Discussion Board Rubric Criteria Criterion 1: Initial post on Wednesday by 12 MN (100 – 300 words) with critical thinking and reference. Remember Do not quote (if possible) on the discussion board. We want your analytical thoughts after reading the material. Criterion 2: Responded to at least 3 classmates by Sunday at MN (100 – 200 words) using critical thinking. No additional reference required Criterion 3: Stimulating further thought and discussion. Evidence of critical thinking (application, Level 5 25 points 25 points Level 4 20 points 20 points Level 3 15 points 15 points Level 2 10 points 10 points Level 1 0 Points 0 points Clear evidence of critical thinking (application, synthesis, and evaluation Some critical thinking evident Beginnings of critical thinking evident Poorly developed critical thinking evident Did not enter discussion 25 points 20 points 15 points 10 points 0 points Responded to 3 classmates Responded to 2 classmate Responded to 1 classmate Did not respond to any classmates Did not enter discussion 25 points 20 points 15 points 10 points 0 points Clear evidence of critical thinking (application, Some critical thinking evident Beginnings of critical thinking evident Poorly developed critical thinking evident Did not enter discussion Criteria analysis, synthesis and evaluation) Criterion 4: Properly cited reference in APA format American Psychological Association (APA) Manual Latest edition/ correct spelling and grammar Overall Score Level 5 25 points synthesis, and evaluation) Level 4 20 points Level 3 15 points Level 2 10 points Level 1 0 Points 25 points 20 points 15 points 10 points 0 points Clear evidence of APA use. Citation within 5 years. Must include at least one citation within the post and a corresponding reference at the bottom of the post in APA format. Perfect to 1 spelling and/or grammatical error Level 5 100 or more Cited in the summary and made a reference, but lacking proper format for APA. Two to four grammatical and/or spelling errors. Cited in the summary did not reference at the bottom of the summary. Five or more grammatical and/or spelling errors. Did not cite in the summary but did make reference. Ten or more grammatical and/or spelling errors. Did not cite in APA or older than 5 years Level 4 80 or more Level 3 60 or more Level 2 40 or more Level 1 0 or more Educational Innovations Five Steps to Providing Effective Feedback in the Clinical Setting: A New Approach to Promote Teamwork and Collaboration Cindy L. Motley, MSN, APRN, FNP-BC; and Mary A. Dolansky, PhD, RN ABSTRACT Background: Feedback is a major component of clinical education. Feedback reinforces or modifies behavior and helps learners to validate knowledge and feel motivated to learn. Traditionally, feedback is used by clinical educators who observe learners’ behavior and provide expert direction. Teamwork and collaboration is one of the six Quality and Safety Education for Nurses core competencies developed for prelicensure and graduate nurses. These skills are important in the current complex health care environment. Method: On the basis of the literature and prior experience, a new approach for clinical educators is using feedback to teach teamwork and collaboration skills. Results: Five steps educators can take to provide effective feedback in the clinical setting are to (a) create a culture of feedback, (b) use structured communication tools, (c) encourage dialogue, (d) acknowledge the human factor, and (e) embrace a leadership role. Conclusion: This new approach enhances feedback and teaches teamwork and collaboration. [J Nurs Educ. 2015;54(7):399-403.] Received: September 6, 2014 Accepted: March 6, 2015 Ms. Motley is Instructor of Nursing, and Dr. Dolansky is Associate Professor, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio. The authors have disclosed no potential conflicts of interest, financial or otherwise. Address correspondence to Cindy L. Motley, MSN, APRN, FNP-BC, Instructor of Nursing, Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106-4904; e-mail: clm84@case.edu. doi:10.3928/01484834-20150617-08 Journal of Nursing Education • Vol. 54, No. 7, 2015 F eedback is a form of communication and is a crucial component of clinical education (Kaprielian & Gradison, 1998; van de Ridder, Stokking, McGaghie, & ten Cate, 2008). Indeed, feedback has been referred to as the cornerstone of effective clinical teaching, and empirical evidence has shown that it can significantly improve clinical performance (Cantillon & Sargeant, 2008; Eggen & Kauchak, 2007). Traditional clinical feedback must be expanded to meet the needs of the learner in the current complex health care environment, which demands interprofessional teamwork. The purpose of this article is to present an expanded approach to feedback that consists of the following five steps that educators can take to provide effective feedback in the clinical setting to teach teamwork and collaboration: (a) create a culture of feedback, (b) use structured communication tools, (c) encourage dialogue, (d) acknowledge the human factor, and (e) embrace a leadership role. This novel approach prepares students to effectively communicate and collaborate by providing and receiving feedback from other health care providers. Feedback is commonly described as information provided about a previous performance that is used as a basis for improvement (Archer, 2010; Dayton & Henriksen, 2007). A more comprehensive definition of clinical feedback identifies feedback as “Specific information about the comparison between a trainee’s observed performance and a standard, given with the intent to improve the trainee’s performance” (van de Ridder et al., 2008, p. 193). Both the behaviorism theory and the social learning theory emphasize the importance of positive feedback in modifying behavior and promoting learning (Eggen & Kauchak, 2007). Negative feedback is also essential for learning and is often the content of difficult conversations (Stone & Heen, 2014). For example, when feedback focuses on the individual, rather than the performance, it can be perceived as judgmental, critical, or controlling by the learner. Barriers to effective feedback in the clinical setting include unclear expectations and goals, no appropriate time or place for feedback to occur, and the tendency for a one-way flow of information from the educator to the learner (Archer, 2010). To be effective, feedback must be presented in a way that allows the learner not only to comprehend and accept feedback but also to know how to apply feedback in practice (Cantillon & Sargeant, 2008; Ramani & Krackov, 2012). Traditionally, providing feedback has been the task of the clinical educator (instructor or preceptor) who observes the 399 EDUCATIONAL INNOVATIONS learner’s (student or orientee) behavior and provides expert direction (Ramani & Krackov, 2012; van de Ridder et al., 2008). However, the current need is for both clinical faculty and students to use feedback-seeking behaviors to understand ways to improve effective teamwork and collaboration (Crommelinck & Anseel, 2013). Providing clinical instruction has become increasingly difficult for educators due to the current complex health care environment. Barriers to clinical education include diversity of settings, complexity of patient populations, limited clinical sites, and time constraints for teaching. Clinical groups may have as many as 10 students per clinical instructor, and preceptors are often undertrained (Cantillon & Sargeant, 2008; Clapper & Kong, 2012; Salas et al., 2009). The protection of professional standards, the self-esteem of students, and the rights and safety of patients must be priority considerations in any clinical learning experience (Archer, 2010). The Joint Commission recognized that breakdowns in communication were the leading root cause for sentinel events between 1995 and 2006 (World Health Organization, 2007). In response to the Joint Commission’s report, the National Patient Safety Goals were established to improve the effectiveness of communication and promote team training programs (American Society of Registered Nurses, 2008; Berg, Wong, & Vincent, 2010; Salas et al., 2009). The Interprofessional Education Collaborative’s Expert Panel (2011) responded by recommending the continuous development of interprofessional competencies by health professions students as part of their learning. Teamwork and collaboration is one of the six Quality and Safety Education for Nurses core competencies for prelicensure and graduate nurses developed by the QSEN Institute (Barnsteiner, 2011). The provision and acceptance of feedback in the clinical educator–student dyad will help to develop the teamwork and collaboration skills needed in the current complex health care environment. Teamwork and Collaboration Skills Step 1: Create a Culture of Feedback To create a culture of feedback, educators must consciously embed feedback implicitly and explicitly into all clinical activities so that it is viewed as a normal, everyday component of the clinical experience and is conceptualized as a sequential process, instead of as a series of unrelated events (Archer, 2010). This begins with the clinical educator modeling a climate of mutual respect by ensuring that the goals and expectations of the clinical experience are clearly understood and embraced by the learner (Ramani & Krackov, 2012). The learner needs to understand that feedback will be given throughout the clinical day in multiple venues and from a variety of sources. Feedback can be provided in a reciprocal one-to-one method between the educator and the learner, but it can also be provided during facilitated group discussion or dialogue sessions with students, nursing staff, other health care providers, or patients. Effective feedback is a two-way interaction, and the learner is encouraged to provide feedback to the educator as well (Archer, 2010; Ramani & Krackov, 2012; van de Ridder et al., 2008). Surveys of learners’ preferences indicate that learners want feedback, but, although educators believe they are providing adequate feedback, it is often not what the learners themselves 400 perceive (Cantillon & Sargeant, 2008; Ramani & Krackov, 2012). Many educators find that providing feedback is an uncomfortable responsibility because they find it difficult to separate the task or performance from the individual learner (Cantillon & Sargeant, 2008). The educators may not know how to respond to the emotional reactions that can result when feedback is perceived by the learner as being negative or critical. Most individuals do not take kindly to criticism, even when it is offered as constructive criticism, because criticism in any form often comes across as being evaluative and judgmental, even if it is meant to be helpful. The key to providing feedback is to encourage the development of self-reflection, sometimes used interchangeably with self-assessment and self-efficacy, to help the learner understand certain events and accept feedback, with the aim of self-improvement (Stone & Heen, 2014). It is time for educators to take a cue from the current health care paradigm shift from a culture of error and blame to a culture of safety and encourage learners to review their experiences in a climate of shared learning, instead of shame, guilt, and punishment. This culture of safety creates an environment where it is more likely that good practice will be reinforced and poor practice will be corrected (Bates, n.d.; Cantillon & Sargeant, 2008). Students assigned to clinical groups are in the ideal position to learn team-building skills. A team is defined as two or more individuals who work toward a common goal and whose behaviors, cognitions, and attitudes combine to create an adaptive and interdependent performance (Weaver et al., 2010). The team becomes the structure for providing feedback and support. A team attribute is that no one particular person has all the answers, but through effective communication and collaboration, team performance can be improved and goals can be met. The team approach establishes a culture of feedback that encourages continual learning and improvement. For example, a student is given the opportunity to place a nasogastric tube in a patient. After reviewing the procedure and collecting the appropriate equipment, the student attempts to place the tube, but on the first few attempts it curls up in the patient’s mouth. The instructor makes several suggestions, and on the next attempt, the tube goes down the trachea instead of the esophagus. By this time the student is anxious, but the instructor facilitates the placement. Afterwards, in a private setting, the student is encouraged to critique the experience from his or her perspective. The instructor then reviews the procedure and reinforces learning. However, feedback has only just begun. The next step is for the student to share the experience in the postclinical conference (debriefing). This gives the student an opportunity to acknowledge his or her feelings about what happened and share what was learned. In return, other students are able to share their experiences, ask questions, and provide support. The instructor’s role is to facilitate the team’s learning. Step 2: Use Structured Communication Tools Structured forms of communication used to provide feedback can enhance clarity, reduce ambiguity, and signal when action is required (Dayton & Henriksen, 2007). TeamSTEPPS® Copyright © SLACK Incorporated EDUCATIONAL INNOVATIONS is an evidence-based program developed in 2006 by the U.S. Department of Defense in collaboration with the Agency for Healthcare Research and Quality to improve communication and teamwork skills among health care professionals (Salas et al., 2009; U.S. Department of Health and Human Services, n.d.). It consists of four competencies—leadership, situation monitoring, communication, and mutual support. The program provides communication tools such as SBAR (Situation, Background, Assessment, Recommendation), call out, check back, briefing, debriefing, and huddle, which provide a standardized structure to improve the way health care providers communicate and function as part of a team (Clapper & Kong, 2012). The use of briefings, debriefings, and huddles ensures that appropriate time is provided for the feedback process to occur. For example, a morning briefing (traditionally referred to as the preclinical conference) provides an opportunity for educator and student alike to clarify questions such as, “What is the goal of the day?” “What is my role?” and “What are the expectations?” A student who is having difficulty interpreting a blood gas analysis for a patient in respiratory distress performs a call out, which is when the student asks the team (the clinical educator and other students) for help and identifies that the process of feedback needs to occur. A debriefing at the end of the shift (traditionally referred to as the postclinical conference) allows team members to reflect on the day’s challenges, acquire feedback from the other team members and educator, and answer the question, “What did I learn today?” (Shunk, Dulay, Chou, Janson, & O’Brien, 2014). By introducing students to structured communication tools and providing opportunities for practice, clinical educators can provide feedback and foster team building and a feeling of mutual support among students. Students must learn to give and receive feedback because it is essential for learning, adapting, and providing safe patient care (Dayton & Henriksen, 2007; Jones, Skinner, High, & Reiter-Palmon, 2013). Step 3: Encourage Dialogue Traditional clinical learning emphasizes skills checklists and summative evaluations, even though the American Nurses Association’s standards of nursing practice require that nurses solve problems, anticipate problems, analyze situations, and apply information (American Nurses Association, 2010). One of the responsibilities of an educator is to promote those higher order cognitive skills (Davidson, 2009). This requires a more complex interaction than what the sender-message receiverback to sender communication model depicts (van de Ridder et al., 2008). As a facilitator of feedback, the educator engages the learner in team discussion, leading to dialogue. No longer is feedback a one- or two-way flow of information, but it becomes multidirectional (Cantillon & Sargeant, 2008; Sargeant et al., 2011). Dialogue occurs when individuals freely and creatively explore experiences, actively listen to each other, and set aside their own opinions and biases to explore options and find solutions to problems (Cowan & Arsenault, 2008). The educator leads the dialogue, following a format using the basic elements of feedback—describe what was observed (who, what, when, where, and how); relate how the behavior or scenario made them feel, being as specific as possible and avoid judgJournal of Nursing Education • Vol. 54, No. 7, 2015 ing or generalizing; and suggest alternative options or another action, behavior, or response based on evidence-based practice (Swihart, 2007). As a team, learners have access to a larger pool of knowledge, have a chance to ask questions and clarify what others are saying, and can reinforce their own knowledge or performance (Arnold, 2010). The next level of team communication is collaboration, which is a process of communication and joint decision making based on shared goals. Collaboration provides a basis and structure on which professional relationships develop (Cowan & Arsenault, 2008). For successful collaboration to occur, dialogue must first take place. Step 4: Acknowledge the Human Factor Again, it is time for nurse educators to take another cue from the current health care environment and recognize how human factors affect the safety and performance of students (Institute for Healthcare Improvement, n.d.). The concept of human factors in health care recognizes the relationship between human beings and the systems in which they function. It focuses on efficiency, creativity, productivity, and job satisfaction, with the goal of minimizing errors (World Health Organization, n.d.). The fundamental basis of human factors is that individuals observe and learn information through a process that is complex and influenced by many factors—both intrinsic and extrinsic. Intrinsic factors for the learner may include pride in work, self-motivation, and interest. Extrinsic factors may include grades, expectations of teachers, and the number of clinical hours required (Nasrin, Soroor, & Soodabeh, 2012; Vanderbilt University, n.d.). When providing or receiving effective feedback, the learner’s personality and temperament cannot be left out of the equation. It is equally important to consider the learner’s background and readiness to change behavior. Experienced clinical educators make the effort to learn the student’s perspectives and their reasons for a specific behavior (Ramani & Krackov, 2012). The emotions, content, and outcomes model takes into account the human factor in the feedback process, which was developed to help raise learners’ insight and self-awareness of their clinical and professional abilities (Krackov & Pohl, 2011). Step one focuses on acknowledging and exploring the emotional reaction to the feedback received. Step two aims to clarify the specific content of the feedback as it relates to the student’s actual performance. Step three seeks to confirm the student’s identified learning and development of an outcome plan to improve performance (Sargeant et al., 2011). Educators must recognize that students work within a complex health care system that consists of both human–machine and human–human interactions, with the potential for errors arising from either area. By emphasizing evidence-based guidelines and standards of care, educators set the expectation of quality and safety in performance. Step 5: Embrace a Leadership Role Clinical nurse educators must actively choose to be leaders and to role model this behavior to learners. A leader must “decide when to include the input of others in the decisionmaking process, when to remain firm using one’s own judg401 EDUCATIONAL INNOVATIONS ment, and when to delegate authority and responsibility to others based on their knowledge and unique experiences” (Clapper & Kong, 2012, p. e371). The traditional leader role is one of controlling and is based on the belief that power comes from the position of authority. In the context of the educator as leader and the student as team member, the relationship becomes a partnership to achieve goals in a climate of trust and support. Feedback links the teaching and assessment roles of the educator and demonstrates commitment to the learner (Ramani & Krackov, 2012). Feedback and assessment are closely related and often overlap in terms of purpose and methodology (Cantillon & Sargeant, 2008). Formative assessment occurs through feedback, with the purpose of promoting learning and improving performance. Summative assessment is about measuring a student’s achievement and conferring a grade or judgment on the performance, with the purpose of determining goal attainment and progression (Oermann & Gaberson, 2014). As a leader, the educator is a role model for both students and other health care professionals. As experienced nurses, educators are expert in technical skills, patient teaching, counseling, monitoring, clinical judgment, collaboration, ensuring the quality of patient care, and working as part of a team (Adelman-Mullally et al., 2013). According to Vanderbilt University (n.d.), educators who embrace a leadership role will: ● Deliver presentations with energy and enthusiasm. ● Use their passion to inspire and motivate students. ● Make the learning experience personal and demonstrate that they are interested in the students’ success and have faith in their abilities. ● Be a coach and get to know the students so they can tailor instruction to the students’ concerns and learning needs. ● Use a variety of learning activities, such as unfolding case studies and team quality improvement projects, as part of the clinical learning experience to prepare students for practice. ● Role model feedback-seeking behavior to improve their own performance. Summary Providing feedback has been identified as a key determinate of learning since 1969 (Rogers, 1969) and requires that educators practice and reflect on their own performance to become expert clinical leaders (Cantillon & Sargeant, 2008). The current high risk, complex health care environment makes clinical instruction an increasingly difficult challenge for educators. Graduates are expected to be prepared to enter the workforce ready to successfully communicate and practice effective teamwork and collaboration, which includes the provision and acceptance of feedback (Barnsteiner, 2011; Interprofessional Education Collaborative, 2011). This article provides an expanded five-step approach to guide educators in the provision and receipt of clinical feedback, which traditionally has been provided as a way to learn in the context of clinical care. The expanded approach enhances teamwork and collaboration by implementing a culture of feedback, using structured communication tools, encouraging dialogue, acknowledging the human factor, and embracing the leadership role. 402 References Adelman-Mullally, T., Mulder, C.K., McCarter-Spalding, D.E., Hagler, D.A., Gaberson, K.B., Hanner, M.B., . . . Young, P.K. (2013). The clinical nurse educator as leader. Nurse Education in Practice, 13, 29-34. doi:10.1016/j.nepr.2012.07.006 American Nurses Association. (2010). Nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Author. Retrieved from http:// www.nursingworld.org/Nursing-Scope-Standards American Society of Registered Nurses. (2008). Communication among caregivers. Retrieved from http://www.asrn.org/journal-nursing/376communication-among-caregivers.html Archer, J.C. (2010). State of the science in health professional education: Effective feedback. 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Further reproduction prohibited without permission. DOI Number: 10.5958/j.2320-8651.1.2.036 International Journal of Nursing Care. July-December, 2013, Vol.1, No. 2 63 Valuing Communication for effective Nurse Leadership in Nursing Practice Elba S D’Souza1, Melba Sheila D’Souza2 Registered Nurse, Fraser Health Authority, British Columbia, 2Assistant Professor, Department of Adult Health and Critical Care, College of Nursing, PO 66, Sultan Qaboos University, Al-Khoud, Muscat 123, Sultanate of Oman 1 ABSTRACT There is a need for establishing effective Nurse Leader communication framework through the application of effective leadership principles. The objective of the paper is a synthesis of the scholarly literature and its application to the Nurse leadership in health care settings. The information gathered will be analyzed in relation to its usefulness for the Nurse Leader communications in hospitals. The attributes and strategies of effective communication are applied into a framework for the Nurse Leadership. Nurse leadership principles and practices provide a new dimension to the Nurse Leader communication. This paper shows that the role of the Nurse Leader is to communicate vision, goals, initiatives and changes in plans and policies that promote both clients’ care and multidisciplinary team work. This paper concludes that effective Nurse Leader communication principles and strategies should be utilized to meet the health goals of clients in nursing practice and education. Keywords: Nurse Leader, Communication, Clinical Nurse Perspective, Interpersonal Relations, Quality Care, Management, Barriers to Communication INTRODUCTION In today’s healthcare industry there is a need for Nurse Leaders (NL) who will intertwine the concept of leadership in everyday role of serving the needs and health issues of the client. The concept of leadership promotes service to others in a holistic approach that develops a sense of community by sharing powers in decision making. Nurse leaders spread a culture of positive attitude and action that makes a positive difference to clients and employees with the ultimate goal of the success and sustainability in healthcare organizations. Transformational and leadership values is about implementing new ideas; these individuals continually change themselves; they stay flexible and adaptable; and continually improve those around them1. One of the major tools involved in the nursing service for enhancing growth and increasing teamwork is the use of creative communication strategies. Leadership is “influencing the attitudes and behaviour of people toward the accomplishment of a goal while meeting the needs of people, including followers2”. In this systematic literature review, nursing leadership refers to the services of a leader utilizing transformational leadership principles and concepts 14. Melba-63-67.pmd 63 to enhance end results. These principles include listening, empathy, healing, awareness, persuasion, conceptualization, foresight, stewardship, commitment to the growth of others, and building community 3. This paper discusses the value and effectiveness of good communications for Nursing Leadership in clinical practice. Approximately 90% of the participants reported collaboration among nurses, physicians and administrators as one of the most important factors in perceptions of a healthy work environment4. The core competencies for professional nurses include skilled communication, collaboration, effective decision-making, appropriate staffing, meaningful recognition and authentic leadership. In recent years, interdependence of professional nurses between departments calls for smart communication strategies because their coordination of service has direct impact on patient care, treatment plans and aims to improve team member relationships. In hospital care effectively communications in the Nursing Leadership will provide a better understanding of client’s healthcare vision and vital information to determine goals for care ultimately aimed to improve nursing care and satisfaction. Most nurses report better team work and participation through forums and open dialogues5. 10/15/2013, 5:33 PM 64 International Journal of Nursing Care. July-December, 2013, Vol.1, No. 2 Nursing Leadership is the connecting force between nurses, clients, their families and the other members of the healthcare team. Through the use of appropriate communication strategies the Nurse Leader can build a cohesive and positive work environment. AIM The aim of this paper is review the principles of communication skills for effective Nurse Leadership in nursing practice. METHOD A synthesis of the scholarly systematic literature review and its application to the Nurse leadership in hospital care settings was undertaken to inform the study. The information gathered was used to analyze its usefulness for the Nurse Leader communications in hospital care facilities. The attributes and strategies of effective communication were used to develop a framework for the Nurse Leadership (Figure 1). This framework detailed the strategies of good Nursing Leadership communications. Through the literature synthesis barriers and influencing factors will be determined for use in the clinical leadership context. The researchers will also draw expertise from professional and educational experiences that add to the credibility of information presented in the paper. REVIEW The online databases used were Business Source, Academic Search Premier, MEDLINE, CINHAL, and SCIRUS. Nurse leaders’ need to listen to problems, perform assessment, and reply constructively, to help patients solve their health issues. All leaders in health care need to optimize their communication skills such as listening, conflict resolution, speaking and writing effectively in order to achieve positive outcomes6. In a case study in an out-patient Cardiac Rehabilitation clinic, the goal was to improve the attendance rates of patients to the unit thus reducing readmission and cost per life year7. The findings show that the Nurse Leader listened to existing problems of the patient and became aware of concerns for non-attendance. The Nurse Leader utilizing information from these patients was able to create solutions by involving the right personnel and thus eliminated frustration to patients. This resulted in increased attendance to the rehabilitation clinic confirming compliance to therapy and improved health. Nursing Leadership programs encourages 14. Melba-63-67.pmd 64 observation, reflection, and communication skills to challenge themselves, other staff and the culture of the organization with the ultimate goal of improving quality care to patients. The nursing staff perceptions of communication and leadership were explored in a study to facilitate improvement in quality of patient care in clinical units8. The study measured communication along openness, accuracy, timeliness, satisfaction, understanding and leadership had four dimensions: high standard, clear expectations encourage initiative and supportive behaviours. The staff reported frustrations with communication and leadership issues that needed improvement. They expressed need for open, accurate, and constructive communication between nurses. They also expressed the need to feel comfortable while making suggestions, bringing forth information and sharing their insights to one another and to their leader. A descriptive study was conducted to investigate nurses, physicians and clients attitudes towards collaboration and leadership in an organization experiencing transition from a traditional model of patient care delivery to a patient-centered model of practice 9. The sample consisted of 419 registered nurses, 61 physicians and 17 clients. The registered nurses scored significantly higher than physician scores for both the need for collaboration and leadership. Nurses have their traditional roots in values of taking care of others while traditional physician roles are as the leaders of the health care team. But both professions and the clients were more positive than negative towards collaboration of professional services to enhance client care. Discussion: Conceptual Framework for Effective Nurse Leader Communication The Nurse Leader can achieve both organizational and client goals by creating an environment and unit culture that foster open, trusting communication10. By adapting to leadership style the Nurse Leader develops a charisma to influence their employees, followers and clients. Spoken and written communications have increased over the recent years due to interdepartmental meetings resulting in more teamwork, and personal contact between clients and professional team members and leaders. These groups of team members (client, multidisciplinary, non-professional and management) serve one great purpose- ‘meeting client healthcare needs and safety’ with the Nurse Leader as a connecting mechanism (Figure 1). 10/15/2013, 5:33 PM International Journal of Nursing Care. July-December, 2013, Vol.1, No. 2 65 Effective communication can motivate mutually accepted values, directed towards providing quality patient care and delivery of effective nursing practice10. A conceptual framework is prepared based on systematic review that guides Nurse Leaders to develop their communications in Client care for positive results in client care and team functioning (Figure 1). The Nurse Leader takes initiative in opening the lines of communication and interactions with the team, client and management and encouraging ongoing input and feedback. Reaching consensus and setting mutually accepted goals are also useful to develop and evaluate standards of nursing care and performance. This framework outlines components to be considered for effective communication in Nurse Leader practice. It is essential that Nurse Leaders are highly competent and dynamic communicators because they deal with information and interactions that can set the tone of success and harmony. valuable members in accomplishing the goals of quality and safe services. Healing or Therapeutic Conversations: Clients in the hospital lose partly or wholly lose their independence and control of their personal everyday lives with complex co-morbidities and illnesses. Healing through communications (counseling, validation of feelings and offering encouragement) depicts the caring nature of the Nurse Leader. Awareness in Communications: The Leader requires increased self-awareness and awareness of those activities happening at the work place for better understanding of the direction they take. The ‘opendoor’ approach positions the leader to get in touch with their staff and clients, formulate priorities and anticipate concerns. Persuasive Communications: The Nurse Leader in client care seeks to promote ‘client-centered’ service and actions through persuasion rather than coercive force of command and orders. Communicating Conceptualization: Nurse Leader prepares themselves for these meetings and discussions by gathering relevant data, and based their suggestions on authentic rationale of nursing and medical services. Fig. 1. Framework for effective Communication in Nurse Leadership in Practice Knowledge of Self and Professionalism: Nurse Leaders communicate advocacy, support, counselor, and collaborative roles in their communications for better client healthcare service. Values, Results and Vision: Nurse Leaders need to realize that ‘means’ is as important as the ‘end’11. In client care, the Nurse Leader wants to communicate the value of justice along with courage to voice right from wrong decisions. Active Listening in Nurse Leader Communications: Giving staff and clients the opportunity for expressing their creativity and opinion will be an important leadership practice for the Nurse Leader12. Communicating Empathy: Nurse Leaders need to support and empathize with the staff and clients as 14. Melba-63-67.pmd 65 Foresight in Conversations: For success, the Nurse Leader critically examines the teams’ present activities and goals, and then projects the path toward the future which is based on the values and previous experiences. Blanchard (1998) describes the visionary role of the leader is to define the direction and future path of the organization (e.g. communicating the mission, objectives, values and beliefs of the organization)13. Stewardship in Conversations: Employees are better motivated and work with passion when they are encouraged to participate in taking accountable decisions in setting goals and planning implementation of standardized care. Communicating Commitment to Growth: Encouraging registered nurses for continuing education sessions, counseling, mentoring, participation in workshops, conferences, and research enhances their growth and development. Building a Community through Communication: Community building in the workplace reduces negative experiences, and gives employees ownership 10/15/2013, 5:33 PM 66 International Journal of Nursing Care. July-December, 2013, Vol.1, No. 2 to making positive changes for better outcomes of services and interactions, participation and decisionmaking for collaboration of multidisciplinary services to the client. Outcomes of Effective Nurse Leader Communications: The topmost responsibility of the Leader it to be strong advocates for quality and safe client care towards delivery of evidence based nursing care. Positive and better interpersonal relationships are outcomes of effective and efficient Leadership communications. The multidisciplinary team, clients and families rely on appropriate and timely communications from the Nurse Leader. A ‘positive’ work culture of respect, fairness, cooperation, and helping each other achieves better and higher outcomes in the unit. Positive communications promote enhanced interpersonal relationships stimulating stronger teamwork and achievement of goals in lesser time and effort. The Nurse Leader will highlight on the mission of the organization so employees have a common purpose to the client they serve. To be an effective communicator the Nurse leader will work to enhance existing techniques, learn new ones, practice and self-evaluate. Overcoming Barriers of Communications in Nursing Leadership: The best and effective communications take place ‘face-to-face’ because they build stronger relations. A Nurse Leader works to remove physical barriers by welcoming discussions through an ‘open-door ’ approach at her office. Emotional barriers are comprised of those negative vulnerable emotions that can result in false messages and interactions. Emotions like fear, mistrust and suspicion can lead a person to feel vulnerable, rejected, and frustrated. Employees and clients in these situations will avoid expressing their feelings and concerns. The Nurse Leader promotes the development of two-way communications with a culture of encouragement and support in the unit. Different cultures have different beliefs, practices and assumptions and way of communications14. The Nurse Leader will have to be open to new learning of expressions, words and meaning. To overcome cultural communications in work it is important to respect each other differences and offer support, patience and time to interactions. Language is a barrier to effective communication because it describes what we want to say in our terms, our expressions, buzz-words and jargon15. In a multi-cultural work place it is important to include every staff into discussions and decisionmaking when needed. Nurse Leaders will understand 14. Melba-63-67.pmd 66 that by promoting communications between employees and team members, they will feel valued and contribute more to the mission of the organization. The Nurse Leader’s responsibility is to ensure safe, clean, and quality care of clients or patients, a resourceful and healthy work environment for staff and clients. Good and effective communication skills are essential for nursing leadership to reach their goal of excellent service and care. Recommendations for clinical nursing practice The Nurse Leader role models to treating clients, their relevant others and the multidisciplinary team with respect and compassion. Effective communication, setting a clear vision and trajectory can increase standards of care and professional integrity that compliments the organizational policies and procedures. Nurse Leadership provides for direction and exchange of vital information within client care services through the effective communication strategies and principles. Nursing leadership is in need of expanding their roles to more proactive decision making and communication strategies. Client care services requires leadership involving walking the talk, striving for ethical and moral values while encouraging nurses and team members to plan ahead. Nurse Leadership need to be good communicators “articulate, persuasive and effective in communicating nursing contributions to healthcare and patient outcomes. Nurse Leadership shares commitment of creating a common vision, within Client care that leads to cooperation and collaboration of multidisciplinary services to the client. The Nursing leadership needs to communicate compassion to their work and people they meet through therapeutic, healing, and listening competencies of conversations. Implications for Nursing Practice Student nurses will require practicum hours in leadership roles and responsibilities to help them develop the art and skill of effective communication. Nursing leadership communications are used in comprehensive reporting, charting client information, entering client information into computers and most of all engaging in therapeutic communications to clients. Communication is also used in nursing education programs in leadership, public education initiative, media interest and forums on health care policy. This study recommends support, validation and evaluation of resources and outcomes to build effective 10/15/2013, 5:33 PM International Journal of Nursing Care. July-December, 2013, Vol.1, No. 2 67 clinical nurse leadership. Healthcare organizations are searching for leadership styles and structures to support a work environment that focuses on quality care for the patient and a meaningful work environment for healthcare providers9. The value of good communication, team-bonding and leadership interventions will help Nurse Leaders to improve their client-nurse care services and inter-team relations. Effective communication can reinforce leadership, make a difference and create alternatives for a hopeful future in the health organization. Utilizing the principles of leadership in the Nurse Leadership communications can be ‘the change’ and support to their followers, thus achieving higher and more effective goals. “People admire and respect leaders who are dynamic, uplifting, enthusiastic, positive, and optimistic17.” 3. 4. 5. 6. ACKNOWLEDGEMENT 7. We thank the nursing experts in the hospital for sharing their experiences in leadership to enrich this integrative review. 8. Conflict of Interest Statement The authors declare that they have no potential competing interests. 9. Funding Disclosure This is a not a funded research, but is carried out with the author’s interest. 10. Ethical Clearance This is a systematic review of literature of the paper. There is no involvement of human subjects or study of human minds. 11. Authors’ Contributions All authors meet the criteria for authorship, have designed, interpreted the systematic literature, drafted, revised and approved the final article and are entitled to authorship. 1. 2. 14. Melba-63-67.pmd REFERENCES Mitchell, K (2009). Week 8: Leadership on educational and professional issues. LDRS 631 H- Health care leadership issues. Retrieved from https://courses.mytwu.ca/course/view.php. Hardin, G. (2001-2009). How to determine your servant leadership quotient. 67 12. 13. 14. 15. Retrieved from http://www.lifeway.com/lwc/ article_main_ page/0,1703, A=160882 & M=150011,00.html Spears, L. (2004). Practicing servant leadership. Leader to Leader (34) 7-11. Retrieved from http:/ /www.pfdf.org/knowledgecenter/journal.aspx American Association of Critical-Care Nurses. (2005). 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