The purpose of this assignment is to examine how registered nurses develop appropriate leadership skills, and how this can be implemented in improving a patients care requirements.

Throughout this discussion I will give a definition of leadership, types of leadership models and theorist. Examine the KSF (Knowledge & Skills Framework) and PDP (Personal Development Portfolio) and discuss the skills and knowledge that nurses need in order to succeed and develop the leadership skills that will be used in improving the patients overall care outcomes.

I will use tools such as the internet eg. CINHAL, Caledonian University library, Blackboard, various journals and books to ensure the information provided is up to date and current within modern day practices and techniques within the nursing profession.

Leadership, according to Grim (2010), is a “complex entity, there are many definitions”, Benton (2005), described leadership as “the art of influencing people to accomplish the mission”, another definition by Huczynski and Buchanan (1991), defines leadership as; “a social process in which one individual influences the behaviour of others without threats or violence”. Cook, (2001), stated that; “Leadership is not merely a series of skills or tasks; rather, it is an attitude that informs behavior”.

When we think of leaders we think of great people such as Churchill, Kennedy, Florence Nightingale and many more, these people are regarded as leaders because they had a vision to change things for the better, they inspired their fellow men with words of wisdom, they challenged authority and seized on opportunities.

There are different styles of leadership;

Autocratic, these types of leaders set their own goals; they do this without allowing other team members to participate in the decision making, (Faugier &Woolnough, 2002).

Bureaucratic, this is where the leadership has no grey areas they stick to the rules, regulations, and policies rigidly.

Participative leader, these leaders allow staff to participate in making decisions, they delegate and pick fellow staff to participate in the decision making. The feeling is that this type of leadership would allow members of the team to feel more committed to the goals set out as they would be part of the team that set them out. (Faugier &Woolnough, 2002).

Laissez faire leadership is a more risky kind of leadership as the staff members are left to their own devices in meeting the goals set out.

According to Faugier &Woolnough, (2002), Ellis and Abbott (2009), a better and fairer leadership style may be situational leadership, this style allows the leader to switch between all the above styles depending on the situation they are dealing with and the competence of the workforce he or she is working with at that time.

There are some theorists who believe that leadership is in-born and that some traits of a leader’s personality such as intelligence, initiative and confidence are what creates leaders. (Goffee and Jones, 2000). There are those who disagree, Kouzes and Posner (2002) for example, argue that the skills of a leader are observable and learnable. Ellis and Abbott (2009), agree with, Faugier &Woolnough, (2002), when looking at models of leadership see that some theorists believe that people get intrinsic satisfaction when given more control over their work they tend to be more productive and better motivated.

The clinical governance and the policy and procedure manuals are all pushing for nurses to be autonomous practitioners, to lead teams, to give patients guidance in looking after their own health. In order to do these nurses have to inspire and motivate their patients and staff. Timmons and McCabe (2009).

As a newly qualified registered nurse, leadership will be a daunting thought, being the newest member of staff, the leadership mantle will not rest on easy shoulders, but Knowledge and skills must be kept up to date throughout the practitioners working life,. (NMC 2004) by taking part in learning activities such as the KSF, a learning tool, that develops the practitioner’s competence and performance.

Throughout the NHS the ongoing training tool which is most commonly applied is the KSF. This is an effective tool used to show the broad skills and knowledge that a nurse or practitioner needs to be effective in their particular post or position.

The framework was introduced alongside the Agenda for Change (AfC) pay system to ensure every NHS nurse receives an annual review to assess the knowledge and skills required to do his or her job.

The aims of the KSF were to show clear and consistent development objectives so that practitioners were aware of what skills would be needed for their chosen role, to help and encourage the development of staff in such a way that they can apply the newly gained knowledge and skills to their post and to help identify any knowledge and skills that may support career progression and encourage the need for life long learning. The KSF will ensure that practitioners are fit to practice and continue to provide a framework for good quality care. (Hinchcliff 2009)

The KSF also highlighted that a review should take place annually, this would be provided by the practitioner’s line manager to agree to any personal development plans that the practitioner may have, if the KSF, is implemented correctly, nurses will have the adequate training and skills to carry out their role effectively. Therefore the KSF will help to raise the clinical standard and standardise the abilities of the staff in specific roles throughout the NHS. (Tanton 2009).

Health, safety and security are the key aspects of the job which the KSF describes; it makes it clear that it is vital that everyone takes responsibility for the safety, health and security of patients and clients, the public, colleagues and themselves. It shows that as staff move forward in their careers that their roles and responsibilities for health, safety and security also progress and that different levels of competence are required. (DoH 2004)

The DoH (2006) is driving a key initiative to facilitate the development of nursing careers across the UK. Four key priority areas have been identified to address this they are;

Develop a competent and flexible workforce.

Update career pathways and career choices;

Prepare nurses to lead, in a changed health care system;

Modernise the image of nursing and nursing careers. (DOH, 2006, p.17)

Leadership skills are being implemented at the start of the nurse training program, communication, listening, self awareness, empathy, motivation, reflection, critical thinking and problem solving, these skills will be required from every registered nurse from the onset of their career.

The knowledge and skills that are obtained are needed for the team to attain clear, shared and attainable goals, which are essential in ensuring patients receive the best possible care. NMC (2004)

Today’s practitioners increasingly require the skills and knowledge to base care on best evidence, to use critical thinking and demonstrate advance leadership and decision making skills, to develop and enhance services in a more complex and diverse healthcare environment. Casey and Clark (2009)

Critical thinking, is a skill that is defined by Wilkinson (1969) as both an attitude and a reasoning process that involves several intellectual skills. Taylor (2006)

Described critical thinking as the rational examination of ideas, inferences, principles, arguments, conclusions, issues, statements, beliefs and actions also referred to as clinical reasoning, clinical decision making and clinical judgement. (Toofany, 2008)

In today’s healthcare environment things are ever changing and so is the information that the medical, clinical and multidisciplinary teams have to analyse. This information has to be critically analysed, weighing up the evidence and arguments that support such information, research suggests, that many newly qualified nurses and students lack the skills acquired to think critically (Shell 2001). According to Luckowski (2003), critical thinking is a skill that all newly registered nurses must have if they are to succeed in nursing. The need to solve problems in clinical practice (Ferrario 2004), is a skill that is necessary for the development of implementing theory to practice. Once qualified the new practitioner will have to think on her feet, critical thinking requires her to make decisions about patient care and to solve problems, these are complex cognitive experiences that nurses have to carry out quickly.

There are structured care approaches such as, Integrated care pathways (ICPs) , protocols and algorithms these are effective tools that will help new nurses and students to learn to be critical thinkers.

Intuition, according to Smith (2009) has its place in nursing, this is the emotional side of critical thinking, and is an important part of decision making when looking after a patient. There is considerable debate about this skill has been linked to expertise and the knowledge of a good nurse, There have been a plethora of research carried out on this subject without any conclusive evidence to disregard it as a skill. Acknowledging intuition is a challenge for nurses, educators and researches, because it is difficult concept to put into words and measure. Rew and Barrow (2007) Turnbull (1999) called intuition the neglected source of knowledge striving for legitimacy. Benner`s (1984) From Novice to Expert, is a model that is used as the conceptual framework for nursing research on clinical expertise and the use of intuition. ( King and Clark 2002,as cited in Smith 2009)

Communication, one of the main skills that a newly qualified nurse can excel in immediately after training, a good handover, passing on messages such as doctors orders, blood results, listening to what patients are saying and also what they are not saying, body language, telephone calls, information appertaining to the patient in her care, this skill may be intrinsic but it can also be a learned skill.

There are many theories and models on communication, much has been written about this subject models such as, `The Circular Transactional Model of Communication`, (Bateson 1979), and a `Skill Model of Interpersonal Communication` Hargie & Dickson 2004) to name only two of them. (Timmons & McCabe 2009) The theories and models may not have a direct influence on how the nurse communicates with her patient, but by reading them it allows discussion and in a nursing context this could illustrate a difference between a task centred approach or a patient centred approach when dealing with her patients.

Communication is one of the most important skills a nurse can learn, it’s one of the first lessons taught at the beginning of her training and carries on for the rest of her nursing profession. According to ( Hinchliff et al 2008pg194) “Clear communication is essential to an effective and ethical professional relationship”. A nurse uses this skill consciously and unconsciously every day of her professional life. To be an effective communicator and have the patient’s best interests, the nurse must communicate openly and honestly, this may not only be with the patient and their family, but other members of the multidisciplinary teams. A registered nurse must develop a range of communication skills, styles, and technique to best suit her patients needs. There also needs to be good communication between the multidisciplinary teams, poorly written information about a patient could have an effect on the outcome of a patients care. NMC Guidelines for records and record keeping (2004), state that,” Good record keeping is a mark of a skilled and safe practitioner”, It is also a fundamental part of nursing, which carries a legal responsibility as patients records are part of the key evidence if a case goes to a court of law.(Hinchliff 2008). A professional nurse may on occasions find herself involved in situations where they may be called to give witness under oath; this is when the skill of good accurate record keeping plays a pivotal role.

Active listening skills are an important skill, establishing a rapport with a patient just stopping for a moment and giving them eye contact smiling and asking open and closed questions will allow the patient to trust the nurse this in turn may reduce the patient’s anxiety levels and allow the patient to see that they are not just an illness but an individual, thus a therapeutic relationship may develop. (McCabe 2004: Astedr-Kurki and Haggman-Laitila 1992; Williams 1998) A nurse also has to be patient centred in her approach to planning, implementing and evaluating patient care, showing qualities of empathy warmth, genuineness, all the following skills are also essential;

Self Awareness and Assertiveness are skills that the newly qualified nurses have to develop, the need to understand themselves and be aware of their own feelings, actions, values, attitudes, beliefs and how they influence relationships and interactions with others. A nurse cannot understand other’s until they themselves are self aware. Self-awareness is a lifelong process and requires the individual to look inside themselves and reflect take on board feedback from others. Senge (2006)

Assertiveness, another valuable skill in the element of communication Balzer-Riley (2000) suggests that “assertiveness is the ability to express thoughts feelings and ideas without undue anxiety or having a negative effect on others”. To have leadership skills nurses must be more assertive, it is well documented (McCabe&Timmins 2006) that in the past most nurses tended to take a submissive role in communication behaviour, today’s nurse with good mentorship and support can be frank, flexible and open-minded and with the right encouragement can motivate and encourage others, without being confrontational or challenging, this can work in the patients best interest to have a confident practitioner.

Self- regulation; this is the component of emotional intelligence that enables the individual to be reasonable in the workplace, with appropriate control over feelings and impulses; they are open to change and have the capacity to create environments of trust and fairness.

Motivation: driven by not only external incentives such individuals are uniquely internally motivated and will display both innate optimism and organisational commitment.

Empathy; this is an essential component, which enables one to understand both the needs of the user of the service and also those of the providers.

Social skills; enables the individual to find common ground and manage relationships. (Timmins & McCabe 2009)

Responsibility is a duty for which one is responsible, while accountability relates to the fact that one can be called to account for ones actions with regard to a duty. Nursing midwifery council, states that a practitioner may be expected to delegate to others who are not registered nurses, they may be health care assistants, (HCAs) or students, but the practititioner still remains accountable for the appropriateness of the delegation. NMC (2004).

“Delegation is the transfer of selected tasks and responsibility for completion of tasks to another person and retaining supervision and accountability for that activity” (Hansten and Jackson 2004).

Delegation is a skill that a new nurse may have to use from day one in her job, she may find herself delegating a task to health care assistances (HCAs) or a student, this may seem inappropriate as the HCA probably has much more knowledge of the task than the new nurse. What a new nurse or in fact any nurse has to weigh up when delegating the task to another is, does this person have the right skills and competence to carry out the task delegated to them, has this person had training to carry out the task, who is liable if any harm befalls the patient or the carers, the person who carried out the task? or the person who delegated the task? The law will state that due to professional accountability, only responsibility can be delegated to others, accountability and liability cannot be delegated. (Cornock 2008) This means that even though the individual took the task on, they may state, that they lacked the authority, knowledge and experience to carry out the task, even though the student/ HCA have took responsibility for the task. The nurse who delegated must from a legal perspective remain nearby to monitor the task, and to offer advice if needed. In America, The National Council of State Boards of Nursing (1995), brought about the `five rights of delegation` these are

The right task,

The right circumstances,

From the right person,

With the right communication,

With the right supervision.

The NMC (2007b) also reflect on this advice with regards to delegation, as delegation is a skill that will develop over time with the right mentorship and guidance. (Hinchcliff 2009)

As the new practitioner’s confidence in her experiences, abilities and competence in the field she has chosen, grows, mentoring will be the next stage of her development. Mentoring whether it’s formal or informal is one of the important roles that every nurse has to take part in. The NMC (2006) states that, nurses who take the role of mentors must be registered with the NMC and be on the same part of the register as the students they assess, the mentor must be on the register for at least 12 months and have completed an NMC approved mentor preparation course, (PA, Panther 2008). The NMC (2004 4.3) states that the practitioner must communicate effectively to others and share knowledge, skill and expertise with other members of the team as required for the benefit of patients. The course is a ten day program following the publication of the NMC, Standards to Support Learning and assessment in Practice (NMC 2006)

Reflection, just like clinical skills reflection needs to be learned, it is an activities that is central to a nurses professional practice. Johns (2000) stated; Reflection is a window that the nurse can view and concentrate on herself within the context of her lived experience, this will help her to confront and understand the problem and work towards resolving it within her practice of what she has done and what she would like to do better. When carrying out tasks with the patient although the nurse does her best, using reflective practice she can look back and see how she could have made this event better for the patient, it may identify a lack of knowledge or a skill that needs to be practiced for the future care of a patient. There are several models of reflection (e.g. Gibbs 1988, Johns 2000, Taylor 2006,) these models help the practitioner by asking structured questions about their experiences in clinical practice which prompt the practitioner to remember certain aspects of the event e.g. who, what, where and when, these questions are a catalyst for the practitioner.

When reflection forms part of a structured learning experience then theory and practice become more integrated and theory informs practice and practice informs theory. (Clark et al, 2001), (Fowler, 2006).

The purpose of this assignment was to examine how registered nurses develop appropriate leadership skills, and how this can be implemented in improving a patients care requirements. The NMC states that as “a practitioner you must keep your knowledge and skills up to date throughout your working life”, this will be helped by carrying out Personal Development Portfolios and following the Knowledge and Skills Framework, as this can benefit the practitioner by highlighting abilities, achievements and experiences. Also the portfolio can show the development of analytical skills through reflective study. The practitioner will need to acquire and develop the skills and attributes required to deal with a range of new and emerging nursing responsibilities in today’s healthcare. Nurses who are competent in the skills of leadership will be able to plan and design the way care is delivered in the future, this will achieve the goals of the health service providers and improve patient care outcomes.

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