decision-making about which tasks are appropriate for LPNs vs RNs.

Assignment Scenarios and Safe Practice

• Typical exam scenarios involve choosing which tasks to delegate to which roles (RN, LPN, UAP) given patient stability, required assessment, and safety concerns.

Nursing Care Delivery Models/Strategies

• Case Method (Total Patient Care): one nurse provides total care for a patient during a shift; emphasizes continuity; holistic care; nurse may weigh resource distribution and supervise care.
• Functional Model of Nursing: care is provided by licensed/unlicensed staff divided by tasks; efficient but can risk fragmented or less coordinated care.
• Team Nursing: RN coordinates a team (RN, LPN/LVN, UAP) to care for a group of patients; aims to leverage team strengths and improve patient outcomes; team leaders manage coordination and communication.
• Primary Nursing: direct, continuous nurse-patient relationship; high accountability; emphasis on family involvement and coordination; hybrids exist (co-primary, practice partnership).
• Hybrids and Patient-Centered Models:
  • Co-Primary and Partnership models: RN paired with a consistent partner for semi-primary care; emphasis on patient-centeredness, satisfaction, and efficiency.
  • Hybrid models incorporate elements of primary and team approaches to balance accountability with workload.
• Case Management and Case Management Roles:
  • Focus on coordinating interventions across levels of care; guided by guidelines, pathways, and transitions; aim to optimize outcomes and resource use
  • Uses Critical Pathways to standardize care and monitor progress; monitors outcomes and variances to improve care delivery

Case Management and Care Transitions

• Case management responsibilities:
  • Coordinating care across disciplines, facilitating continuity, and improving efficiency and quality
  • Advocating for clients and families; acting as a liaison; ensuring patient needs are met and rights protected
• Critical Pathways (care maps or clinical pathways):
  • Provide structured, evidence-based guidance; help determine length of stay and outcomes; involve multi-disciplinary teams
  • Help organizations set benchmarks and measure outcomes
• Hospital discharge critical pathway example: decision tools to determine home vs skilled facility vs continued hospitalization, based on criteria like daily MD evaluation, stability, and home caregiving support

Organizational Structure and Culture

• Mission, Vision, and Philosophy:
  • Mission: reason or purpose for being; focus on treatment, prevention, diagnosis, maintenance, and support
  • Vision: future-oriented statement of desired organizational future
  • Philosophy: nursing practice ideals within the organization to achieve the mission and health goals
• Work Environment:
  • Scope of practice is guided by state nursing boards and institutional policy; practice within licensure and policy; use decision trees per jurisdiction
• Mentorship and Orientation:
  • Mentorship as a guide for novice nurses; formal orientation programs (e.g., Maine statute on nurse orientation) ensure competency-based progression and documented plans

Conflict and Resolution

• Conflict and high-stakes situations: emotions, opposing opinions, and possible escalation
• Modes of conflict resolution:
  • Avoiding, Accommodating, Competing, Compromising, Collaborating
• Lateral violence: aggressive or destructive peer-to-peer behavior; impairs team function and patient care

Quality Management and Safety

• Quality Management focuses on patient safety and satisfaction of patients and staff; continuous measurement and feedback
• Quality Assurance vs Quality Improvement:
  • QA: conformity to a standard
  • QI: systematic, iterative improvement process with data and outcomes
• Quality Improvement (QI) process steps:
  • Identify consumer needs
  • Assemble a team
  • Collect data
  • Establish measurable outcomes
  • Plan and implement actions
  • Collect data to evaluate implementation and outcomes
• Key indicators and benchmarks:
  • Outcome indicators, structure indicators, process indicators; benchmarks set targets
• Root Cause Analysis (RCA) when benchmarks aren’t met:
  • Examine contributing factors, consequences, and surrounding variables
  • Propose corrective actions and timetable for reevaluation

Risk Management and Patient Safety

• 2024 National Patient Safety Goals (NPSG) by Joint Commission:
  • Improve patient identification accuracy
  • Improve communication among caregivers
  • Improve medication safety
  • Reduce harms from clinical alarms
  • Reduce healthcare-associated infections
  • Hospital identifies safety risks in its patient population
  • Universal Protocol for preventing wrong-site/wrong-procedure applies to all procedures
• Risk management concepts:
  • Define situations that place the system at risk, frequency, and prevention strategies
  • Never events (preventable and serious), sentinel events (serious, unexpected harm or death), near-misses, and incident/variance reports
• Incident reporting:
  • Document unexpected incidents affecting patients, staff, or visitors
  • File within 24 hours when possible; include objective description, actions taken, and patient status
  • Risk management investigates incidents as part of quality assurance

Incident Reporting and Documentation

• What to document on incident reports:
  • Description of the incident
  • Actions taken to safeguard the patient
  • Assessment and treatment provided, if any
• After-action responsibilities:
  • Ensure chart documentation reflects the incident and response
  • Risk management will investigate and use data for quality improvement

Policy, Governance, and Levels of Leadership

• Levels of policy making:
  • Workforce-level shared governance
  • Local level: community systems
  • State coalitions and specialty organizations
• Shared governance:
  • Dynamic decision-making and accountability; nurses participate in policy development and practice improvement
  • Benefits include empowerment, career ladders, evidence-based practice integration, and professional recognition

QSEN: Quality and Safety Education for Nurses

• Core competencies (six listed in the material):
  1) Provide patient-centered care: identify and respect patient values, coordinate care, involve patients and families, inform and educate patients
  2) Teamwork and collaboration: clarify roles, minimize risks during transitions, coordinate care
  3) Evidenced-based practice (EBP): integrate research with clinical expertise and patient values; participate in research activities
  4) Apply quality improvement: identify errors, apply safety principles, measure care using structure/process/outcome indicators; design and test/process changes
  5) Promote safety: use safety technologies, reduce risk, report hazards, participate in root cause analyses
  6) Use informatics: communicate and manage knowledge to support decision making and reduce errors
• Practical guidance for new nurses:
  • Demonstrate knowledge of QSEN competencies in resumes, interviews, and responses to questions; use them to guide inquiries about workplace systems

Evidence-Based Practice (EBP)

• Definition (Yoder-Wise, 2015):
  • The integration of the best research evidence with clinical expertise and the patient’s unique values and circumstances in making decisions about the care of individual patients.
  • Emphasizes the alignment of evidence, practice, and patient values across clinical decisions.
• Key elements of implementation:
  • Ask a clear clinical question
  • Acquire the evidence
  • Locate best sources of evidence
  • Appraise the evidence
  • Apply the evidence
  • Assess outcomes
• Practice-Based Evidence:
  • Examines practice in real-world settings
  • Compares interventions, develops variations, includes diverse participants
  • Encourages collaboration and supports program implementation
• Barriers to implementing EBP (example study 2008 Kohen & Lehman):
  • Time constraints and limited knowledge of research as barriers
  • Need for strategies to promote EBP adoption in nursing practice

Role Transition: Student to Professional

• Pathways and professional development:
  • Students choose positions aligning with professional goals
  • Take ownership, take risks, seek learning opportunities, and engage with the profession
  • Ensure alignment with corresponding education and the baccalaureate standard of the profession
• Novice to expert progression concept: initial stages lead to developing expertise and confidence over time