Nursing Leadership: Reflective Analysis of Management Roles

Introduction: Identifying Management Strengths and Weaknesses

Using the "Check Your Effectiveness" self-assessment instrument (Facts, 1997), my highest score of 58 was in the Mentor Role, while my lowest score of 48 was shared equally between the Initiator Role and the Service/Care Provider Role (Facts, 1997). The following reflective analyses examine significant clinical experiences that illustrate each of these roles, followed by an analysis of a management event using the full eight-role management framework developed by Quinn et al. (2003).

Reflective Analysis of the Mentor Role

When writing a reflective analysis of myself in the Mentor Role, I recognize that a key competence of this role is to understand myself as well as others. I have a positive self-image and see myself as intelligent and respectable, and I treat others accordingly. I know myself well, am confident, and hold high expectations of myself. I would never set standards for someone else to achieve if I am unable to achieve them myself. I would like to say that I understand my peers, although I do not always agree with their decisions.

In terms of interpersonal communication, being an effective leader requires excellent communication and interpersonal skills. I speak with a European accent, and my communication may be perceived differently because of this, sometimes leading to misinterpretation of my message. I consciously speak slowly and enunciate words with a non-European accent when giving instructions and guidance. Since facial expression and body language constitute a large part of communication, I always strive to use a receptive facial expression and non-threatening body language. Communication is the most important factor that reflects who we are, how we react, and how we approach and interpret problems.

Developing subordinates as a mentor requires not only patience but also the ability to listen actively and the willingness to teach. It requires clinical expertise and, most certainly, the establishment of a trusting rapport with the mentee to optimize learning. As Vestal (1999) states: "We need to work together, as a nursing profession, as a healthcare profession, and as a society, and we need to understand each other's perspectives." I enjoy mentoring because I love to share the knowledge I have acquired. Teaching a skill to a new nurse is rewarding because of my personal mastery and self-assurance. The mentee will be successful if they implement newly learned techniques and work to perfect them.

I am employed as a Registered Nurse on a general 12-bed Pediatric Ward, primarily in a charge nurse capacity. I assign patient care based on acuity and according to education, training, and skill level. Compared to other units in our hospital—excluding the Neonatal Intensive Care Unit (NICU) and the Intensive Care Unit (ICU), where the patient-to-nurse ratio is six to seven patients per nurse—our floor seldom exceeds two patients per nurse. As charge nurse, my duties include establishing acuities, interpreting lab results, managing telephone calls, solving problems, taking a patient census, and orienting new nurses. I often take on my own patient load to ensure a consistent patient-to-nurse ratio and to provide the highest level of patient care. Overall, my staff—consisting of Licensed Vocational Nurses (LVNs) and Certified Nursing Assistants (CNAs)—demonstrate professionalism by providing compassionate care to our pediatric patients and their parents.

One of my most challenging experiences as a mentor involved an LVN who had been on staff for 17 months. I experienced an internal struggle to challenge and develop her. Her average skill level determines her daily assignments, which are often less demanding than others. She demonstrates negativity—verbally or through body language—by displaying a non-team-playing attitude. She complains about her assignment or makes comments about admissions, though this has not yet disrupted our daily routine.

My observations of her at the nurses' station include not responding to a call light unless it belongs to her patient, and even then she often has to be reminded. She frequently seeks a second opinion before making permanent entries in the patient's chart, suggesting significant insecurity about her assessment findings. On many occasions, her failure to maintain a patient's IV site through regular flushes necessitates starting a new IV, which is always traumatic for young patients and their parents. Most concerning is her disregard for our "Safe Haven" policy, and her habit of delegating minor tasks to CNAs—such as emptying a urinal she is already holding—vividly demonstrates poor task planning.

All of this makes me feel annoyed, irritated, and frustrated. As a leader, I must maintain calm, remain rational (Nursing, 2003), analyze the full picture, and respond with a productive and reasonable intervention. I am often successful, but there are times when I fall short. I express my frustration by performing assessments myself—both for reassurance and because my time is limited. I find it particularly frustrating when a nurse is unable to count manual respirations or interpret lung sounds, as these are fundamental skills taught in every entry-level nursing program. Because I hold a charge nurse position, neglect or inadequate patient care would burden me professionally and ultimately reflect on my staff and my licensure.

Aware of the potential for daily mishaps, I plan my schedule with additional time built in. After morning report and delegation of assignments, I ask my staff to work together and wish them a good shift. I make morning rounds, introduce myself to patients and parents, and make myself available for questions. I also follow up with nurses about their assessment findings, which may warrant a call to the resident or physician before grand rounds. In casual conversations with this particular LVN, I have tried to understand her as a person, hoping it might explain her behavior. However, I find myself immediately put off by what seem to me like unreasonable justifications, and I struggle to empathize with her position. I have come to believe that her work ethic is lacking. I self-talk, framing her behavior as representing "a lot of growing and learning to do," and though I sometimes feel like raising my voice, I control my emotions. I would prefer not to have her on my shift, but after discussing the matter with my head nurse, I understand that we cannot choose our colleagues. I cannot change her as a person, and so it is easier to accept her as she is and hope she adapts and learns.

As I self-evaluate, I realize I do not fully know how others perceive my leadership. Although I have read and learned about various leadership styles, I am as unique as anyone else, particularly in my approach to patient care. This is a continuing path of professional and personal growth, and only practice will perfect it—if it can ever truly be perfected. The key competencies for the successful mentor are "to understand myself and others," "to develop others," and to demonstrate "interpersonal communication" (Quinn, Faerman, Thompson, & McGrath, 2003), which prompts me to reconsider my approach. After studying this management module, I recognize that I need to spend considerably more time analyzing my strengths and weaknesses. I make it a daily effort to adapt to various leadership styles and to find a productive balance. Although I always believed I was well-balanced, my study of this module suggests that may not be the case.

Management Event: Implementing the Alcohol-Based Hand Gel Policy

This was vividly demonstrated on one particular shift. The admission was a teenage female with diabetes who had been placed on an insulin pump during a prior admission—a frequent patient on our unit. With straightforward written physician's orders for blood sugar checks every two hours and before every meal, her non-compliant history warranted closer observation. In morning report, her blood sugar was recorded at 108 mg/dl at 5:00 a.m. By approximately 7:00 a.m. it had dropped to 70 mg/dl, and breakfast was served per a 2,000 kcal American Diabetic Association diet. I checked her tray for a proper breakfast and, as the nurse reported the blood sugar result, asked her to serve the tray.

After completing other duties, I made my routine rounds at approximately 8:00 a.m. Upon entering the room I found the patient asleep with her breakfast untouched. I gently woke her, introduced myself, and offered her a chance to use the bathroom before eating. She responded appropriately and gave me no immediate cause for concern. I informed the primary nurse of my findings and asked her again to monitor the patient closely. At approximately 9:00 a.m., another blood sugar check was due. I asked the primary nurse how her patient was doing and instructed her to prepare for a finger-stick, also asking her to allow the patient to perform the test herself for teaching purposes.

Shortly afterward, the call light went off in the patient's room. When I arrived, the primary nurse was stuttering and nervously told me she could not get a clear response from the patient and asked what she should do. I felt my pulse quicken as I assessed the situation. I called for the glucometer, which should have been at the bedside. I asked the nurse to obtain a blood sample quickly while I attempted to rouse the patient—successfully. The patient appeared lethargic but showed no signs of slurred speech, seeming instead as if she had been woken from a deep sleep. Her glucose level was now 58 mg/dl. Another staff nurse quickly brought orange juice to the bedside, and the patient drank 118 ml. A recheck approximately 20 minutes later showed a glucose of 69 mg/dl. I was temporarily satisfied with the outcome. The patient was coherent and making conversation while eating her breakfast, and I returned her to the care of her primary nurse with instructions to remain with her and monitor her closely. I informed the morning attending physician of the hypoglycemic episode.

Later that morning, I asked the primary nurse to speak with me about the event. I was initially furious at the incompetence. There had been no glucometer at the bedside, charting was not updated, and the nurse had to be directed at every step. I needed to know whether she felt competent to work on a pediatric floor and what her plan of action would have been in a true emergency. I took time to compose myself before the conversation, and by the time we met I was calm and in control of my emotions. I asked her what she had been thinking when she asked me what to do. Had she not read the orders? Was it a lack of knowledge, had she panicked, or did she simply not know what to do? I listened to her reasons and justifications, found them unsatisfactory, and informed her that the nursing care she delivered was unacceptable. I told her I would need to file a 4106 unusual occurrence report—not as a punitive measure, but as a trigger for remedial education to sharpen or enhance clinical skills. I directed her to our patient education resources, asked her to consider the patient's multiple prior admissions, and encouraged her to reflect on the role of non-compliance and peer pressure in contributing to the patient's condition, noting also that the patient's parents were not involved in her care.

Looking back on this situation, by defining the problem and establishing clear objectives I was acting in the Initiator role (Quinn et al., 2003), but by assuming the brief direct care of the patient I moved into the Service/Care Provider role (Quinn et al., 2003). I accepted personal and professional responsibility (Nursing, 2003), assessed the risk, and achieved my immediate goal of stabilizing the patient. I also shifted partly into the Facilitator role by counseling the staff nurse and initiating the unusual occurrence report, becoming an effective team player who depended on my team and made a definitive decision. It is clear, however, that I failed to delegate effectively.

After studying this subject matter, I came to appreciate that nursing practice from the early 1980s is not outdated or unacceptable (Covey, 1989)—it is simply different from a more empathetic and caring environment designed to support newer nurses. Several frameworks developed in the 1980s and 1990s address caring in nursing theory (McCance, McKenna, & Boore, 1999; Watson, 1988; Roach, 1987), demonstrating how central caring has always been and continues to be. We are now implementing teaching strategies and mentorship to support the new generation of graduating nurses, and the need for this is clearly evident with this staff member. Although the tasks delegated to her are completed to my dissatisfaction, I remain accountable and responsible for the care she delivers (Nursing, 2003). Delegation is not merely distributing nursing care among staff, but also involves matching the work required to the nurse's competency while maintaining the highest professional standards (Covey, 1989; Donaldson & Fralic, 2000; Lane, 1990). My experience across multiple settings has taught me that textbooks are a wonderful resource, but in real-life clinical situations there is sometimes no time to stop, analyze, rationalize, and explain.