Introduction – changing healthcare environment and role of the nurse
The nursing profession has evolved during the last century to cope with new demands and new issues. Nurses today are required to provide a wide range of services independently and several other services in collaboration with other healthcare providers (CUSN, 2006). This shift towards a collaborative work environment has changed the nature of nursing tasks in the clinical environment and the perception of the roles of nurses (ANA, 2006). State legislatures have widened the authority of nurses to practice independently like primary care physicians and establish collaborative practices whereby they can share clinical responsibilities with the physician (CUSN, 2002). Managerial skills involve the basic four functions of planning, organizing, motivating, and controlling whereas leadership skills involve communication, delegation, time management, team building, conflict resolution, and other skills. With expanding roles of nurses in the present-day context, it seems imperative that nurses at all levels acquire both managerial and leadership skills to cope with the changes. They can become more efficient by developing fresh approaches to solving problems, acquiring decision-making and strategy formulating skills, acting as a change agent, mentoring other nurses, being professional, and acquiring team-building and team-managing skills (CNA, 2002). This paper deals with the importance of developing communication and critical thinking skills for nurses to achieve the ultimate goal of becoming more efficient leaders and managers in the healthcare environment.
Management versus leadership
Managers acquire their power from the position they hold and are expected to have both technical and leadership competencies and successful managers are often successful leaders. Leadership qualities are thus a desirable component of the directing function of nursing management. According to Mitchell, there are five major attributes of a leader: “adjustment to a complex social environment of multiple units; ability to influence and guide subordinates; emotional and intellectual maturity as a preparation for leadership; ability to think through and make the decision and to translate decisions into effective action; capacity to see beyond the immediate or surface indications and with experience to acquire perspective” (Roussel and Swansburg, 2006, 173). These hold true in the case of effective nurse leaders and leader-managers as well. According to Linda Roussel and Richard J. Swansburg, leadership is a subsystem within the management system and it can be considered as an element of management. Leading is viewed as equivalent to the directing function of the management. Leadership theories were earlier applied in nursing only in the context of management and administration and these involved mainly motivational skills. With the redefinition of the role of the nurse in changing times, more leadership is expected from nurses (Milstead and Furlong, 2006 ). Nursing involves two main tasks: the care of the sick and the potentially sick and the tending of the entire environment in which care happens (Diers, 2004). In order to discharge these two tasks efficiently, the nurse in the present day context must be “a generic worker who is client-focused, possesses multidisciplinary skills, manages the care environment, delivers all but the most highly specialized services to the client, humanizes the system at the point of contact, and acts therapeutically as the experience is lived by the client” (Pearson, 2000). This implies that the nurse needs to be a leader with leadership skills such as resource management, interpersonal communication, time management, prioritizing workload, making clinical judgments, decision making, delegation, problem-solving skills, conflict resolution, and quality assurance. The nursing profession is still plagued with a lack of professionalism and increasing rigidity regarding role boundaries.
Critical Thinking Skills for Nurses
Critical thinking and problem-solving have always been associated with leadership. In the earlier time, nurses were discouraged from being critical thinkers because they were not expected to make independent decisions. However, to apply organizational policies to patient needs in a sensible way, nurses need to have good judgment and critical thinking skills (Fabre, 2005). Critical thinking involves the acquisition of knowledge, reasoning and rational appraisal skills, analytic problem-solving behaviors, and reflective thinking. Critical thinkers are marked by their tendency “to ask questions, evaluate evidence, identify assumptions, examine alternatives and seek to understand various points of view” (White, 156). Bandman and Bandman (1995) have perceived critical thinking as the rational examination of ideas, inferences, principles, arguments, conclusions, issues, statements, beliefs, and actions. The ideal clinical judgment needed of the nurse is best described as a critical thinker. The critically thinking person is one who has made it a habit of being curious, gathering information, and being analytical of the information. Kataoka-Yahiro and Saylor (1994) have found that nurses need to have critical thinking skills in order to be safe, competent, and skilled practitioners in their profession. To be critical thinkers, nurses must develop a questioning attitude, a willingness to conform judgment and action to principle, a commitment to seek reason, love for a reason, value good reasoning, and care about reasoning (Seigel, 1989). Brookfield (1987) enumerates these attributes as identifying and challenging assumptions, becoming aware of the importance of creating meaning, imagining and exploring the meaning, and developing a reflective skepticism. Nurses often face a situation where they have to make use of their clinical judgment in the context of healthcare and this is when they need critical thinking skills. Such critical thinking is also useful for nurses to understand personal relationships and to make decisions. Nurses also need to critically assess the patient before making any changes to his treatment plan More critical thinking functions of nursing have been listed by Bandman and Bandman (1995:7-8): daily events, uses and misuses of language in nursing; nursing problems; analyzing meanings in their context; analyzing arguments and issues; nursing assumptions; reporting data and clues; make and check inferences based on data; formulate and clarify beliefs; verify and justify claims, beliefs, conclusions, decisions, and actions; make value judgments; seek logic and application of nursing principles; evaluate the soundness of decisions (Masters, 2005, 86). According to Benner (1999), there are two practices in nursing that are associated directly with critical thinking – clinical grasp and clinical forethought. Clinical grasp refers to problem identification and clinical judgment over time regarding patients and their families. Clinical forethought refers to future thinking, clinical forethought about specific diagnoses and injuries, the anticipation of risks for particular patients, and seeing the unexpected. Both clinical grasp and clinical forethought need critical thinking skills (Masters, 2005).
Communication Skills for Nurses
Nursing education has been so designed so as to foster critical thinking skills in the student nurses through class and clinical activities. Kathleen Masters (2005) lists the teaching strategies that may be used for critical thinking development – lecture format with participative activities such as group discussions, presentations, seminars, short ‘critical thinking’ exercises at the end of each class, etc. These lessons would help the nursing students to practice analysis of concepts, values, and attitudes, and apply critical thinking to the clinical component of the nursing education process. Other innovative ways of developing critical thinking skills suggested by Kathleen Masters include journaling, using simulated testing situations, videotapes, and computers. Stark (1991) suggested using stories of patients to be analyzed by the nursing students. Concept clarification is another strategy that can be used for developing critical thinking skills. Here the student is allowed to search for meaning from multiple data sources to create and examine meaning toward some purpose.
In the context of communication, nurses face the issue of having confusing reporting lines. Currently, many nurses have clinical reporting lines to a doctor; operational reporting lines to a manager; and “professional” reporting lines to a nurse. This lack of clarity in communication creates an “unbounded” system and often leaves nurses uncertain as to how to communicate most effectively to achieve impact or change. The nurse leader has to perform a variety of communication activities, routinely interacting with patients, families, peers, professional and nonprofessional team members, colleagues, salespeople, members of the press, spiritual representatives, etc. Their need to perform a wide range of roles such as an interpreter, marketer, negotiator, soother, problem solvers, influencer, organizer, delegator, etc, and all of this requires clear communication. In the main healthcare context, the nurse has to communicate with the client, assess his needs and use specific therapeutic communication techniques that are suitable for the client’s state of development during nursing interventions (Craven and Hirnle, 2006) Sometimes the nurse-client relationship is short term and focused s in the case of a child delivery process. When the nurse treats terminally ill patients, the nurse has to spend more time with the client and family and teach the family how to care for the client. The nurse has to be a caregiver, teacher, and counselor. The external environment is important and care should be taken regarding the position of the nurse and client, noise, and privacy. The client’s internal environment made up of his background, beliefs and experiences can also affect communication especially when the nurse has a different set of beliefs (Craven and Hirnle, 2006). Therapeutic communication techniques to be used by the nurse are as follows: making oneself available to the client, asking questions to encourage the client to talk, using general statements based on observation and assessments about the client, using repetition, identifying the emotions behind the words, asking goal-directed questions, encouraging elaboration, seeking clarification, giving information, looking at alternatives, allowing silence in communication and summarizing (Craven and Hirnle, 2006). When a nurse communicates with the client, the focus must be on the client, his needs, and his problems. Time and experience help in making nurses good in communication skills. However, communication skills may be improved by studying one’s interactions either by tape recording or by recreating a client-nurse conversation from memory. The conversation can be made into a transcript and analyzed for the techniques used, their timing, and suitability. Apart from meeting the therapeutic needs of the client the nurse may be required to adopt different styles of communication depending on the other needs of the client. Sometimes the patients may need reassurance and real reassurance must be based on fact and not on minimizing the client’s situation. Giving false reassurance violates the client’s trust. Moreover, sometimes nurses are expected to give advice in the form of suggestions. Care should be taken not to change the subject, not to be moralistic, and not to get nonprofessionally involved. Children, old people, and adolescents need to be treated with care. Children are responsive to nonverbal communication and nurses must talk to children at eye level in order to prevent intimidation (Craven and Kirnle 2006).
Traditionally the role of nurses was limited and they had to obey the orders of the physician. But today, nurses are expected to function almost like primary care physicians. They should be able to make decisions, communicate properly, motivate their team, keep themselves positive, solve problems, and critically think their way through them. In other words, nurses of today need to have leadership qualities whether they are managers or not. This paper has focused on two of the leadership skills – critical thinking and communication. Critical thinking is essential for nurses for both clinical grasp and clinical forethought and critical thinking skills can be nurtured by including them in the education of the nurses. Likewise, communication is an important vehicle for nurses to carry out their diversified range of tasks. Like critical thinking skills, communication skills too may be developed in many ways. For nurses, the development of their critical thinking skills and communication skills will make them more professional in their approach. These are major leadership skills needed in the present-day healthcare context for nurses to function efficiently.
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