Achieving Competencies: For Nursing Practice

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Edited by Sheila Reading
Achieving Competencies
A handbook for student nurses
for Nursing Practice
and Brian Webster
Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.
Achieving Competencies for
Nursing Practice
Achieving Competencies for
Nursing Practice
Edited by Sheila Reading and Brian Webster

Open University Press
McGraw-Hill Education
McGraw-Hill House
Shoppenhangers Road
Maidenhead
Berkshire
England
SL6 2QL
email: enquiries@openup.co.uk
world wide web: www.openup.co.uk
and Two Penn Plaza, New York, NY 10121-2289, USA
First published 2013
Copyright © Sheila Reading and Brian Webster 2014
All rights reserved. Except for the quotation of short passages for the purposes of criticism and
review, no part of this publication may be reproduced, stored in a retrieval system, or transmitted,
in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without
the prior written permission of the publisher or a licence from the Copyright Licensing Agency
Limited. Details of such licences (for reprographic reproduction) may be obtained from the Copyright
Licensing Agency Ltd of Saffron House, 6-10 Kirby Street, London, EC1N 8TS.
A catalogue record of this book is available from the British Library
ISBN-13: 978-0-335-24674-8
ISBN-10: 0-335-24674-5
eISBN: 978-0-335-24675-5
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Fictitious names of companies, products, people, characters and/or data that may be used herein
(in case studies or in examples) are not intended to represent any real individual, company, product
or event.
Praise for this book
“What we have in this textbook is a user friendly but rigorous presentation of the main
competencies for professional nursing practice. Its easy style and ‘readability’ is one of its
most pleasing features and the case studies, information boxes and key learning points
give structure to the book as well as helping to engage readers. The short chapters are
interesting and authoritative and can be read on a ‘stand-alone’ basis, allowing readers
to ‘dip in and out’.
This book has arrived at an opportune time. The public and the nursing profession has
been shocked by the findings of the Francis Review of the Mid Staffordshire NHS Foun-
dation Trust. Research informed competencies were never more necessary. To provide
patient care without expertise in the competencies required would be like starting a new
journey without a map. This book is one of the best maps of the competency terrain that
I have come across.
I recommend with enthusiasm this book to would-be readers. It is a solid and signifi-
cant contribution to the on-going development of best nursing practice. It should be on the
recommended reading list of any nurse who plans, delivers and evaluates patient care.”
Professor Hugh P. McKenna CBE, PhD, B.Sc(Hons), RMN, RGN, RNT, DipN(Lond),
AdvDipEd, FFN RCSI, FEANS, FRCN, FAAN, Pro Vice Chancellor,
Research and Innovation, University of Ulster, UK
“[This book] clearly fills an important niche in the market. It frames the notions of compe-
tence, and addresses the NMC standards for pre-registration nursing clearly for students,
mentors and educators in ways that are easy to understand, and encourages students
to consider the implications behind the words they encounter and what these mean for
them in their own practice. The expertise held by the range of authors ensures the book
presents informed detail relating to nursing domains and competencies, and enhances the
relevance of interpretation and examples through the four fields of nursing and both core
and field specific concepts. To date, I would consider this the ‘must-have’ book on achiev-
ing competence for any nursing student in all four countries of the United Kingdom.”
Melanie Jasper, Professor of Nursing and Head of the College of Human
and Health Sciences, Swansea University, UK
v
Contents
The editors and contributors xiii
Foreword xvii
Introduction 1
1. The importance of evidence-based professional nursing practice 5

Sheila Reading and Brian Webster
Section 1: Professional values 19
2. Professional values for nursing 21

Owen Barr and Chris McLean
3. Owning your standards of care 37

Ruth Taylor and Debbie Banks
Section 2: Communication and interpersonal skills 51
4. Developing effective communication and interpersonal skills 53

Mary Addo and Alison Brown
5. Developing skills in solution-focused interactions 67

Steve Smith
6. Com munication in difficult situations 81

Kay Townsend, Beth Sepion and Delia Pogson
Section 3: Nursing practice and decision-making 95
7. An introduction to clinical decision-making in practice 97

Mary-Jane Baker
8. Advanced decision-making: involving patients and relatives

in decisions on care 113
Jackie Bridges
Section 4: Leadership, management and team working 125
9. Effective leadership, management and team working skills 127

Yvonne Middlewick
10. Enhancing and developing leadership, management and team working

skills in the community setting 141
Heather Bain and Mark Rawlinson
11. Leadership, management and team working in an acute care setting 157
Debbie Goode and Pauline Black
vii
Contents
Section 5: Achieving competencies: simulation, working
with mentors and learning when working abroad 173
12. Simulation: crafting your care 175

Eloise Monger and Kate Goodhand
13. Working with mentors: how to get the most from working with
your mentors in practice 187
Sheila Reading, Alison Trenerry and Cathy Sullivan
14. Learning abroad: the student experience of nursing in a European

or international context 203
Avril Milne, Jean Cowie and Brian Webster

Domains Appendix: NMC Competencies for entry to the register 219
Index 253
viii
List of tables
2.1 A good life for me 24 7.3 Stages of reflection model
6.1 Common fears, beliefs and challenges (Driscoll 2000) 110
that hamper effective communication 13.1 An example of a learning contract 194
(adapted from National End of Life 14.1 The benefits of learning abroad:
Care Programme 2011b) 86 student evaluations 206
6.2 Understanding parents and children 14.2 Key personal and professional
in end-of-life care 87 prerequisites for a learning
7.1 Possible stages of decision-making 102 abroad experience 213
7.2 Patterns of knowing 106 14.3 Key tips for a learning abroad
experience 214
ix
List of figures
1.1 Practice and theory inform each other 10 11.2 Qualities of an effective team member 164
5.1 Different media for scaling questions 73 11.3 Factors that distinguish effective team
5.2 The solution-building process 77 members 166
6.1 Managing difficult conversations 92 11.4 How to build a safe environment 168
9.1 An example of a patient journey 135 11.5 Developing a strategy to address
9.2 Bruce Tuckman’s (1965) stages of team conflict 170
development 136 12.1 Learning relationships 176
10.1 User-centred matrix 143 12.2 Skills stacking 181
10.2 Cycle of delegation 150 13.1 Conscious Competence Model
10.3 Health and social care model Diagram adapted from Howell 1982 189
(DH 2005) 151 13.2 Sources of support for students
10.4 Components of case management 152 while in practice 198
11.1 The toxic triangle: elements in three 14.1 The support networks in place for
domains related to destructive students studying abroad 212
leadership 162
xi
The editors and contributors
The editors has a range of clinical experience in mental health
which is grounded in effective communication and
Sheila Reading is an adult nurse who has worked
interpersonal relationships with clients in order to
in a variety of clinical, research and education
empower them to improve the quality of care. She
roles including primary care contexts in the NHS
is an active researcher in mental health and has a
and the university sector. She is currently a prin-
distinctive passion for communication skills as a
cipal teaching fellow in the Faculty of Health Sci-
pivotal part of all nursing care.
ences, University of Southampton. She has wide-
ranging experience of planning, developing and Heather Bain is a lecturer at the Robert Gordon
leading on a large number of undergraduate and University, Aberdeen. She is currently the course
postgraduate programmes and teaches on several leader of the masters awards portfolio at the
professional courses, study days and workshops. School of Nursing and Midwifery and has a wealth
Her education and research interests are broad but of experience in district nursing. She has written
have a particular focus on exploring the student several books and journal papers on this subject
experience of undergraduate project supervision. and has developed and implemented several pre-
She is interested in supporting student learning scribing courses for non-medical prescribers.
about the importance of research and evidence
Mary-Jane Baker is a lecturer in adult nursing in the
related to implementing sound clinical practice
Faculty of Health Sciences, University of South-
and how it can best be used by practitioners to
ampton. She has extensive experience of nurs-
enhance the quality of patient care.
ing and her role as a student academic tutor and
Brian Webster is professor of nursing and Assistant practice academic coordinator has enabled her
Dean at the Faculty of Health, Life & Social Sciences to continue to work closely with clinical practi-
at Edinburgh Napier University. He is both a mental tioners at all levels and in different settings. The
health nurse and an adult nurse and has worked NMC domain of nursing practice and decision-
in a wide range of clinical settings including sub- making encapsulates one of her particular areas
stance misuse, forensic psychiatry, emergency med- of expertise in promoting students’ development
icine, oncology and gastroenterology. A nurse for of critical thinking and application of knowledge
over 30 years, Brian also chairs the Scottish Heads and skills to practice. Mary-Jane is keen to encour-
of Academic Nursing & Allied Health Profes- age, support and guide students to make sense of
sions which is the voice of nursing education and decision-making within the various complex set-
research in Scotland, as well as being an executive tings of contemporary clinical practice.
member of the Council of Deans of Health UK. His
Debbie Banks is a senior lecturer and teaching
research focus is on alcohol use and misuse espe-
fellow at the Robert Gordon University. She is an
cially among higher education students.
experienced mental health nurse and has worked
in a wide range of clinical settings. She has writ-
ten and created many undergraduate programmes
The contributors during her time as an academic and has also imple-
Mary Addo is a lecturer in mental health nursing mented several creative pedagogical initiatives
at the Robert Gordon University, Aberdeen. She as part of the student experience in nursing. Her
xiii
passion for listening to service users and incor- ers in a range of clinical settings allows her to
porating their views and experience into student remain up to date with the importance of commu-
learning is a pivotal part of her role. nication as a fundamental and pivotal aspect of
quality care for all nurses.
Owen Barr is professor of nursing and head of the
School of Nursing at the University of Ulster. He Jean Cowie is a lecturer at the Robert Gordon
is dual registered in learning disabilities and adult University. She has a wide-ranging clinical back-
nursing. Owen was a member of the NMC Generic ground including accident & emergency nursing
Writing Group who developed the draft compe- as well as being a qualified and practising health
tency statements and contributed to the develop- visitor. She has played an active role in sup-
ment of the Standards for Pre-registration Nurse porting the Erasmus Programme within the pre-
Education. He views professional values as core in registration nursing programme at the university
the development of a student nurse’s identity and as well as running the health visiting pathway in
behaviour, and in the promotion of a competent the post-registration portfolio.
and confident registered nurse who will integrate
Debbie Goode is a lecturer in nursing at the Uni-
the NMC Standards and guidance documents into
versity of Ulster School of Nursing with a clinical
their daily work to deliver a professional and com-
background in intensive care. She is the course
petent service.
director for the BSc (Hons) Nursing Adult Course.
Pauline Black is a lecturer in nursing at the School Her interest in leadership and management began
of Nursing at the University of Ulster. Her clini- during her BA (Hons) in business studies. This
cal background is in acute and critical care nurs- interest was developed further as a team leader in
ing. She was a member of the team involved the regional intensive care unit.
in developing the new undergraduate pre-
Kate Goodhand is a senior lecturer in clinical skills
registration nursing curriculum at Ulster and has
and a teaching fellow at the Robert Gordon Uni-
a keen interest in developing methods to support
versity. She is an experienced nurse and academic
effective learning for students. Pauline has a par-
who is well experienced in developing students
ticular interest in the impact of effective teamwork
learning through simulated practice and using
in acute care, developed during her experience
feedback to improve their performance. In addi-
and research in the intensive care unit, Belfast City
tion she has the role of a learning enhancement
Hospital.
coordinator, responsible for embedding new and
Jackie Bridges is a senior lecturer in the Faculty creative approaches to learning, teaching and
of Health Sciences, University of Southampton. assessment to enhance the student experience.
Her expertise is in the care of the older person,
Chris McLean is a lecturer in adult nursing in the
particularly in acute hospital settings. Her clini-
Faculty of Health Sciences at the University of
cal work with older people and a well-established
Southampton and held the role of field lead for
research programme in this area have enabled her
adult nursing in the undergraduate nursing pro-
to pursue an interest in the nursing contribution
gramme between 2010 and 2012. He played a cen-
to health care, including the factors that influence
tral role in the development of the ‘values-based’
how nurses make decisions.
curriculum, one of the first validated undergrad-
Alison Brown is a senior lecturer in practice learn- uate programmes in England. He has a particu-
ing at the Robert Gordon University. She has lar interest in the philosophy of care, particularly
worked in a variety of settings including cancer in relation to concepts of virtue and character in
care and sees communication as a pivotal aspect nursing practice. His doctoral research explored
of both nursing practice and education. Her cur- aspects of how nurses think and talk about
rent role and partnership working with practition- patients.
xiv
Yvonne Middlewick is a lecturer in the Faculty of communication skills as fundamental to achieving

Health Sciences at the University of Southampton the NMC competencies and fulfilling their role of
and her current role is the mental health field lead working with people.
for undergraduate programmes. Yvonne is a dual
Mark Rawlinson is a lecturer and pathway lead for
registered nurse, adult and mental health. She
community nursing in the Faculty of Health Sci-
has a keen interest in how nurses can influence
ences, University of Southampton. He passion-
teams and organizations to enhance patient care,
ately believes that every nurse has the capability
strongly believing that this should begin early in
to improve the quality of care to patients, families
nurse education. The NMC Standards fully sup-
and carers, and considers that this can be demon-
port this and her interest is to focus on leadership,
strated not only through care and compassion, but
management and team working, helping students
also through the ability to lead. As a nurse with
to see how these influence their development as a
25 years’ experience in community nursing, Mark
nurse in preparing for an exciting and challenging
notes that it is apparent that the direction set by
career.
the NMC endorses this view.
Avril Milne is a senior lecturer at the Robert Beth Sepion is currently a lecturer in children’s
Gordon University. She has established several nursing in the Faculty of Health Sciences at the
Erasmus links within the pre-registration nursing University of Southampton, following on from a
programme as well as pioneering international well-established clinical career in children’s can-
exchanges for students in the USA. She is cur- cer nursing. Beth has particular interest in the use
rently the head of pre-registration programmes of experiential learning strategies such as sculpt-
at the School of Nursing and Midwifery as well as ing and forum theatre to facilitate child field stu-
developing a research profile in cultural compe- dents’ development of effective communication
tence in nursing. skills. She has significant experience of commu-
nication skills training in children’s palliative and
Elosie Monger is the faculty lead for clinical skills
end-of-life care. Her motivation as a lecturer is the
in the Faculty of Health Sciences at the University
desire to develop child field practitioners who can
of Southampton. She has been actively involved
facilitate compassionate and sensitive conversa-
in developing the practice and research of simula-
tions with children and their families encountering
tion in the undergraduate nursing and midwifery
end-of-life situations.
curricula in the faculty since 2002. Her doctoral
research has developed a novel technique for the Steve Smith Is a lecturer in mental health nursing
analysis of video-captured behaviour in simulated and an enterprise fellow at the School of Nursing
practice to elicit the factors which contribute to and Midwifery, Robert Gordon University. He is a
mentors’ assessment of student nurse compe- leading solution-focused therapist and heads one
tence. of the few training courses in solution focused
brief therapy in the UK. Steve has a range of skills
Delia Pogson has worked as a senior lecturer in the
in developing tailor-made education for practi-
Faculty of Health Sciences, University of South-
tioners in this area as well as progressing research
ampton and is a registered nurse in learning dis-
to improve the patient experience.
abilities. Her interest is in the complexities faced
when working for people with learning disabilities Cathy Sullivan is a lecturer at the Faculty of
and the communication challenges that they may Health Sciences, University of Southampton. She
experience. She recognizes that staff working with has a professional background in adult nursing
people with learning disabilities sometimes also and mental health practice. She is keenly inter-
experience difficulties in understanding people ested in learning in practice and believes that a
and hence she views the development of students’ practice experience is not just the place where
xv
students put ‘theory into practice’ but is most a well-established clinical career in cancer
essentially the time where the principles of prac- nursing, Kay has a particular interest in the edu-
tice are learned, as well as giving students an cational use of narratives and in critical com-
opportunity to build on the knowledge and skills panionship. She has significant experience of
already gained. She considers this learning to be communication skills training in palliative and
crucial, as it is where each student will learn the end-of-life care. Her teaching is driven by the
culture and skills of nursing that will ensure they need to develop practitioners who can have sen-
offer high quality care for all service users and sitive and compassionate conversations with
their families. people who are faced with end-of-life situations.
Ruth Taylor is Professor of nursing and Deputy Alison Trenerry is the education, quality and learn-
Dean at Anglia Ruskin University. Ruth’s expertise ing environment lead at University Hospital South-
is in education relating to clinical leadership, and ampton NHS Foundation Trust. Her role focuses
she has a keen focus on the enhancement of care on enhancing the learning experience in the clini-
through the development of students who have a cal practice setting for students and on the sup-
commitment to achieving high standards. port of mentors and educators who work closely
with students who over three years are develop-
Kay Townsend is a lecturer in cancer care in ing their competencies for registration. She is an
the Faculty of Health Sciences at the Univer- experienced nurse with a clinical background in
sity of Southampton. Coming to this role from cardio-thoracic nursing.
xvi
Foreword
It is a significant honour to be asked to write the trable professional and institutional boundaries,
foreword for this important new book. I was closely leading and managing teams, and being account-
involved with the process of developing the Nurs- able for the care delivered. There is no reason to
ing and Midwifery Council (NMC) Standards for believe that those realities will change or that the
Pre-registration Nursing Education over a period of role of the nurse in the delivery of care will become
about five years, latterly as the chair of the NMC’s less complex.
Stakeholder Advisory Group. I believe, and said at There are core issues that confront all nurses
the time of their launch, that the Standards pro- whatever their specific field of practice. Health care
vide a flexible professional framework, delivering should be safe, personalized and effective. Nurses
on the NMC’s core responsibility for protection of should demonstrate the skills, values and knowl-
the public, and also offering significant opportu- edge to provide skilful, intelligent and compas-
nities for innovation in programme development sionate care wherever they work. These issues are
and delivery. It will be for education providers and reflected in the four domains of the NMC compe-
clinical practice, working together, to make the tency framework that sets out the standards for
most of the opportunity offered. I believe that this competence, and the individual competencies, to
book will make a significant contribution to deliv- be successfully achieved for registration as a nurse.
ering that for student nurses. It is a significant strength of this book that it uses
It is also the right book at the right time. those domains to organize the chapters, but it is
Criticisms of the quality of health care and, by not constrained by this. I like the domains: profes-
extension, criticisms of nursing, have become sional values; communication and interpersonal
commonplace in the past few years. While I am skills; nursing practice and decision-making; and
certain that most nurses are able to demonstrate leadership, management and team working. There
the care, compassion and technical expertise that could have been other legitimate ways of divid-
service users and carers should reasonably expect, ing up what nursing is, what nurses do and how
it is clear that this is not always achieved by all. I nurses and nursing relate to others, but this seems
am also convinced that nursing education is not to ring true as encapsulating the important con-
fundamentally flawed, and this belief is regularly ceptual and practical issues for nurses. It is also a
reinforced through contact with student nurses strength that the authors have chosen to address
who seem well able to demonstrate the best of the all four fields of practice of nursing in a single vol-
caring attributes I would look for in a registered ume. Past distinctions in terms of the service user
nurse. population or the location of practice are becom-
The context of nursing practice has, however, ing meaningless, and the NMC’s concept of generic
become increasingly complex and nursing educa- and specific competences is intended to address
tion has a responsibility to ensure future graduate this. The thematic, domains-based approach of
nurses are well equipped for contemporary nurs- this book means that students, and their teachers,
ing practice. The nurse of the future will practise will find great value in each chapter whatever their
in an increasingly differentiated context. He or destination field of practice.
she will often be expected to work autonomously, One of the most significant changes to the NMC
crossing what had previously seemed impene- Standards was to establish that the newly-qualified
xvii
Foreword
nurse would be a graduate at the point of regis- sional accountability) that the strengths of the new
tration. Looking back, this was probably one of preregistration nursing programmes will lie. Uni-
the least contentious of the developments. There versities and their partners in practice will develop
have been nurses with degrees for many years, programmes that reflect their local needs and pri-
many more nurses ‘top-up’ to a degree post- orities, and this book can support that process.
qualification, and there has been a widespread While it is clearly aimed at students, this book
belief that the increasing complexity of the nurs- will be of great value to educators, mentors and to
ing role would be best served by graduate prep- nurses in practice who want to refresh their think-
aration. While ‘graduateness’ implies a level of ing and practice. Sheila and Brian have assem-
education and expertise within the subject area, it bled a remarkable group of contributors, whose
also implies a set of general and transferable attri- breadth and depth of experience, insight and pas-
butes that will help prepare the graduate for a future sion for excellence in nursing education and prac-
that is largely unknowable. I believe that it is in tice are reflected in each chapter. It is my view that
the strengthening of these attributes and abilities this book is a ‘must read’ for all student nurses.
(to be reflective; to weigh evidence; to articulate
clear professional values; to demonstrate resil- Iain McIntosh
ience; to communicate effectively in challenging Dean, Faculty of Health, Life & Social Sciences,
situations; to demonstrate personal and profes- Edinburgh Napier University
xviii
Introduction
In an environment of increasing public expecta- We believe that the competencies, which are
tions and demands this book specifically high- integral to all nursing programmes, require some
lights the nature and importance of the Nurs- interpretation, discussion and analysis by you as a
ing and Midwifery Council (NMC) competencies student nurse who will be experiencing theoreti-
which apply to all nurse education programmes cal learning in a university setting and undertaking
in the UK. The NMC safeguards the health and practice in a diverse range of clinical environments.
well-being of the public by maintaining a register
of qualified nurses and midwives. To be accepted About this book
onto the register student nurses need to demon-
strate that they have achieved the knowledge, This book is for all student nurses on pre-registration
skills, attitudes and technical abilities to be quali- degree programmes in nursing across the UK. It
fied graduates who are fit for practice in a range supports the development of graduate thinking
of roles. In addition, the education providers are and the demonstration of graduate attributes by
required to confirm that students who have met the individual student in clinical practice. The pri-
all course requirements are in both good health mary aim of the book is to offer a text for student
and of good character. The successful delivery of nurses, whatever their chosen field of practice, to
quality patient care relies on the demonstration of explore the relevance and meaning of the NMC
competencies by nurses at all stages of their edu- competencies to their personal learning through-
cation and developing career. out the duration of their course. There are chap-
ters that relate to all four fields of practice – child,
adult, mental health and learning disabilities. Each
The NMC competency framework field of nursing is acknowledged and addressed as
The NMC competency framework has laid out the every student requires an insight into all fields of
standards for competence and the related compe- nursing practice. The book also provides a basis
tencies that every nursing student must acquire for exploring other fields of care and identifying
under the following four domains: areas of best practice for the student to adopt.
Furthermore, it addresses the radical move to
professional values; specific generic and field competencies – that is,
communication and interpersonal skills; competencies required by all nurses, irrespec-
nursing practice and decision-making; tive of their chosen field of study as well as spe-
leadership, management and team working. cific competencies to their chosen field of study.
The book also supports the rich opportunities in
These four domains are at the heart of professional shared learning required by all nurses to develop
health care and in this book are explored in a way their graduate thinking. We believe that it will also
that will encourage you as a student to consider, on be helpful for academics, educators, mentors and
your own and with others, including peers, clients/ the many other practitioners that support students
patients, practice educators, academic staff and in diverse settings as part of their preparation for
other health care professionals, how the compe- their roles as first-year, second-year, third-year or
tencies support the provision of effective care in even fourth-year students (Scotland) and finally as
practice. graduate practitioners.
1
Introduction
The chapters have been written by expert and or using knowledge/evidence (Chapter 1) to help
experienced nurses in their fields who explore the solve problems in practice and make clinical deci-
competencies from a variety of perspectives. The sions (Chapters 7 and 8) which support patients
chapters are divided into sections according to and clients in improving, maintaining or recover-
the domain which they address, but inevitably ing health. As graduate nurses you will work in
there will be some overlap as the reality is that as teams, managing complex situations and lead
part of holistic health care competencies are not others – therefore, it is important to begin to learn
discrete or separate from each other. Each chapter how to achieve these competencies at an early
provides a specific focus and offers examples to stage of your programme and constantly develop
enable a creative understanding of how the com- your expertise as leaders in various health care
petencies may be demonstrated in the different settings (Chapters 9, 10 and 11).
contexts where practice occurs with individuals, As simulation is increasingly used to support
groups or communities. The intention is to pro- health care professional learning and provides
voke ideas to support your understanding and help an opportunity to learn, practise and perfect your
you to reflect on how the competencies underpin knowledge, clinical skills and competencies, this
professional health care practice and can best be book includes a chapter to support your achieve-
achieved. Due to the fact that competencies can ment of competencies in this way (Chapter 12).
be measured and assessed both in theory, practice It will be important for you to assess what has
and simulated settings and at different progres- been achieved and what further personal develop-
sion points, the book is a valuable resource for ment you may require. The use of personal devel-
you to use with others and to revisit throughout opment portfolios, learning contracts and working
your entire programme. In fact an important and with mentors and others in practice are addressed
pivotal part of a graduate nursing programme is in relation to achieving the competencies and
to ensure that previous concepts, knowledge and demonstrating excellence in practice (Chapter 13).
skills learned at the start of university education Our view is that it is important that all health
are revisited, built upon and analysed further as care students are encouraged to think about
in order to develop the professional application of health care beyond the UK context and indeed, as
these as a nurse. some have an opportunity to undertake an elec-
This book aims to offer a rich and wide-ranging tive placement outside the UK, the text acknow-
exploration of existing theoretical and knowledge ledges the importance of recognizing the global
bases relating to the competencies, which will health care setting and the richness and benefits
challenge you to ask questions and think about that working in a different global health care set-
situations you may experience in practice. It will ting can provide to your own knowledge, skills
also challenge you to reflect on your own under- and confidence (Chapter 14).
pinning values and belief systems and analyse
how these may differ from others with whom you
work or those you may care for (Chapters 2 and 3).
Using this book
It is intended to be used to foster an approach This book will provide you the reader with a guide,
which promotes an honest and open exploration or handbook, which, rather than being a text to
of different understandings of competence and to read from cover to cover, can be used to dip in and
promote in-depth exploration, questioning and out of as you progress through your programme of
analysis of different attitudes and beliefs which learning and encounter new situations in practice.
underpin communication styles (Chapters 4, 5 and The book will also be a valuable tool to you for
6) and actions used by clients/patients and other use in the practice setting to encourage dialogue
professionals within your chosen field of practice. with clients/patients, and for mentors and others
We make no apology for the emphasis on seeking who are pivotal in assessing practice achievements.
2
Introduction
We envisage that you will use this book as a tool for ties in each chapter will help you to think about
promoting peer and group discussion both in prac- the underlying principles, literature, research and
tice and in the university context, possibly during other evidence that informs understanding.
seminars or action learning groups. In particular it
would be useful for sharing experiences and learn-
ing from practice, and for identifying further theo-
A note on terminology
retical knowledge that may be required. The text It is important to note that throughout the book,
can be used to encourage your learning through rather than attempt to apply one term consistently
reflection on critical incidents when elements of across all chapters, the words ‘patient’, ‘clients’,
your clinical practice may have been very success- ‘service user’ and ‘individual’ are used as the
ful or possibly when you need future adaptation for chapter contributors felt best, in recognition of the
specific situations. variations observed and applied within different
Reflecting on current and future contexts of health care contexts.
health care provision, case studies are included
to illustrate how you might demonstrate compe-
tencies in specific settings with a particular indi-
In conclusion
vidual, client group, community or society. The We hope you will find this a helpful and construc-
book focuses on illustrating specific concepts and tive book as you develop your graduate think-
themes to provoke wider thinking through a series ing, analysis of evidence and application of your
of activities and some suggested further reading. knowledge and skills to the quality care that you
The chapter topics are not intended to be pre- learn to provide to patients. It is our intention in
scriptive but rather to be illustrative. The hope is writing this book that your development as profes-
that this will promote and develop the attributes sionals will ultimately lead you to provide a high
of a graduate nurse. We think it is important to standard of evidence-based care to the patients
encourage you as students to add your own voices you care for. We wish you well.
to the interpretation of the competencies in order to
make them meaningful for yourselves. The activi- Sheila Reading and Brian Webster
3
The importance of
evidence-based professional
1
nursing practice
Sheila Reading and Brian Webster
Chapter contents
Introduction Using evidence in practice
Domain 1: Professional values – generic standard RCN information literacy competences
for competence Critically assessing evidence
Domain 3: Nursing practice and decision-making Using different types of evidence to answer
What is evidence-based practice? practice questions
The importance of evidence-based practice Challenges and limitations of evidence-based
within the current context of nursing practice
Your role in promoting evidence-based practice A lack of research undertaken
RCN competences: finding and using information A lack of clarity on how to proceed
Using evidence for decision-making and The informed and knowledgeable practitioner
problem-solving in practice Reflection in and on your practice
Knowledge and skills needed to use evidence Conclusion
in practice Further reading and resources
The evidence-based practice process References
Creating evidence
Introduction nursing practice and decision-making;

The concept of evidence-based practice under- leadership, management and team working.
pins contemporary health care. Throughout your
programme of nursing study you will develop the Throughout this book you are provided with
skills to demonstrate the application of evidence- examples of how to integrate existing evidence
based nursing practice. You will learn to think crit- into your practice to illustrate and support your
ically about the theoretical literature, research and learning. For all aspects of nursing, there is a
other evidence informing your understanding to wealth of diverse evidence to draw on and you will
help you achieve the Nursing and Midwifery Coun- become familiar with accessing and using various
cil (NMC) competencies (2010) which are arranged sources of knowledge concerning values, ethics
within the following four domains. and compassionate care; communication studies,
interactional research and theory; approaches to
professional values; decision-making and leadership; and manage-
communication and interpersonal skills; ment research.
5
Chapter 1 The importance of evidence-based professional nursing practice
Evidence-based practice is a fundamental aspect the conscientious, explicit and judicious use
of all you do as a nurse and this chapter will support of current best evidence in making decisions
your learning and achievement of the competen- about the care of individual patients. The prac-
cies within the NMC Standards for Pre-registration tice of evidence based medicine means inte-
Nursing Education (NMC 2010) by facilitating you to: grating individual clinical expertise with the
best available external clinical evidence from
understand what is meant by evidence-based systematic research.
practice; (Sackett et al. 1996: 71)
appreciate the diverse types of evidence that
can be used to inform practice; This definition captures a broad overview of the
explain the importance of evidence-based key considerations of how evidence should be
practice; used to inform practice. Often it appears that
develop the knowledge and skills you need to the main focus is on being able to critique research
demonstrate evidence-based practice; and apply it to practice, but read the definition
critically consider the limitations and chal- carefully again and you will recognize that much
lenges of evidence-based practice. more is being indicated.
This chapter specifically addresses the following 1 The words conscientious, explicit and
NMC standards but evidence-based information judicious
underpins all the standards.
These words convey how each health care
Domain 1: Professional values – generic practitioner embracing an evidence-based
standard for competence approach to care should conduct them-
9 All nurses must appreciate the value of evi- selves. Conscientious means being thorough,
dence in practice, be able to understand and meticulous and painstaking. Explicit means
appraise research, apply relevant theory and being open, clear and precise and judicious
research findings to their work, and identify indicates the need to be cautious, shrewd,
areas for further investigation. prudent and well-judged.
Domain 3: Nursing practice and

2 When using ‘best evidence’
decision-making
What counts as best evidence has been con-
1 All nurses must use up-to-date knowledge
tested and remains controversial (Rycroft-
and evidence to assess, plan, deliver and eval-
Malone et al. 2004). Therefore a consideration
uate care, communicate findings, influence
of the value of a range of evidence available
change and promote health and best practice.
should be made.
They must make person-centred, evidence-
based judgements and decisions, in partner-
3 The care of individual patients
ship with others involved in the care process,
to ensure high quality care. They must be able Transferring evidence to the real world of
to recognise when the complexity of clinical practice which involves caring for individual
decisions requires specialist knowledge and patients is challenging and complex. While
expertise, and consult or refer accordingly. research-based knowledge provides theories
and clear-cut solutions it is often difficult to
use in practice where there are uncertainties
What is evidence-based practice? and multiple variables which are unable to
Evidence-based practice first came to the fore during be controlled for (Schön 1983; Mantzoukas
the 1970s and one of the most quoted definitions is: 2007). In addition, every nurse and patient
6
and their interaction is unique and subjective chapter focuses on how best to assess pain and
(Kitson 2002; Rolfe and Gardner 2005). use evidence to manage, relieve and evaluate
pain. Various sources of evidence are provided:
4 Integrating individual clinical expertise
with the best available external clinical prevalence of pain;
evidence the science/theories of pain;
Kitson (2002: 181) has highlighted that in the human, social and financial burden of pain;
nursing: pain assessment tools (using validated tools);
accessing evidence to pain management;
EBP [evidence-based practice] should
using evidence to manage pain (pharmaco-
embrace ways of being able to demon-
logical and non-pharmacological).
strate the effectiveness of expert knowl-
edge on individual and collective patient
In reality there are many different types of
decisions; the impact of existing research
evidence which inform nursing and add to its
and outcomes and the ability to integrate
knowledge base. Did you manage to consider the
patient experience into decisions about
following after completing Activity 1.1?
outcome.
Sackett et al. (2000: 1) describe the value of
randomized controlled trials (RCTs);
tailoring care and using professional experi-
systematic reviews – the Cochrane Collabora-
ence and clinical judgement as:
tion (www.cochrane.org) is one source and
the ability to use our clinical skills and academic journals also produce such reviews
past experience to rapidly identify each (e.g. the International Journal of Nursing Stud-
patient’s unique health state and diagno- ies, www.journalofnursingstudies.com);
sis, their individual risks and benefits of clinical guidelines such as those produced by
potential interventions, and their personal the National Institute for Health and Clinical
values and expectations. Excellence (NICE) for England and Wales and
the Scottish Intercollegiate Guidelines Net-
The rationale for basing practice on the best avail- work (SIGN: www.sign.ac.uk);
able evidence is to ensure that nursing practice controlled trials;
is informed, appropriate, transparent and safe. case control;
Underpinning this is a question concerning what cohort studies;
counts as evidence. case studies;
descriptive studies/reports;
qualitative studies.
Activity 1.1
However, it is pivotal to your practice as a nurse
Think about the types of evidence to understand that evidence is not solely derived
that might underpin how you assess a person’s from research. There are other non-research
need for pain relief. sources of evidence such as:
List all the possible sources of this knowledge
you might draw on. evidence from theory (e.g. theories about the
grieving process, parent and child bonding,
etc.);
Allcock and Day (2012) provide information psychosocial, cultural and pharmacological
which enables nurses to adopt an evidence-based knowledge that can inform patient care and
approach when caring for people with pain. Their clinical practice by offering evidence regarding
7
possible non-concordance with drug treatment There are many texts for nursing which pro-
(e.g. unpleasant side-effects, personal belief vide a balance of evidence for practice (e.g.
systems); Newell and Gournay 2000; Bullock et al. 2012).
evidence of experts, experienced profes- Bullock et al.’s book for adult nurses demon-
sional opinions, professional consensus and strates how evidence can be used to benefit the
respected authorities; patient with common health conditions or with
audit data; specific health needs, and improve the patient
quality/performance data; experience of care.
evidence from patients and carers (e.g. patient Knowledge that informs nursing practice is not
feedback); always based on studies of clinical effectiveness
evaluation data; such as systematic reviews and RCTs. In real-
guidelines; ity, relatively little health care is based on evi-
knowledge of the organization and the cul- dence which indicates precisely what effective
ture; care is and there is often no suitable guidance
clinical expertise/professional experience; for practice. However, it can never be acceptable
professional networks; to ignore evidence that already exists and carry
policy documents, national and local. out patient care if we are unable to justify and
explain why we are doing it. Where there really
While research-based information is a key ele- is no published evidence, it is acceptable to base
ment informing the provision of quality care and practice on what we know works and be ready
meeting patient needs, audit data, patient surveys, to defend this position based on confirmed expert
patient and carer stories, laboratory tests and knowledge, experience and patient viewpoints.
other results also help build up a picture of best This provides an opportunity to then monitor and
care. evaluate the results of that care and make pro-
posals for further research.
Kitson (2002: 185) has argued for a broaden-
ing of the concept of using evidence in health care
Activity 1.2 which acknowledges the importance of patient-
You may hear people say things that focused care:
justify why they have chosen to do something
in a particular way in practice. Below is a list Nursing’s theoretical and practice base requires
of phrases/expressions you may have heard a broad interpretation of the term evidence.
used in the clinical practice environment. Do Definitions of evidence need to be understood
you think any of these has a role in helping us in the context of establishing effective therapeu-
develop evidence-based practice? If so, why? If tic relationships with clients and by balancing
not, why not? evidence from patients, clinical experience and
research in order to arrive at the best clinical
‘In my opinion this is what should be done.’ decision for care . . . This does not mean that
‘In my experience this seems to work.’ nursing science cannot draw from studies of
‘I have always done it this way.’ effectiveness but it may be that as a discipline,
‘Traditionally, we do it this way.’ it still needs to do a lot more describing, refin-
‘Well it’s not clear what is best so let’s give this ing and classifying of basic constructs and con-
a try.’ cepts before it can put great reliance on the evi-
Justify your responses and discuss with col- dence that emerges from intervention studies
leagues. alone. Researchers within nursing need to be
equipped with the full range of methodological
8
approaches, and not create a hierarchy that sets nurse consultant/consultant practitioner;
one approach above another. research nurse.
We would suggest that rather than focus on a It is clear from the list above, which is not exhaus-
debate as to what counts as best evidence, nurses tive, that a range of roles are available for you once
must become competent in asking practice-based you have qualified. What is certain is that these
questions, accessing and synthesizing the full roles require graduate-prepared nurses, with clear
range of available information to answer the ques- skills of problem-solving, leadership, critical anal-
tion, improve their clinical practice and enhance ysis and an ability to gather, interpret and apply
patient care. the best possible evidence to care and support the
patients they are looking after. Many roles will
require further education and preparation, often to
Key learning
There is a range of types of evidence
! masters level and some to doctoral level, and this
development gives recognition to the important
autonomous and patient-focused approach that
that you will be required to understand to nurses can bring to patient care and management.
inform your practice.
Evidence from a range of sources, includ-
ing audit documents, patient surveys, clinical
guidelines and policy documents plays a piv- Activity 1.3
otal role in informing your practice as a nurse. In choosing to become a nurse what
skills and attributes do you think you bring to
this profession?
The importance of evidence-based How might these support you in the delivery of
practice within the current context evidence-based clinical care?
of nursing
Nursing is never a static practice and during the
last decade there has been a significant increase There are many skills and attributes to sup-
in the skill set and knowledge base expected of port you in being an evidence-based practitioner
the qualified nurse. Nursing has become a more including:
diverse and complex profession across the four
fields of practice and the opportunities to develop being ready to question care and practice;
and grow in a chosen field are now greater than wanting to understand more about what you
they have ever been. In the UK nurses can now do and why you do it;
aspire to become a: the desire to be knowledgeable, well informed
and aware of the latest policies, guidelines and
staff nurse (community or hospital based); research;
GP practice nurse; the desire to provide the best high quality care
public health nurse; based on clear evidence;
school nurse; the ability to challenge, and be challenged,
occupational health nurse; about aspects of your practice;
sister/ward manager; a readiness to change your own practice to
clinical nurse specialist; improve patient or health outcomes;
nurse practitioner/advanced practice nurse; wanting to be a consumer of research and
practice education facilitator; possibly even generate some research-based
lecturer/practitioner; knowledge.
9
Your role in promoting of supporting graduate student nurses in achiev-

evidence-based practice ing competencies for practice. The aim is to assist
When you graduate and register as a qualified nurses in evaluating evidence derived from pro-
nurse you will be in a position to lead others in fessional standards and benchmarks.
delivering high quality evidence-based care within
a complex and changing health care environment. Using evidence for decision-making
Increasingly people, are able to access the exten- and problem-solving in practice
sive health information available to them and are Many sources of evidence are used in the decision-
well informed about their own health care needs making process for nursing practice (see Chapters
(Kitson 2002). It is essential that your clinical prac- 7 and 8) and it is important to emphasize again
tice is supported by the best available evidence in that evidence is not the only dimension inform-
order to ensure that what you do actually improves ing how you deliver care. It is now clear that your
individual, and population, health outcomes. This knowledge and the clinical care given to patients
means that you will need to remain up to date is informed by a variety of sources and adapted to
with the latest and best evidence to keep yourself suit your patient preferences (related to their val-
informed and be able to draw on the many sources ues: see Chapter 2) in light of your experience and
of knowledge to ensure quality care. developing expertise.
During your nursing programme you will During your time at university, whether attending
become familiar with academics presenting you lectures or action learning groups, reading articles
with research-based information and giving you a and books, or undertaking online learning, you will
sound understanding of other types of evidence, engage in activities that encourage you to identify
including the science and theory underpinning a problems, think critically, generate knowledge or
range of health care initiatives. As a student nurse information and ultimately solve problems. Mod-
you will learn to access, judge and use evidence to ules of study will include both theory and practice
present clear reasons for the care you deliver, both and encourage you to apply one to the other, or to
in written assignments and in clinical placements. integrate knowledge from theory and practice (see
However, as evidence is constantly being added to, Figure 1.1). The same will be true of your practice
you will need to maintain and adapt your knowl- experience. Fundamental to this is the application
edge and skills of searching for evidence, synthe- of your theoretical knowledge to your develop-
sizing and using it to inform your practice once ing clinical practice and care of patients, whether
registered as a professional nurse with the NMC. that be at a hospital, in a home or some other area
where you have contact with patients. In practice
RCN competences: finding and you will assess specific individual needs by looking
using information at care plans and observing patients for a range of
One helpful tool for nurses has been produced by signs and symptoms to add to the evidence needed
the Royal College of Nursing (RCN 2011) which to identify and solve their particular problems.
introduced a strategy and document called ‘Find- Some of the skills you will develop as a student
ing, Using and Managing Information: Nursing, Mid- nurse will focus on how to best make use of the
wifery Health and Social Care Information Literacy wide range of knowledge available to you and
Competences to support the enhancement of skills
in accessing information from the various sources
available in health care practice and delivery of
patient care. The intention was to enable nurses Practice Theory
to find and analyse evidence for use in the provi- Informs

sion of safe and effective clinical practice. Online Figure 1.1 Practice and theory inform each other
resources have been provided with the intention
10
apply this to your care of patients. These skills will Whenever you do this the aim will be to generate
be developed as an integral part of your education new evidence that will add to the existing knowl-
as a student nurse and will continue to grow, be edge base of nursing-focused and patient-centred
shaped by and enhanced in your role as a quali- findings. Many nurses actively engage in research
fied practitioner. This is part of your journey as a to build the knowledge base underpinning practice.
lifelong learner, a professional who is willing, able Some follow a career in research or combine clinical
and open to change, gathering new information practice with research and practice development. As
and using this to inform your clinical practice. We the profession of nursing builds and strengthens its
believe that learning how to use evidence and the research and evidence base it is important to under-
knowledge and skills required to do this is a devel- stand that as a nurse you can be active in gener-
oping attribute of the graduate nurse. ating evidence, translating evidence and using that
evidence to inform your own practice and therefore
Knowledge and skills needed to provide the best possible care to your patients.
use evidence in practice
Using evidence in practice
The evidence-based practice process We take here hygiene needs as an example. All of
The process of using evidence to best inform your us attach great importance to our personal care
clinical practice usually starts with you asking a and hygiene needs, and it is only when the usual
question regarding an aspect of care you require facilities for showering, brushing teeth and wash-
an answer to. It is necessary to translate the ques- ing our hair are removed that we are reminded of
tion into one that will help you focus your ideas the impact this has on our feelings of comfort, self-
and guide your search for evidence from a range esteem and general well-being. During periods of
of sources. The following evidence-based practice illness many people require nursing interventions
process is usually adopted. to meet their hygiene needs and of course the very
young and the very old will require specific inter-
1 Develop a well-framed practice-based ques- ventions as part of their daily care.
tion.
2 Search systematically for evidence to address
the question. Activity 1.4
3 Search and select the best available evidence Think of someone you cared for during
to answer your question. your recent practice experience who required
4 Appraise that evidence, synthesize and sum-
assistance with their hygiene needs.
marize: translate into recommendations or What evidence did you draw on and use to
guidelines. inform your care to best meet that person’s
5 Apply the evidence in practice, taking account
hygiene needs?
of patient preference and local organizational
What resources/evidence/guidelines did you
context.
use to ensure best clinical practice?
Were you aware of that person’s view of being
6 Evaluate the result of the use of that evidence.
assisted with their personal hygiene?
7 Disseminate the evidence to others. Did you assess their specific hygiene needs
and personal preferences, rather than adopt
Creating evidence routine and ritualized care?
It is possible that you may choose to undertake some Reflect on what other evidence/information/
research yourself either as part of a research module knowledge you would like to have in the future
or for an honours component within your degree, or to improve this aspect of care.
indeed at a later stage in your professional career.
11
You may want to discuss your answers to Activity This example highlights just one area where the
1.4 with peers, your tutor, your mentor or even generation of audit data, guidelines and benchmark
with some patients you have cared for. This is standards is valuable for ensuring health care pro-
likely to reveal areas where you need to learn more fessionals are enabled to use evidence in practice
about what evidence exists to help you improve that there are improvements in patient care as a
patient care in this area. result. Clinical guidelines help you make decisions
Some people will require specifically adapted about what is effective in clinical practice. Summa-
nursing interventions to support their hygiene ries of evidence do exist and these are helpful as
needs. For example: they combine evidence from various sources which
inform care. In mental health nursing, the quantity
people who are unconscious, semi-conscious and quality of evidence is increasing and numer-
or sedated; ous guidelines inform the organization of clinical
people with certain mental health problems; practice (Newell and Gournay 2000).
people with physical disabilities; Other evidence gathered from patients, such as
people with learning disabilities; NHS surveys (see www.nhssurveys.org) also help
people receiving end-of-life care; to inform best practice. But, as always, there is a
babies and young children. need to be cautious and to carefully and critically
consider the value of these types of evidence for
You should consider how evidence of best practice your own context and local practice. Guidelines
might need to be adapted for these patient groups. can become outdated and need regular reviewing.
Using audit data
In relation to hygiene needs, evidence gathered by RCN information literacy competences
the Healthcare Commission (2007) (now known The RCN suggests that when seeking evidence for
as the Care Quality Commission – CQC) indicated practice you use the following framework.
that 30 per cent of complaints by patients about
hospital care related to poor attention to dignity, 1 Identify why information is needed (question
privacy and basic personal care. This audit data practice and recognize gaps in evidence).
provides evidence of areas where improvement is
2 Identify what information is needed (what
needed.
type of evidence is needed to address a prac-
Using benchmarks, clinical guidelines and tice topic?).
protocols to inform practice 3 Carry out a search to find information (iden-
Rather than expecting every nurse to access and tify and select best evidence available).
search for evidence related to improving this aspect 4 Evaluate how the information meets the
of care, quality benchmarks for hygiene care have identified need (judging the quality and rel-
been produced and published in Essence of Care evance of the evidence).
(DH 2010). In this document quality indicators to
5 Use information and knowledge inclusively,
support best practice are provided and include:
legally and ethically.
assessing individual preferences and agreeing 6 Manage information.

personal care needs for individuals for their 7 Create new information or knowledge, draw
skin, teeth, nails, eyes, ears and nose; conclusions and make recommendations for
documenting, communicating and evaluating practice.
the hygiene care provided;
ensuring the evidence base that underpins This framework will support health care profes-
care is reviewed and kept up to date. sionals to ensure care is informed by best evidence,
12
which inevitably will have an impact on the patients

you look after. Key learning
Always approach evidence with a criti-
!
Critically assessing evidence
cal stance which looks for both strengths and
We take here the Mental Health Network (MHN)
weaknesses in the research which may impact
as an example. In 2011 the MHN NHS Confedera-
on the findings.
tion produced a fact sheet on mental health statis-
All studies have strengths and weaknesses in
tics and resources. This kind of evidence is drawn
spite of attempts to ensure rigour.
from several sources and helps to set in context
key information when deciding on NHS service
provision, budgets and investment in new services
for people with mental health problems.
One example taken from the fact sheet is:
Using different types of evidence to
answer practice questions
Statistics derived from surveys and other quan-
There are currently 750,000 people in the UK with
titative studies only represent part of the clini-
dementia, which is expected to grow to over one
cal practice scenario. For example, we may
million by 2021. The cost to the UK economy cur-
know how many people in the population have
rently stands at £20 billion per annum and is pro-
depression, but what may be equally important
jected to rise to £27 billion per annum by 2018.
is to understand the experiences and perspec-
It is essential to first understand how this informa- tives of those who have this condition in order
tion was generated and critically analyse what the to respond effectively and meet their needs. Such
figures actually mean. For example, prevalence fig- information is usually provided by both quanti-
ures such as this vary as they do not always mea- tative and qualitative evidence addressing ques-
sure the same thing. This can be for a number of tions such as:
reasons. For example, in practice, psychiatric diag-
Why do people suffer from depression?
nosis can be difficult and different health care pro-
Are some people more at risk of becoming
fessionals may diagnose dementia differently. As a
depressed than others?
result figures of prevalence and incidence may be
How can we maintain personal well-being in
distorted. A further problem that arises is that data
order to try and prevent or avoid depression
may be collected on the number of people who are
(consider social, economic and employment
cared for by mental health professionals. It has to
factors, and how stress relates to these)?
be recognized that many individuals may never be
How does depression impact on the person
in contact with health care services and as a result
and their family?
the ‘facts’ may not be entirely accurate.
How long might it last for any individual?
Statistics appear to be convincing but should
not be treated as facts. It is important to explore
how statistical figures were arrived at and exam-
Challenges and limitations of
ine the reliability and validity of the data in ques-
evidence-based practice
tion. The following questions could be asked:
It can be a challenge to know what to do in a situ-
What was the sample size? ation when there is no evidence, conflicting evi-
How representative is the sample of the popu- dence or a lack of consensus across the evidence.
lation? Indeed, in nursing the evidence for effectiveness in
Are there any methodological weaknesses in clinical practice and improving patient outcomes
how data was collected? is still limited (Randell et al. 2007).
13
A lack of research undertaken A lack of clarity on how to proceed

A systematic review by Griffiths et al. (2009) con- It is not unusual that the interpretation of research
cluded that the body of evidence informing learning evidence leads to conflicting or contradictory
disability nursing remains small and underdevel- ideas about how evidence may be used. You will
oped, and consists mainly of small-scale evaluations be aware of reports in the media on a weekly
which can offer some guidance for service develop- basis regarding research that seems to indicate
ment. Importantly this review highlighted that more conflicting findings. This can cause confusion for
research is needed and learning disability health people who receive health care as well as for pro-
care requires more focus, funding and resources to fessionals attempting to provide it. Even rigorous
develop the evidence base for practice and care. research does not always provide a clear answer
In addition the review helped identify areas on what to do in practice.
where particular research is required as a prior- To give an example of this, a systematic review
ity. For example, the need to identify strategies for and meta-analysis is now explored (see below).
improving the experience of general health care The reality of clinical practice is that people
for people with behavioural problems, as this was experience health problems in a range of diverse
identified as being particularly problematic. As ways and respond to treatment in similar ways.
a nurse it is important to be aware that in some The nature of nursing itself is complex and subtle.
areas the evidence informing practice is limited ‘Gold standard’ research seldom offers absolute
or simply just not available (French 2002), and to certainty and is rapidly superseded by new research
recognize this as an opportunity to identify areas that is constantly being produced (Rycroft-Malone
for future research that will support the growth of et al. 2004). Despite the difficulties encountered in
evidence-based practice. finding and using evidence, it is important not to
Example of a systemic review identifying a lack of evidence to inform nursing

practice
Clark, C.E., Smith, L.F.P., Taylor, R.S. and Campbell, J.L. (2010) Nurse led interventions to improve control
of blood pressure in people with hypertension: systematic review and meta-analysis, British Medical
Journal, 341: c3995.
Background
A major cause of cardiovascular morbidity is essential hypertension, a public health problem which is
increasing with the ageing population. A Cochrane review (by Fahey et al. 2005) indicated that an orga-
nized system of regular review along with anti-hypertensive drug therapy significantly reduced blood
pressure in those with hypertension above target level.
Clarke et al. considered that perhaps the primary care setting could offer a nurse-led intervention
which would effectively deliver best monitoring and treatment of people with hypertension. Evidence
from previous studies indicated that nurse-led care was associated with greater observance of protocols
and guidelines as well as increased patient satisfaction – possibly all at a lower cost. However, the evi-
dence was conflicting. Clarke et al. undertook a systematic review of RCTs of interventions by nurses,
nurse prescribers and nurse practitioners which aimed to improve blood pressure. However, they had to
conclude that there was little evidence that could be applied to a UK setting that indicated any benefit of
nurse involvement in hypertension within the NHS.
This example highlights the complexity of applying evidence to practice. The study provided no clear
answer; instead it highlighted the need for more research and that in itself is an important research outcome.
14
surrender to the problem but rather remain hope- The dynamic nature of knowledge which is con-
ful and tackle ‘sub-problems’ and look for answers stantly being added to and revised will require you
which can enhance care. This is part of the com- to maintain an interest in the latest evidence once
plexity of nursing and demonstrates the need for you graduate and qualify in your chosen field. It
the nurse graduate to continue to apply the skills is a professional requirement that you continue
of problem-solving, critical thinking and analysis. to build on your knowledge and, importantly,
Where there is insufficient, conflicting or incon- remain curious about practice issues which pres-
clusive evidence it is important to look for the most ent challenges (Yoder-Wise 2008). This curiosity
robust quality of evidence available. Hierarchies of will enable you to remain open to new evidence,
evidence tend to put systematic reviews and RCTs which will in turn enrich your personal practice
at the top. However, central to your role as a nurse and patient care and set the foundation for your
is the need to use your own knowledge, judgement continuing professional development (CPD).
and interrogation of a range of evidence available The NMC field standard competence for adult
to inform the best outcome for patient care. Rather Mental Health, Learning Disabilities and Children’s
than have a debate about which evidence is best nurses (2010) highlights this:
for nursing, remember that all evidence informs
Domain 1 Professional value
practice and interventions are not the be-all and
end-all. McKenna et al. (1999) propose that a lack 7 All nurses must be responsible and account-
of research does not prevent evidence-based deci- able for keeping their knowledge and skills
sions from being made. up to date through continuing professional
development. They must aim to improve
their performance and enhance the safety
The informed and knowledgeable
practitioner and quality of care through evaluation,
We cannot emphasize enough the importance supervision and appraisal.
of being an informed and knowledgeable practi- 8 All nurses must practise independently,
tioner who can use their clinical expertise and that recognising the limits of their competence
of other health care professionals to make careful, and knowledge. They must reflect on these
judicious use of current best evidence when caring limits and seek advice from, or refer to, other
for individual patients. Your clinical expertise will professionals where necessary.
provide you with knowledge of the context of care,
local resources, the patient, their family and car- Reflection in and on your practice
ers. In addition it is now not unusual that users of It is important to ensure as a practitioner that the
health care services are involved in the decision- knowledge base you are using is credible and
making process regarding their care (see Chapters informed. This can be achieved through reflection
7 and 8). Rolfe (2006) provides wise advice in sug- and made transparent to others for critical analy-
gesting that there are different approaches to using sis. Benner (1984) made an important contribution
evidence in practice. Pivotal to this is the consid- to the understanding of nursing practice by uncov-
eration of what evidence-based practice really ering and articulating the knowledge embedded
means to your own practice as a professional. in practice experience. Her research identified five
Evidence-based practice is a continuous pro- levels of competency in clinical nursing practice:
cess and as a student you will learn much about the
importance of evidence for your practice. As nurs- Level 1 novice practitioner
ing research increases and new technologies and Level 2 advanced beginner
approaches to care are developed, it becomes Level 3 competent practitioner
clear that competence in evidence-based practice Level 4 proficient practitioner
will require a commitment to lifelong learning. Level 5 expert practitioner
15
on best evidence rather than habitual practice.

Activity 1.5 Reflection is identified in Chapter 7 as integral to
clinical decision-making and can support you in
Using Benner’s five levels of practice, try
changing your practice.
to identify individuals you have worked with and
begin to make an assessment as to where they
stand on the scale. Why did you think that? What Conclusion
skills and attributes of a professional nurse did Evidence informing clinical practice can be drawn
they demonstrate for you to make that assess- from many disciplines such as epidemiology, soci-
ment? It will be helpful for you to discuss this with ology, psychology and biology. Accessing best
your peers. evidence, critiquing it, and translating it for use
in your particular area of practice presents chal-
lenges within daily nursing. The main consider-
Importantly, Benner argues that experience ation in promoting evidence-based practice is
refers to ‘the refinement of preconceived notions ensuring that robust and relevant knowledge is
and theory through encounters with many actual generated, synthesized, disseminated and used in
practical experiences that add nuances or shades practice.
of difference to theory’. This highlights how formal The reality of evidence-based practice is com-
theory is used to inform practice in the real world. plex and requires skills that are developed, adapted
An experienced nurse has a wealth of knowledge and applied over a period of time. As a graduate
on which to draw for interpreting new situations nurse we would encourage you to engage with
but that knowledge remains difficult to articulate. the concept and application of evidence-based
Throughout this book there are many refer- practice from the early stages of your career and
ences to the place and value of refection for prac- education, and develop the necessary skills so that
tice and to various models of reflection. According it becomes a fundamental part of your everyday
to Mantzoukas (2007) reflection makes it possible working life. This is an important aspect of your
for us to consider what information is inform- role in delivering high quality patient-focused
ing our decision-making and in that way we can care and a professional requirement as a lifelong
review the extent to which our practice is based learner.
Further reading and resources

Barker, J. (2010) Evidence-based Practice for Nurses. London: Sage.
Newell, R. and Burnard, P. (2011) Research for Evidence-based Practice in Healthcare. Chichester: Wiley/Blackwell.
RCN (Royal College of Nursing) (2007) Understanding Benchmarking: RCN Guidance for Nursing Staff Caring for Chil-
dren and Young People. London: RCN.
RCN (Royal College of Nursing) (2011) Finding, Using and Managing Information: Nursing, Midwifery Health and Social
Care Information Literacy Competences. London: RCN. This publication complements the RCN’s clinical compe-
tence framework, helping nurses and nursing students develop their skills in using information and knowledge
and applying this to their practice. The competences are intended to support the individual’s and the nursing
team’s thinking about the information required to inform activities of varying complexity.
Joanna Briggs Institute: www.joannabriggs.edu.au. Supports evidence-based health care by providing a range of
resources.
References
Allcock, N. and Day, R. (2012) Managing pain, in I. Bullock, J. Macleod Clark and J. Rycroft-Malone (eds) Adult Nursing
Practice: Using Evidence in Care. Oxford: Oxford University Press.
16
Benner, P. (1984) From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison-
Wesley.
Bullock, I., Macleod Clark, J. and Rycroft-Malone, J. (eds) (2012) Adult Nursing Practice: Using Evidence in Care. Oxford:
Oxford University Press.
Clark, C.E., Smith, L.F.P., Taylor, R.S. and Campbell, J.L. (2010) Nurse led interventions to improve control of blood
pressure in people with hypertension: systematic review and meta-analysis, British Medical Journal, 341: c3995.
DH (Department of Health) (2010) Essence of Care: Benchmarks for Fundamental Aspects of Care – Personal Hygiene.
London: DH.
Fahey, T., Schroeder, K., Ebrahim, S. and Glynn, L. (2005) Interventions used to improve control of blood pressure in
patients with hypertension, Cochrane Reviews, CD005182.
French, P. (2002) What is the evidence on evidence-based nursing? An epistemological concern, Journal of Advanced
Nursing, 47(3): 250–7.
Griffiths, P., Bennett, J. and Smith, E. (2009) The size, extent and nature of the learning disability nursing research
base: a systematic scoping review, International Journal of Nursing Studies, 46(4): 490–507.
Healthcare Commission (2007) Caring for Dignity: A National Report on Dignity in Care for Older People While in Hos-
pital. London: Commission for Healthcare Audit and Inspection, available at www.healthcarecommission.org.
uk/_db/_documents/Caring_for_dignity.pdf.
Kitson, A. (2002) Recognising relationships: reflections on evidence based practice, Nursing Inquiry, 9(3) 179–86.
Mantzoukas, S. (2007) A review of evidence-based practice, nursing research and reflection: levelling by hierarchy,
Journal of Clinical Nursing, 17: 214–23.
McKenna, H., Cutcliffe, J. and McKenna, P. (1999) Evidence based practice: demolishing some myths, Nursing Stan-
dard, 14(16): 39–42.
Newell, R. and Gournay, K. (eds) (2000) Mental Health Nursing: An Evidence-based Approach. Edinburgh: Churchill
Livingstone Elsevier.
NMC (Nursing and Midwifery Council) (2010) Standards for Pre-registration Nursing Education. London: NMC.
Randell, R., Mitchell, N., Dowding, D., Cullum, N. and Thompson, C. (2007) Effects of computerised decision-support
systems on nursing performance and patient outcomes: a systematic review, Journal of Health Services Research
and Policy, 12: 242–9.
RCN (Royal College of Nursing) (2011) Finding, Using and Managing Information: Nursing, Midwifery, Health and Social
Care Information Literacy Competences. London: RCN.
Rolfe, G. (2006) Evidence-based practice, in M. Jasper (ed.) Professional Development, Reflection and Decision-Making.
Oxford: Blackwell.
Rolfe, G. and Gardner, L. (2005) Towards a nursing science of the unique: evidence, reflexivity and the study of per-
sons, Journal of Research in Nursing, 10: 297–310.
Rycroft-Malone, J., Seers, K., Titchen, A., Harvey, G., Kitson, A. and McCormack, B. (2004) What counts as evidence
in evidence-based practice? Journal of Advanced Nursing, 47(1): 81–9.
Sackett, D.L., Rosenberg, W.M.C., Muir Gray, J.A., Haynes, R.B. and Richardson, W.S. (1996) Evidence based
medicine: what it is and what it isn’t, British Medical Journal, 312: 71–2.
Sackett, D.L., Straus, S.E., Richardson, W.S., Rosenberg, W. and Haynes, R.B. (2000) Evidence based medicine: how
to practise and teach EBM, 2nd edn. London: Churchill Livingstone.
Schön, D. (1983) The Reflective Practitioner. London: Temple Smith.
Yoder-Wise, P.S. (2008) Lifelong learning in nursing: a drill down of the Macy Foundation Report, Journal of Continuing
Education in Nursing, 38(3): 99.
17
Section
Professional values 1
Professional values for
nursing
2
Owen Barr and Chris McLean
Chapter contents
Introduction Absence of value-based care
Domain 1: Professional values – generic standard Competing values
for competence Ethical considerations in nursing practice
The NMC and professional standards Professional values in different fields of practice
Thinking about values Conclusion
Your professional conduct as a student nurse Acknowledgements
Variations in the interpretation of values Appendix
Values-based practice Field specific competence statements
Professional values Further reading and resources
Professional values underpinning nursing practice References
Introduction been heightened with reports of poor nursing care

In applying for your nursing programme it is likely in the areas of maintaining privacy, dignity and
you read about and prepared answers to possible communication with people as individuals (Parlia-
interview questions concerning why you wanted mentary and Health Service Ombudsman 2009;
to become a nurse and what you thought the qual- Patients’ Association 2009; Independent Commis-
ities of a ‘good’ nurse were. In preparing for your sion on Dignity in Care 2012).
interview you will have realized that nursing is Your programme of nurse education is designed
not only about having the appropriate up-to-date to ensure that you achieve the competencies
knowledge and skills, but is also about the values required by the Nursing and Midwifery Council
you are expected to hold as a student nurse and as (NMC) that are necessary for you to register as a
a registered nurse (RN). Indeed there is increasing nurse, but the introduction to this book has already
consideration being given to how to establish or observed that competence is a complex concept.
at least get an indication of the values of potential In all activities, be they in work or recreational
student nurses during the recruitment and selec- contexts, to be competent at something requires
tion of students for nurse education programmes. possession of certain knowledge, skills and tech-
The need to pay attention to the values (and pre- nical abilities. Your programme of nurse educa-
vious conduct) of people applying to nursing is tion will enable you to develop these important
due to the centrality of person-centred care and areas, and they are the subject of later chapters
professional conduct that will justify public trust in in this book. It is clear though that knowledge and
the profession (NMC 2011). The perceived need for technical ability alone are not enough to make a
specific attention to the values of applicants has good nurse, and that all aspects of nursing are
21
Section 1 Professional values
dependent upon possessing appropriate profes- and acknowledges diversity. Where neces-
sional values and attitudes. Nursing education pro- sary, they must challenge inequality, discrimi-
grammes must also address these areas and they nation and exclusion from access to care.
are the focus of this chapter. 3 All nurses must support and promote the
This chapter specifically addresses the follow- health, wellbeing, rights and dignity of people,
ing NMC standards. groups, communities and populations. These
Domain 1: Professional values – generic include people whose lives are affected by ill
standard for competence health, disability, ageing, death and dying.
Nurses must understand how these activities
All nurses must act first and foremost to care
influence public health.
for and safeguard the public. They must practise
autonomously and be responsible and account- 4 All nurses must work in partnership with ser-
able for safe, compassionate, person-centred, vice users, carers, families, groups, commu-
evidence-based nursing that respects and main- nities and organisations. They must manage
tains dignity and human rights. They must show risk, and promote health and wellbeing while
professionalism and integrity and work within aiming to empower choices that promote
recognised professional, ethical and legal self-care and safety.
frameworks. They must work in partnership 8 All nurses must practise independently,
with other health and social care profession- recognising the limits of their competence
als and agencies, service users, their carers and and knowledge. They must reflect on these
families in all settings, including the community, limits and seek advice from, or refer to, other
ensuring that decisions about care are shared. professionals where necessary.
1 All nurses must practise with confidence
according to The code: Standards of conduct, The NMC and professional
performance and ethics for nurses and mid- standards
wives (NMC 2008),* and within other recog- Within the UK the NMC is responsible for the regu-
nised ethical and legal frameworks. They lation of nurses and midwives in so far as ‘to safe-
must be able to recognise and address ethical guard the health and wellbeing of the public, as
challenges relating to people’s choices and required by the Nursing and Midwifery Order 2001’
decision-making about their care, and act (NMC 2010a: 4). To ensure this is achieved the NMC
within the law to help them and their families maintains a register of nurses and midwives (which
and carers find acceptable solutions. all practising nurses and midwives must be on), and
2 All nurses must practise in a holistic, non- sets standards of education, training and conduct.
judgmental, caring and sensitive manner that The NMC also publish mandatory guidance and
avoids assumptions, supports social inclusion; advice as well as reviewing the professional prac-
recognises and respects individual choice; tice to ensure that nurses and midwives keep their
skills and knowledge up to date, and uphold the
standards of their professional code (NMC 2008).
* Relates to the Standards in place at the time of the
The NMC stipulates that nursing practice and
publication of the NMC (2010a) Standards for Pre-
nurse education are underpinned by values. The
registration Nursing Education. It is important to be
public need to be assured that RNs and midwives,
aware that the standards for education will also relate
to the most recent NMC standards for conduct and along with students of these courses, will ‘act with
therefore student nurses must remain up to date with professionalism and integrity’, and practise in ways
any revision of standards by regularly reading the that are ‘compassionate’ and ‘respectful, and which
nursing press and also visiting to the NMC website at maintain dignity (NMC 2010a: 5). In order to ensure
www.nmc-uk.org. that these values are achieved the NMC publishes
22
Chapter 2 Professional values for nursing
and regularly updates standards for professional your values. By engaging with the ideas and activi-
conduct which RNs and midwives are required to ties presented in this chapter you will begin to
meet (NMC 2008). The NMC also publishes guid- appreciate why this is necessary. This will mean
ance on the expected professional conduct of stu- examining the nature of values, what characterizes
dents of nursing and midwifery (NMC 2011). It is professional values, and the importance of specific
important that RNs and student nurses keep up to values which characterize nursing as a profession.
date with the latest versions of these documents. Before beginning to consider the nature of pro-
fessional values, it is important to consider what
a value actually is. We have noted that it is natural
Thinking about values when we first think about values to consider that
Values underpin nursing practice and your pro- our values (perhaps like our beliefs) are personal. In
gramme of nurse education. We have begun to order to illustrate the nature of values themselves
examine how these values underpin the standards it is therefore appropriate to begin by considering
of behaviour that are expected of you are as a your own personal values in Activity 2.1 below.
practitioner and as a student. In order to examine This activity makes it clear that our values repre-
the nature of these professional values it is impor- sent general and broad goals about what we con-
tant to explore the nature of values themselves. sider a good life to be. Our values relate to what we
In order to gain registration with the NMC on consider to be a good life, but this does not mean
completing your programme, you are required to that they are self-centred or egocentric. Very often
make a statement that you are of ‘good character’ our own idea of what constitutes a good life is inti-
(NMC 2010b). This requirement appears to suggest mately linked with our relationships with others.
that in order to be a nurse you need to be a particular By identifying our values in this way, it becomes
kind of person (apparently a good one!). It can there- clear that we would expect these values to hold
fore be challenging to realize that nurse education in other situations. We would anticipate that the
explicitly sets out to develop your personal values. ‘fictional’ person who wrote the list in Table 2.1
After all, ‘our values express who and what we are’ would also value ‘security’, ‘family and relation-
(Mohr et al. 2001). They are personal values and ships’, ‘human dignity’ and so on in other ways.
are normally considered to be just that – personal. Values can therefore be seen as ‘desirable trans-
You may believe that it is important to simply situational goals’ (Schwartz 1994), or as ongo-
respect, rather than seek to change, the values of ing beliefs or attitudes that certain behaviours or
others, and may be inclined to question whether it states are desirable and preferred (Rokeach 1973
is legitimate for nurse educators to try to change cited in Rassin 2008).
Activity 2.1
Imagine for a moment that you have just been given a million pounds, legitimately yours to spend
as you wish. Now think about each of the three elements of this activity below.
Spend a few minutes writing a list of the things that you would do with the money, entitled ‘A good life
for me’. Don’t worry too much about exactly how much these things would cost (you can have another
million if you need it!) – but create a list of at least five or six items.
Revisit each of the items you have listed and create another column stating why you would want these things.
Finally, create a third column and ask yourself how these reasons begin to make clear what it is that you value.
Once you have completed this activity you will end up with a similarly formatted list to that shown in Table 2.1.
23
Table 2.1 A good life for me
Item Because a good life for me involves Therefore I value

Pay off my mortgage Being free from debt and having no Security
concerns about where I will live
Take my parents on the Spending time with family and thanking Family and relationships
holiday of a lifetime them for what they have given me in the past
A long weekend with my Being able to take time out for myself for Myself and my own
partner in a luxury spa hotel rest and relaxation well-being
Donation to Amnesty Living in a world in which other people Human dignity
International are not subject to torture and inhuman or
degrading treatment
Take a university course in Thinking deeply and critically about new Intellectual challenge
philosophy subjects and accomplishment
A new car Not being embarrassed in front of my Social status
friends by the car I drive
We started this section by observing that our

values are related to character and therefore to Case study 2.1:
the kind of person we are. The above exercise Tomasz Krawiec
therefore also makes it clear that our values are Mr Krawiec is an 83-year-old man who has lived
revealed by what we actually do. If someone were to alone since he was widowed three years ago after
win a million pounds and then spent the whole 53 years of marriage. He spent his early career in
sum on a very expensive car for themselves, we the Air Force, and is immensely proud that for the
would generally take this to reveal that person’s first time in his life he is independently taking care
true values regardless of whether they claimed to of his own domestic needs such as cooking and
value ‘relationships’ or ‘human dignity’ above all laundry. His primary means of socializing is to meet
else. The caveat ‘above all else’ is important here friends in the betting shop a few hundred metres
because we all have a range of different values, down the road, and he bets small amounts on races
and we can attach varying importance to them on most days. He has a history of heart failure for
(Schwartz 1994). An individual may acknowl- which he is prescribed diuretic tablets, and has also
edge that they do value social status, but they may recently been diagnosed as having early dementia.
nonetheless hope and assert that this is not more A community nurse has visited Mr Krawiec
important to them than other things that they and expressed some concern that he is not look-
value, such as relationships. This demonstrates ing after himself. She reports that he is not taking
that on occasion the tensions between our per- his medication in the mornings because it makes
sonal values can cause conflict. him want to go to the toilet while he is at the bet-
While understanding that people may have ting shop. She also feels that he is evasive or vague
different values is important in nursing, it is also when asked how he is managing his medication,
important to recognize that other people may pri- and that his flat is cluttered and appears chaotic,
oritize their values differently. Consider the case with laundry hanging over every item of furniture.
study opposite and then attempt Activity 2.2.
24
by the institution providing your course, and will

Activity 2.2 be used as criteria to review any allegations of
student misconduct. In many ways the expec-
From the above information it is reason-
tations in relation to the values held and acted
able to surmise that there are many things that
out by student nurses and midwives at all times
Mr Krawiec values. Some of these are listed below,
distinguish them from many other university
and you may wish to add more that you think are
students who do not have to meet the same
relevant to him.
expectations.
Safety
Independence
Dignity
Security
Activity 2.3
Physical well-being
Friendships The latest versions of NMC publications
Personal cleanliness are on their website (www.nmc-uk.org). Go to the
‘publications’ page and download the latest ver-
Now attempt the following. sion of Guidance on Professional Conduct for Nurs-
ing and Midwifery Students. Read through it and
Once you have added any others to this list, try
note your initial thoughts on the expectations and
to put the items in the order of priority that you
requirements that the NMC has placed on student
think will be most important to Mr Krawiec.
nurses and midwives.
Then examine some of the stories and experi-
Discuss your initial impressions with some of
ences of other people from one or more of the
your peers, in particular:
following major reports, all readily available
online. Whether there are there any points of guid-
Care and Compassion? Report of the Health ance you feel are central to nursing and must
Service Ombudsman on Ten Investigations be present?
Into NHS Care of Older People (Parlimentary Whether there are any points of guidance you
and Health Service Ombudsman 2009). feel are not central and should not be required
Patients Not Numbers, People Not Statistics of student nurses and midwives?
(Patients’ Association 2009). Any areas of guidance that relate to your
The Point of Care: Enabling Compassionate behaviour as a student on a nursing course and
Care in Acute Hospital Settings (King’s Fund not specifically to the provision of nursing care:
2009). what do you think about the need to follow this
Having reflected on some of these experi- guidance at all times?
ences, revisit the priorities you attached to Any challenges you think you may experience
the values Mr Krawiec may hold. Have your in following the guidance and how you can
views changed, and why? What have you effectively respond to such challenges.
learned that will inform your nursing prac-
tice? It is very important to remember that NMC
publications are reviewed on an ongoing basis
and it is therefore essential that you ensure
you are always following the latest published
Your professional conduct as guidance. The guidance discussed in this
a student nurse book was correct and up to date at the time
The NMC guidance on students’ professional of writing.
conduct will be reflected in the guidance offered
25
integrity: acting in accordance with accepted

Key learning
Being knowledgeable and skilled as a
! standards of practice; truth-telling;
social justice: upholding moral, legal and
humanistic principles; assuring equal treat-
nurse is not enough; appropriate professional ment and equal access.
values and attitudes are essential.
NMC guidance on conduct for student nurses
Values-based practice
and midwives will be reflected in your univer-
The above activities should have helped you to
sity programme.
explore why an understanding of values is of such
central importance in nursing practice (or any other
health care practice). Values-based practice (Fulford
2004; Fulford et al. 2012; McLean et al. 2012) is
Variations in the interpretation an approach which recognizes that working with
of values people who are receiving health care is dependent
In a global community the values of nursing in upon recognizing and working with their values.
other countries such as the USA are worth exam- Health cannot be narrowly defined, and a holistic
ining and comparing with our own in the UK. For understanding of health requires us to recognize
example, the American Association of Colleges of that because people have different values they will
Nursing (AACN 2008) identifies the values which have different ideas of what constitutes ‘health’ or
student nurses in the USA are expected to aspire a ‘good life’. Nurses enable other people to achieve
to as: their health-related goals, and this means not only
recognizing the values of others, but also that
altruism: concern for the welfare and well- nurses may be involved in helping others to clarify
being of others; their own values and to work out what ‘health’ or
autonomy: right to self-determination; ‘a good life’ may be for them.
human dignity: respect for the inherent worth In order to explore these points, consider the
and uniqueness of individuals and popula- details given about Chloe Arnold in Case study
tions; 2.2, and then complete Activity 2.4.
Case study 2.2: Chloe Arnold

Chloe is 15 years old and attends a local comprehensive school where she is doing well and is
predicted to achieve 11 good GCSEs at grades B or above. She hopes to achieve her dream of becoming
an architect. Chloe’s mother Aileen has been alcohol dependent for a number of years and this was a fac-
tor in her divorce six years previously. Chloe therefore lives with her father Andrew, and sees her mother
(whose lifestyle is still somewhat chaotic) only occasionally.
Chloe has always been physically healthy and active as a member of the school athletics team, but in
the last 18 months her father has noticed that she is running more frequently, eating very little and losing
weight. A year ago Chloe was diagnosed as having anorexia nervosa.
Despite support from health services, Chloe has continued to lose weight over recent months, and was
yesterday admitted to hospital as her body mass index (BMI) had dropped to a critical level of 13. Sam is a
student nurse who meets Chloe on the first day of her hospital admission while she is waiting for a review
by the consultant and full medical team.
26
Sam approaches Chloe and notices that she is sat in bed using a tablet PC to read material on a ‘pro-
ana’ website. Although she turns the screen away, Sam notes the name of the site and decides to investi-
gate it before returning to talk to Chloe again. Sam goes online to look at the website and is particularly
struck by the following statements:
Anorexia is a lifestyle not a disease.

Giving in to food shows weakness.
Being thin is more important than being healthy.
Sam also notes that the site recommends that girls who are ‘pro ed’ (eating disorder) may recognize
each other by wearing a red beaded bracelet around their left wrist, and recalls that Chloe is wearing
such a bracelet.
(Some content in this case study is taken from: http://proanalifestyle.blogspot.co.uk, accessed
20 August 2012)
The above activity may have helped you to begin

Activity 2.4 to understand how meeting the health needs of
other people can challenge our own values, but it is
Consider what you now know about
also clear that Chloe appears to be establishing who
Chloe and take some time to answer the following
she is in part by adopting the values of the online
questions.
‘pro-ana’ community. Discourse analysts study-
What values do you think she may be expressing websites such as these have observed that they
ing in her behaviours? Consider whether you represent communities in which apparent health
know these are her values or whether they are or appearance concerns are reframed as markers
your presumptions? of success. Participants actively (re)produce their
Does Chloe appear to have values which con- identities as people with eating disorders (Riley et al.
flict with one another? 2009). The quotes from the site mentioned at the
In what ways may Chloe’s values conflict with end of the case study give a clear indication of the
your own? values of this group: that being thin is more valued
How would you say that Chloe was expressing than being healthy; that resisting food is a sign of
her identity by associating with particular sets strength (and therefore good). In as much as Chloe
of values? adopts these values, she is asserting herself as being
a member of this group, and this is further reinforced
The information about Chloe generates many
by the fact that she chooses to wear a ‘badge’ of this
questions. For example:
identity in the form of the red bracelet.
What sort of hospital environment do you think It can also be seen that Chloe, like anyone else,
Chloe may be in? has a range of conflicting values. An important part
What environment may be appropriate? of the nurse’s role will be in helping Chloe come to
What field of nursing did you suppose Sam understand that the values of the ‘pro-ana’ group
is studying? Children’s nursing, mental health are not consistent with what she otherwise values
nursing, adult nursing or learning disabilities? in relation to being ‘healthy’ and living a ‘good life’.
What support from health services may have It is clear that there are several reasons why an
been available to Chloe prior to her hospital understanding of personal values is important in
admission? nursing. Firstly, it is important for nurses to have
the skills necessary to recognize that other people’s
27
values can be different from their own. This means Professional values underpinning
that people will have different ideas of what ‘health’ nursing practice
means to them. Secondly, nurses need to recognize Writers such as Sellman (2011) follow the philoso-
that people may hold values which conflict with pher Alasdair MacIntyre (1985) in holding that nurs-
one another. Nurses therefore do not simply help ing is a ‘practice’ and a form of cooperative activity
other people to achieve particular values (such as which is uniquely defined by having its own stand-
being thin), but set out to work with others in ways ards of excellence, and which seeks to achieve
which take account of all of their different values so particular goals. It was noted above that nursing
that the individual can ‘flourish’ (Sellman 2011) or has the goal of ensuring that other people ‘flourish’
‘thrive’ (Aslan and Smith 2012) and live a good life. or ‘thrive’, and professional values in nursing are
therefore those which help to ensure that the people
for whom we care ‘flourish’. Nursing practice offers
Key learning
Your values will be visible to others by
! the opportunity to make a difference to people we
come into contact with. Central to nursing is the
recognition of the privileged nurse–patient relation-
what you do and say. ship, working in partnership, collaboratively with
Meeting the health needs of others requires individuals and in teams, and the acceptance of
nurses to recognize and respect other personal accountability for decisions and actions.
people’s values. Defining precisely what professional values actu-
ally entail is not straightforward. It is by no means
clear to what degree being ‘compassionate’ or ‘per-
Professional values son-centred’, or ‘respecting human dignity’ actu-
It was made clear in the discussion about Chloe ally reflects different values or expected behaviours.
that adopting particular values can be associated Within the nursing literature the meaning of terms
with membership of groups within society. We all such as ‘care’ and ‘person-centred’ is widely debated,
know that our personal values are influenced by and ‘human rights’ themselves involve complex
our family, our culture, our education, our religious ethical and legal questions. The NMC (2010a) makes
upbringing and other social groupings to which we it clear that professional values are central to the
belong, including the professions we work within competencies required for registration, and central
and the behaviours they expect of us. Acceptance of to The Code: Standards of Conduct, Performance and
a set of values is part of being a member of a group. Ethics for Nurses and Midwives (NMC 2008) as well as
Whether this group is a university swimming club, a to Guidance on Professional Conduct for Nursing and
set of friends forming a study group or a faith-based Midwifery Students (NMC 2011). Nonetheless, these
organization, it will have goals which reflect some documents do not provide a clear ‘list’ of what those
of its values such as physical well-being, academic professional values are. More recently the policy
achievement or celebrating spirituality. Becoming document Compassion in Practice (DH 2012c) has
a nurse involves joining a professional group, and attempted to capture the key values and behaviours
therefore means adopting the values of that group. required of nurses and caregivers into six Cs:
It is important to note that people receiving health
care may encounter differing values being embod- Care. Delivering and enabling people to receive
ied by different health professions or between dif- the best possible care.
fering fields of nursing practice (see ‘Professional Compassion. Care given with empathy,
values in different fields of practice’ on p. 31). Rec- thoughtfulness, kindness, respect and dignity.
ognizing that these different values may be priori- Competence. Care that is skilled, knowl-
tized and reflected in decisions about care can be edgeable, based on best evidence and able to
a central challenge for the interdisciplinary team. deliver excellence for all.
28
Communication. Recognizes the value of lis- enabled to speak out if they see poor care taking
tening to patients’ views and involving them in place. Hand in hand with this is a need to support
all decisions about their care. an environment where collaboration, partnership
Courage. Speaking up if something is wrong, working and excellent care are promoted.
being an advocate and always doing the right Other examples of a person’s dignity being vio-
thing. lated include being left alone and having the call
Commitment. To act in a way that ensures bell removed, or a patient being refused help to
excellent care and being passionate about this. have a shower at night because it does not fit with
ward routine or procedures. Sometimes being
Absence of value-based care too busy or short staffed can result in a situation
The importance of holding appropriate professional where patient values are ignored, however, every-
values becomes clear when we examine what hap- one has a human right to dignity and it is unethical
pens when this is not the case. Although The NHS practice to ignore those rights (Heijkenskjold et al.
Constitution (DH 2009) expresses an ideal of deliv- 2010). Nurses can experience ethical conflict when
ering care with care and compassion, reports such ensuring the rights of individuals are maintained
as those by the Parliamentary and Health Service if the organizational culture is such that it over-
Ombudsman (2009, 2011), and the King’s Fund looks patients’ rights. This can be disheartening
(2009) make clear that these ideals are not always for individual student nurses, and in such cases it
realized. If you have examined these reports, or is important to seek support from mentors, man-
if you use the suggested resources at the end of agers, personal tutors and the university link staff,
this chapter, it will become clear that many people and take the courage to speak out or take action.
experience care that does not respect their dignity Complaints received by the Healthcare Com-
or meet their needs so as to help them ‘flourish’. mission (2007) cited examples of patients being
The National Service Framework for Older People left in soiled clothing or bedding. In particular the
(DH 2001) identified areas where respect and dignity values manifest in the nursing care of older peo-
were not maintained, resulting in what was per- ple and people in vulnerable circumstances are
ceived as ageism and negative patient experiences. perceived by some to be poor (DH 2012b). Poor
Examples of a lack of respect for patients included: practice is unacceptable and although it may only
be a minority of nurses who behave in such ways,
being made to feel a nuisance; the result is that the values of the profession come
being ignored; under severe scrutiny by the public and the media,
generally being rushed and not being listened to; who expect the highest professional values to be
having to eat with fingers rather than helped to demonstrated by nurses.
eat with a knife and fork. Stretched health care resources, or organizational
cultures which clash with nursing’s professional
In the recent case of Winterbourne View Hospi- values can challenge nurses who seek to deliver
tal, the abuses revealed there were acknowledged value-based care. This not only impacts on people’s
as serious failures in the systems of ensuring qual- experience of care, but nurses themselves experi-
ity care. An in-depth review set up in the after- ence burnout, frustration and disillusionment if they
math of the scandal focused on the lessons to be feel themselves to be delivering care that is not con-
learned and the actions needed to prevent such sistent with their professional values (King’s Fund
failures in future. The findings were published in 2009). Nonetheless, however difficult delivering val-
Transforming Care: A National Response to Winter- ues-based care may be, the NMC (2010a) makes it
bourne View Hospital (DH 2012a). Specifically high- clear that a nurse must be ‘willing to accept personal
lighted was the need to promote a culture where and professional accountability for his/her actions’.
poor practice can be challenged and individuals With this in mind one of the greatest challenges you
29
will face as a student nurse is to always act like the communication between staff and patients
nurse that you want to become. takes place in a way that always respects their
individuality and rights.
Competing values
As with personal values, you may well have iden- Ethical considerations in
tified a range of professional values which conflict nursing practice
with one another. For example, it is easy to imagine The NMC Code (2008) obliges nurses to demon-
circumstances in which ‘recognizing and respecting strate sound ethical decision-making skills and,
individual choice’ may conflict with the value placed importantly, this is underpinned by law. As a stu-
upon using evidence-based practice. Or, what hap- dent you will constantly be developing your under-
pens if an individual chooses a treatment option standing of legal and ethical issues which influence
which the evidence suggests is unlikely to have the maintenance of professional standards. Ethics
positive outcomes? Similarly, there are challenges is concerned with reflecting on values and making
involved in managing risk while aiming to empower decisions. In health care ethics is concerned with
choices that promote self-care and safety. Consider ‘doing the right thing and with being a certain
how to balance the risk of someone falling in the kind of person’ (Gallagher and Hodge 2012). Daily
bathroom with the fact that they need to learn to you will be faced with ethical dilemmas and it is
safely care for themselves. While the competences important to appreciate that there is not always
provide guidance on the standards expected, central an easy or ‘right’ answer. The four moral princi-
to the role of a nurse is their individual clinical deci- ples underpinning health care ethics developed by
sion-making as they seek to make decisions to bal- Beauchamp and Childress (2001) are:
ance competing priorities in the pursuit of the ‘pro-
vision of care to enable people to improve, maintain beneficence: practising in a way that promotes
or recover health, to cope with health problems, and the good of the person;
to achieve the best possible quality of life, whatever non-malevolence: avoiding harming the per-
their disease or disability until death’ (RCN 2003: 5). son;
In arriving at a decision, student nurses and autonomy: respecting the person’s right to
RNs should be able to explain what factors they make his or her own decisions;
considered, how these were weighted against justice: treating the person fairly and equitably.
each other with consideration to possible out-
comes and why they ultimately made the decision These principles provide the tools to help you to
they did and acted accordingly (see Chapters 7 and make choices. However, because we all have dif-
8 for further discussion on decision-making). ferent value and belief systems as well as different
It can be important to draw on evidence derived past experiences, our decisions will not always be
from research or clinical guidelines and highlight aligned with our colleagues or our patients.
the benchmarks for care to present the reasons for You will become increasingly accountable for
your practice. The Essence of Care (DH 2003) bench- your actions during your programme as you work
marks for privacy and dignity best practice highlight towards graduation and explore how related con-
the need to ensure the following patient outcomes: cepts such as respect for individual rights, confi-
dentiality, duty of care and the preservation of dig-
patients always feel they matter; nity are central in providing quality nursing care.
patients and carers can access an area that However, while standards and codes offer guid-
safely offers privacy; ance, your decisions will always remain individual
patients experience care in an environment ones and will be influenced by the values and ethi-
that takes full account of individual values, cal stance prioritized by you in any particular con-
beliefs and personal relationships; text. Making effective decisions will require that
30
you draw on the knowledge developed during your

programme related to ethical principles and frame- Activity 2.5
works, legislation and policies in place within the
Study the generic competencies related to
care environment.
professional values presented on page above, and
answer the following three questions for each of them.
Professional values in different
fields of practice Which competencies do you think reveal values?
Within the UK there are four ‘fields of practice’ (pre- What are the goals that will be achieved if
viously referred to as ‘branches’) possible in pre- nurses possess these competencies?
registration nurse education: mental health, learn- What are the underpinning values of the pro-
ing disability, children’s nursing and adult nursing. fession that are being expressed?
To reflect the differing emphasis within these areas
of nursing, in addition to the generic competencies Now complete activity 2.6 which enables you
already noted, the NMC has also identified ‘field to focus on the specific NMC competencies for
specific’ competencies within the professional val- your field of nursing.
ues domain (see Appendix, p. 33). These field spe-
cific competences must be incorporated within, and
Activity 2.6
achieved by students undertaking, the related pro-
gramme. Across the fields of nursing practice there Review the field specific competences
are differing numbers of field specific competences, for your field of nursing in the Appendix (p. 33)
as a result of the consultation process involved in and make notes on what you believe these
the development of the Standards for Pre-registration competencies indicate about the values priori-
Nursing Education (NMC 2010a) and the responses tized within your field of nursing.
received related to each field of practice. Some Now review the field specific competences
fields advocated more detailed competency state- for the other three fields of nursing and again
ments to reflect their priorities while others sought make notes about what you believe these indi-
to have broader competency statements. There is cate about the values prioritized within those
also some repetition of field specific competencies fields of nursing. Then compare and contrast
across some but not all fields of nursing – for exam- the similarities and differences with your field
ple, the first field specific competency for adult, of nursing and the possible priorities within the
mental health and learning disability nursing is the other fields of nursing.
same, but is not identified in children’s nursing.
This book sets out to help you achieve the com-
petencies for professional nursing practice required
by the NMC. These competencies are within four
Case study 2.3: John Wetherall
domains, the first of which is that of professional John is 50 years old and people who
values. Within this domain the NMC expects stu- know him describe him as a friendly, energetic
dent nurses to develop competences by the time person with an interest in sports and his appear-
they have completed their pre-registration nursing ance. He lives in a residential care home and
education and are applying for entry to the NMC has severe learning disabilities. He has regular
Register. contact with his family and enjoys spending time
Now undertake Activities 2.5 and 2.6 which with them. He has limited verbal communica-
will help you to identify the values that under- tion but can make his needs and wishes known
pin the NMC overall standard of competence in through sounds and gestures. After a day of feel-
relation to professional values and the individual ing unwell John has been admitted to your ward
competency statements in that domain. and has been diagnosed as having had a stroke.
31
Make your own notes on how the field spe- made clear that people’s personal values (includ-
cific competences from your course will influ- ing our own) are complex and potentially con-
ence the decisions you make in the provision flicting. Nurses need to have highly developed
of care and support for John. skills in order to recognize and work with the
Discuss your priorities from above with col- values of the people they care for. This abil-
leagues from another field of nursing and ity is a key aspect of nursing decision-making
explore how similar values and priorities in (explored further in Chapters 7 and 8). These
relation to John’s care provide opportunities values may themselves be seen as the goals
for collaboration. which people themselves hold to be important
Discuss how potential areas of differing pri- in living a good life and ‘flourishing’. The values
ority may create challenges in collaborative of the nursing profession relate to our profes-
working and how these could be effectively sional goal of ensuring that the people we care
responded to in order to improve care and for ‘flourish’. Nurses value autonomy because
support for John. they recognize that flourishing requires people to
have control over their own lives and bodies;
Review the story of Martin Ryan (Parliamen-
nurses value a respect for dignity because living
tary and Health Service Ombudsman 2009:
a good life requires that we are recognized and
56–61). In this case it was concluded that ‘had
treated as unique and valued persons. Above all
the care and treatment Mr Ryan received not
else, the professional values of nursing require
fallen so far below the relevant standard, it is
that nurses prioritize the values of the people they
likely that his death could have been avoided’
work with. It is for this reason that the NMC Code
(p. 60). While health professionals normally
begins by stating that nurses must ‘make the
seek to provide effective care, harm and indeed
care of people [their] first concern’ (NMC 2008,
death can occur when there is failure to deliver
emphasis added).
values-based nursing care. It is important that all
This chapter has helped you to consider the
nurses learn from such examples of poor care if
nature of professional values and recognize the
these are to be avoided in the future. What evi-
values that you wish to embody. However, it
dence can you see that the values required by
is adopting these values and making sure they
your field of practice were applied in Mr Ryan’s
are reflected in your practice that is central to
care and what values appear not to have been
becoming a nurse. Nursing practice requires
applied?
nurses to have courage (Day 2007) and to be
of ‘good character’ (NMC 2010b). Becoming a
nurse requires you to have the personal integ-
rity to practise in accordance with your profes-
Key learning
As a nurse you may at times experience
! sional values at all times (Ekeberg 2011). The
NMC (2010a) notes that newly-qualified nurses
cannot be expected to have extensive experi-
tensions in prioritizing your values in practice. ence or specialist expertise, but makes clear
Poor standards of care reflect a failure to that all nurses can be expected to practise with
deliver values-based nursing care. integrity.
Acknowledgements
Conclusion Our thanks to Chris Gale from the University of
This chapter has examined the nature of per- Southampton for comments on and improve-
sonal and professional values in nursing. It has ments to the case study about Chloe.
32
Appendix and ensuring minimal restrictions on their

lives. They must have an in depth under-
Field specific competence standing of mental health legislation and
statements how it relates to care and treatment of peo-
Adult nursing ple with mental health problems.
Adult nurses must also be able at all times to 3.1 Mental health nurses must promote
promote the rights, choices and wishes of all mental health and wellbeing, while chal-
adults and, where appropriate, children and lenging the inequalities and discrimination
young people, paying particular attention to that may arise from or contribute to mental
equality, diversity and the needs of an ageing health problems.
population. They must be able to work in part- 4.1 Mental health nurses must work with
nership to address people’s needs in all health- people in a way that values, respects and
care settings. explores the meaning of their individual
1.1 Adult nurses must understand and apply lived experiences of mental health prob-
current legislation to all service users, pay- lems, to provide person-centred and recov-
ing special attention to the protection of ery-focused practice.
vulnerable people, including those with 8.1 Mental health nurses must have and value
complex needs arising from ageing, cogni- an awareness of their own mental health
tive impairment, long-term conditions and and wellbeing. They must also engage in
those approaching the end of life. reflection and supervision to explore the
emotional impact on self of working in men-
Mental health nursing tal health; how personal values, beliefs and
Mental health nurses must work with people emotions impact on practice, and how their
of all ages using values-based mental health own practice aligns with mental health legis-
frameworks. They must use different methods lation, policy and values-based frameworks.
of engaging people, and work in a way that pro-
motes positive relationships focused on social Learning disability nursing
inclusion, human rights and recovery, that is, Learning disabilities nurses must promote
a person’s ability to live a self-directed life, the individuality, independence, rights, choice
with or without symptoms, that they believe is and social inclusion of people with learning dis-
meaningful and satisfying. abilities and highlight their strengths and abili-
ties at all times while encouraging others do the
1.1 Mental health nurses must understand
same. They must facilitate the active participa-
and apply current legislation to all service
tion of families and carers.
users, paying special attention to the protec-
tion of vulnerable people, including those 1.1 Learning disabilities nurses must under-
with complex needs arising from ageing, stand and apply current legislation to all
cognitive impairment, long-term conditions service users, paying special attention to the
and those approaching the end of life. protection of vulnerable people, including
2.1 Mental health nurses must practise in those with complex needs arising from age-
a way that addresses the potential power ing, cognitive impairment, long-term condi-
imbalances between professionals and tions and those approaching the end of life.
people experiencing mental health prob- 2.1 Learning disabilities nurses must always
lems, including situations when compul- promote the autonomy, rights and choices
sory measures are used, by helping people of people with learning disabilities and sup-
exercise their rights, upholding safeguards port and involve their families and carers,
33
ensuring that each person’s rights are 1.1 Children’s nurses must understand the
upheld according to policy and the law. laws relating to child and parental consent,
3.1 Learning disabilities nurses must use including giving and refusing consent, with-
their knowledge and skills to exercise pro- drawal of treatment and legal capacity.
fessional advocacy, and recognise when 2.1 Children’s nurses must recognise that all
it is appropriate to refer to independent children and young people have the right to
advocacy services to safeguard dignity and be safe, enjoy life and reach their potential.
human rights. They must practise in a way that recognises,
respects and responds to the individuality of
4.1 Learning disabilities nurses must recog-
every child and young person.
nise that people with learning disabilities are
full and equal citizens, and must promote 3.1 Children’s nurses must act as advocates
their health and wellbeing by focusing on for the right of all children and young peo-
and developing their strengths and abilities. ple to lead full and independent lives.
4.1 Children’s nurses must work in partner-
Children’s nursing ship with children, young people and their
Children’s nurses must understand their role families to negotiate, plan and deliver child-
as an advocate for children, young people and and family-centred care, education and
their families, and work in partnership with them. support. They must recognise the parent’s
They must deliver child- and family-centred care; or carer’s primary role in achieving and
empower children and young people to express maintaining the child’s or young person’s
their views and preferences; and maintain and health and wellbeing, and offer advice and
recognise their rights and best interests. support on parenting in health and illness.

DHSSPS (Department of Health, Social Service and Public Safety) (2008) Improving the Patient & Client Experience,
available at: www.dhsspsni.gov.uk/improving_the_patient_and_client_experience.pdf.
This document explores how patient and client experience can be positively or adversely impacted upon
through the actions or omissions of health and social care professionals. It focuses on the areas of respect, atti-
tude, behaviour, communication, privacy and dignity. It provides practical examples of indicators for how appro-
priate standards for care can be provided in these areas.
Griffith, R. and Tengnah, C. (2010) Law and Professional Issues in Nursing, 2nd edn. Exeter: Learning Matters.
King’s Fund (2009) The Point of Care: Enabling Compassionate Care in Acute Hospital Settings. London: King’s Fund.
Local Government Association/NHS Confederation/Age UK (2012) Delivering Dignity: Securing Dignity in Care for
Older People in Hospitals and Care Homes, available at: www.nhsconfed.org/documents/dignity.pdf.
Parliamentary and Health Service Ombudsman (2009) Six Lives: The Provision of Public Services to People with Learning
Disabilities, Part 1: Overview and Summary Investigation Reports, Second Report Session 2008–2009. London: The
Stationery Office.
Parliamentary and Health Service Ombudsman (2011) Care and Compassion? Report of the Health Service Ombudsman
on Ten Investigations into NHS Care of Older People. London: The Stationery Office.
www.nmc-uk.org/Students. The NMC student resource. The NMC provides advice and guidance with a focus on
students’ conduct during and following their pre-registration nurse education. This is updated regularly.
Listening to the stories of people who use health services can be a powerful way of coming to understand the need
for all health care practitioners to embody appropriate professional values. Two useful websites where you can
do this are:
www.patientvoices.org.uk. The Patient Voices programme aims to facilitate the telling of some of the unwritten
and unspoken stories of ordinary people so that those who devise and implement strategy in health and social
34
care, as well as the professionals and clinicians directly involved in care, may carry out their duties in a more
informed and compassionate manner.
www.tellingstories.nhs.uk. This resource has been developed to promote understanding among all health profes-
sionals of the impact genetics has on real life, and its relevance to health care practice. The website draws on
stories that cover a range of genetic conditions including single-gene disorders, chromosomal abnormalities and
multifactorial conditions such as cancer and heart disease. The section on ‘issues raised’ is particularly useful.
References
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DC: AACN.
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36
Owning your standards
of care
3
Ruth Taylor and Debbie Banks
Chapter contents
Introduction The impact of poor practice on patient care
Domain 1: Professional values – generic standard Student nurse behaviour
for competence Learning to achieve high standards of care
Reflection and owning your standards of care The importance of your role as a nurse
Standards of care Conclusion
Impact of poor standards Further reading and resources
Clinical governance References
Introduction this chapter is that as a student nurse you have

a responsibility to own the standards of care you
This chapter aims to facilitate your understand-
provide. In this respect, it is clear that all of the
ing of standards of clinical care and the responsi-
Nursing and Midwifery Council (NMC) competen-
bilities that you have to ensure your own practice
cies across the domains are relevant to your learn-
achieves the standard expected of you at each
ing in this chapter. However, particular attention is
stage of your course. It also aims to ensure that
paid to Domain 1 (professional values) so that you
you continue to develop your standards of care
can contextualize your learning and consider the
as you progress through your course and on
impact that your actions, approaches to care and
into professional practice. It builds on the pre-
attitudes have in the context of owning your own
vious chapter and is underpinned by the theo-
standards of care.
ries of value-based care. You will be exploring
In particular we would draw your attention to
standards in relation to quality through the key
the following NMC competencies.
concepts of safe, effective and person-centred
care and how these relate to you as a developing
Domain 1: Professional values – generic
professional.
standard for competence
Policy and different types of evidence from
across the fields of practice including examples All nurses must act first and foremost to
of situations where standards have not been care for and safeguard the public. They must
achieved will be considered. In addition, carers practise autonomously and be responsible
and former patients bring their voice to the issues and accountable for safe, compassionate,
that affect good quality care. Finally, we provide person-centred, evidence-based nursing that
you with some practical approaches that will respects and maintains dignity and human
enable you to continually work towards enhance- rights.
ment of your practice, and the achievement of 1 All nurses must practise with confidence
good standards of care. The key message within according to The Code: Standards of Conduct,
37
Performance and Ethics for Nurses and Mid- The outcome of reflection provides insight and
wives (NMC 2008), and within other recog- learning that can enable people to become
nised ethical and legal frameworks. more effective in their personal and profes-
sional lives.
Reflective practice is hard work and requires
Reflection and owning your commitment and practice.
standards of care
To commence the chapter, we invite you to con- What emerges in Johns’ work is the relation-
sider the role of reflection in relation to the care ship between mindfulness and reflection. He
you provide. It is likely that you will have been asserts that ‘The ultimate expression of reflec-
introduced to the concepts of reflection and reflective practice is mindfulness’ (2010: 15). Kabat-
tive practice as part of your nurse education so far. Zinn (2004: 4) describes mindfulness as ‘paying
We offer an overview of reflection and its use for attention in a particular way: on purpose, in the
you as a developing professional, but acknowl- present moment, and non-judgementally’, while
edge that the topic is far-reaching and widely writ- Siegel (2010: 26) describes it as a ‘particular atti-
ten about. It is an area that you will explore fully tude toward experience – whatever that experi-
as you work your way through your course. What ence may be [to achieve] awareness of present
we recommend is that you use this section as a experience with acceptance’. We will return to
starting point and as a focus for your work within the relevance of mindfulness for you later in the
this chapter. chapter.
The term reflection is widely described through For the purposes of this chapter we offer a
different theoretical and experiential perspec- reflective model that should allow you to think
tives. For us, the key focus for reflection is about more easily about your practice, but recommend
using a framework to look back on your experi- that you review the work of Johns who takes a
ences of practice or your experiences as they are complex and in-depth approach to the develop-
happening, so as to enhance your learning and ment of reflective practice in an attempt to enable
therefore your competence in practice. This us to become all we can be as professionals.
action of reflection should be an ongoing pro- The model by Gibbs (1988) is widely used and
cess that takes place every day, and one which comprises a number of specific steps, as follows:
develops as you develop as a person and as a
1 Description: what happened?
professional.
Johns and Freshwater (2005) write eloquently 2 Feelings: what were you thinking and
about transforming nursing through reflective feeling?
practice. Having extensively written about reflec- 3 Evaluation: what was good and bad about
tive practice, Johns (2010) sets out several key the experience?
points about the essence of reflection. These mir- 4 Analysis: what sense can you make of the
ror our views and are reflected in the statements situation?
below.
5 Conclusion: what else could you have done?
Reflection is a way of being rather than doing, 6 Action plan: if it arose again what would you
it is more than a technique for learning through do?
experience. 7 Back to Stage 1.
Becoming mindful of self is the central quality
of reflective practice. We will be asking you to reflect upon your own
Being a reflective nurse is always being mind- experiences of practice later in the chapter and
ful in practice. suggest you refer to Gibbs’ model to do so.
38
Chapter 3 Owning your standards of care
The policy context is clearly focused on the

Activity 3.1 achievement of high standards of care within a
complex and evolving health care system. The
We recommend you keep a log through- nature and extent of change within health care can
out your practice placements, perhaps in your be observed through the following (Basford and
professional development portfolio, of the times Kershaw 2008; NMC 2010; Scottish Government
you ask patients how their experiences can be 2010):
improved. You will be able to use the information
you gain from these conversations in a number of patient empowerment;
ways. co-production;
As part of your reflective practice so that you scientific and technological advances;
can determine how well the standards of care the importance of outcome as measured by the
are enacted in practice settings. patient experience and other types of indicators;
In group work and other classroom learning the move towards more stringent professional
activities such as critical incident analysis and regulation;
enquiry-based learning in order to understand financial constraints;
more fully the nature and impact of nursing the emergence of more rigorous frameworks
practice. for managing risk and promoting safety.
As part of your leadership and management
learning at later stages in your course. We need to remember that health care is not
delivered in isolation, and that increasingly nurs-
ing and health care teams are working along-
side social care professionals as part of a shift
Standards of care towards delivering integrated care. The chal-
The term ‘standards’ refers to the principles or lenges associated with working across boundar-
values that govern a person’s decision-making ies are explored in the interprofessional literature
and behaviour. However, the word ‘standard’ (e.g. Taylor and Brannan forthcoming) and can be
has a variety of meanings, two of which are also summarized as:
relevant to this chapter: one meaning is ‘norm’ –
norms are the customary ways we behave that are the need for flexible approaches to working
accepted by society. A second meaning is ‘a level within and across roles;
of quality or excellence’ to be achieved, which the expansion and evolution of roles and the
implies that a standard can be used as a bench- associated impact on other professions;
mark. Kleinman (2006) states that professional the organizational structures and cultures
standards articulate what is important or desired, that impact on team working, leadership and
and standards what is good or acceptable. Stan- decision-making;
dards of care exist at a micro level in practice at the professional challenges associated with
the point of delivery where they impact on the interprofessional working, including hierarchi-
experience of the participants in the care process, cal issues;
through to the macro level of health care as articu- a collective vision of the meaning of standards
lated through policy and published statements by and ownership of standards of care.
a range of professional bodies and stakeholders. A
key purpose at the macro level is to make trans- Despite the emphasis here on interprofes-
parent to the public what the government’s, pro- sional working, you may feel that some of the
fessions’ and health care providers’ intentions are challenges noted above apply equally to working
in order to instil public confidence. towards high standards of care within a team of
39
health professionals. It is imperative that we work efficient;

towards breaking down the barriers across pro- equitable;
fessions and across health and social care where timely.
they exist. When you come to look at cases of
care which went wrong later in this chapter, you Policy accentuates standards of care. The way
will see that these boundaries are sometimes the in which we, as a professional group and as indi-
cause of difficulties in ensuring that care is of good vidual nurses, enact the policy direction within our
quality. practice is crucial. In conjunction with the NMC
Standards (2010) and Code (2008), a clear vision is
articulated. Regardless of the fast pace of change,
!
it remains the remit of the nurse to work in part-
Key learning nership to deliver professional, person-centred,
The standards of care you provide are safe and effective nursing care that is both evi-
owned by you. dence-based and values-based (NMC 2010; Scot-
Reflection is a pivotal component of enhancing tish Government 2010).
your own standards of care. Evidence- and values-based practice, as dis-
cussed in Chapters 1 and 2, are crucial compo-
nents to making care decisions. Evidence-based
In relation to the health care policy context, the practice is concerned with how we ensure safety,
three quality ambitions below present a summary effective outcomes, efficiency and improvement,
of current national policy. You may wish to inves- and that what we do is best practice. Values-
tigate further and access policy that has specific based practice is concerned with how we uphold
reference to your own field of practice – the policy people’s rights, ensure equality, establish mean-
documents identified at the end of this chapter are ingful relationships, use communication skilfully,
relevant across all fields. convey compassion and respect, and ensure dig-
The focus of the NHS Scotland Quality Frame- nity, so that the patient care experience meets
work (see resources at end of the chapter) docu- their expectations. The standard of your care is
ment is to continue to drive up standards of health entrenched in how you bring these two elements of
care across all settings through the enactment of care together. As a student nurse, you need to
the three quality ambitions: be motivated to learn about both and integrate
them into your practice to achieve the level of
1 Mutually beneficial partnerships between professionalism that is inherent in the standards
patients, families and those delivering health of care expected. The NMC has made it clear that
care. our graduate nurses will not only deliver care to
2 No avoidable injury or harm for people from certain standards, but will drive up standards of
the health care that they receive. care (NMC 2010). Therefore a priority area for you
as a student nurse is to recognize the importance
3 The most appropriate treatments, interven-
of both theoretical learning and practice learning
tions, support and services at the right time
in influencing the standards of care you deliver
and in the right way.
and to challenge yourself to engage equally in
Linked into these are the six dimensions of both.
health care quality: As a student nurse we would encourage you to
bear the following in mind:
person-centred;
safe; To be clear about your own values so you can
effective; explore them in relation to your behaviour and
40
their alignment with the values and principles Impact of poor standards
that relate to professional nursing. You will
Kleinman’s (2006) seminal paper ‘Ethical drift:
explore this later in the chapter.
when good people do bad things’ highlights some
Within every clinical setting there will be cus-
key areas that are worthy of note before we go on
tomary ways of doing things that you will
to look at examples of poor practice in relation to
observe and perhaps be expected to adopt.
high profile cases and in day-to-day situations.
You therefore need to be able to make judge-
ments relating to the evidence-base and val- Most nurses enter the profession to care for
ues associated with practice. patients.
You will have customary ways of doing things Their values are about maintaining high stan-
which may or may not reflect the standards dards and doing their best for patients.
expected. As part of your development pro- Resource constraints are often cited as the
cess you need to be able to accept and discuss main reason nurses feel they work in ways that
feedback and be open to the need for change. interfere with or compromise the values they
This is a key part of your learning process. hold.
All registered nurses must adhere to codes, Collaboration where managers and clinicians
practice guidelines, frameworks and proce- share the same or similar values heightens
dures. Individual, team and service performance morale in difficult times.
are assessed against these. As a student nurse, Where different agendas are perceived, an
your performance will be assessed against the ‘ethos’ gap can occur where professional val-
NMC competencies but encompassed within ues and priorities for managers and clinicians
these is the requirement to demonstrate com- conflict.
pliance with a range of other standards that are In some cases of patient care, deviation from
in place within the placement environment. a person’s ethical foundation and values can
The outcome of nursing care is increasingly the be blatant and represent a major issue or
subject of measurement to ascertain effective- incident.
ness, improve services and the patient expe- In other cases a gradual erosion of ethical stan-
rience as well as develop the evidence base. dards and care occurs which can go unnoticed
As a student nurse on placement, you will be as minor deviations are justified as acceptable
expected to take every opportunity to become in that situation.
personally effective and enhance the patient Gradual ethical drift can escalate until care
experience with the support of your mentors. is significantly below standard but is not rec-
This aspect of your practice relates to one of ognized, continues to be rationalized as rea-
the progression assessment points required sonable in the light of other demands and is
by the NMC: ‘Works more independently, with usually characterized by a lack of awareness.
less direct supervision, in a safe and increas- One concession to self-interest over values
ingly confident manner’. makes it easier to continue to act in this way
and leads on to others.
Although published statements make trans-
parent what should be done, it is at the point As you progress through this section and are
of delivery that standards of care matter. While introduced to examples of poor practice, you might
much of the care that is provided in practice will find it useful to look back at the points Kleinman
be of an appropriate standard, we know that makes as a way of understanding some of the
standards are not always as high as they should dynamics of the cases presented.
be. We will now explore the impact of poor stan- There are many examples where standards of
dards on practice. care have fallen far short of what is required. If
41
you listen to the news regularly you will hear situations in which care was poor is to ignore
repeated media coverage of problems associ- the responsibilities that each individual has to
ated with the care of patients across many set- continuously improve care. We have provided
tings. In the most serious of cases there are some examples of where care has gone wrong in
publicly available documents that enable stu- Box 3.1. Take the time to reflect on these cases.
dents and professionals to reflect on incidents Although they relate to specific fields of practice
of poor care and to learn from these. It is not they are relevant for all students to consider in
happy reading, but as professionals we have a order to enhance their own practice-focused
responsibility to seek out learning from these learning and their understanding of organiza-
situations and to make sure that we strive to tional cultures and responsibilities.
improve in all aspects of our practice. So, tak- From these examples you can probably see that
ing ownership of our standards of care involves there are many aspects of customary practice that
a proactive approach to learning from difficult went wrong, with ethical drift as a feature. Mason
situations. Leadership in practice is key within (2002) asserts that part of our professional devel-
all this – from leadership at a strategic level by opment is to question and change habitual ways
the director of nursing for example, to leader- of responding which are often developed to cope
ship at an individual level at the point of interac- with specific situations in practice. As a student
tion with the patient or family. going into your practice placements you are a
new pair of eyes and can ask relevant questions
Clinical governance regarding practice – staff will usually be pleased
Clinical governance is a set of measures that to discuss critical questions relating to the ways in
works towards ensuring that standards of care which care is delivered.
are appropriate. Recent policy, as discussed Having looked at incidents of poor practice
earlier, emphasizes the need for patient-centred, that have become well known nationally and
safe and effective care and all are relevant to the led to significant changes to policy and practice,
notion of clinical governance. In terms of nurs- we will now look at aspects of poor practice that
ing practice, we as a group of professionals are may occur on a day-to-day basis, that go unre-
responsible for ensuring that our practice is at ported, and have the potential to escalate. To set
a high level in all these areas. The challenges the context, take time to think about Activity 3.1
associated with this aspiration are rehearsed in and how what we are asking you to do within
the media – resourcing in service, education of this activity has the potential to impact positively
nurses, culture in practice, among others (if you on your awareness of the patient experience. As
look at the BBC website you are very likely to you will see, the types of practice that have a real
come across topical news items relating to stan- impact on the patient experience are often things
dards of care and, in particular, the public percep- that are within our control as individuals.
tion of the standards of nursing care – see www. The examples given in Box 3.2 are based on a
bbc.co.uk/news/health). range of stories found on the patient opinion web-
In addition, nurse leaders have highlighted site at www.patientopinion.org.uk. They are used
concerns about standards of care in certain situ- to illustrate how poor practice is often about the
ations (McSherry et al. 2012). The authors coun- very things we see as fundamental to good stan-
terbalance the concerns by emphasizing that not dards of care.
all care is bad and that the core attributes of nurs- Take some time to think about the key point
ing (dignity and respect, caring and compassion) made earlier about owning your standards of
can be demonstrated at organizational, team and care and the ideas that Kleinman (2006) discusses
individual levels. However, not to do anything about why nurses might lose sight of their values
to change practice in the light of learning from and standards. Then undertake Activity 3.2.
42
Box 3.1 Inquiries into poor care
CHILDREN AND YOUNG PEOPLE

The Victoria Climbié Inquiry Report (House of Commons Health Committee 2003)
Victoria Climbié died of multiple injuries inflicted on her by her great aunt and her great aunt’s partner
over a period of months. They were convicted of her murder. Victoria’s story is a harrowing one – and
very powerfully written in this document. You will see from the report that there is a vast amount of
learning for health and social services. While the problems associated with the case related to a
systemic failure of services to provide what was required, specific issues relating to health care
included: problems with history-taking, note-keeping, handover of care and monitoring of outcome,
among others. Reflection on our responsibilities as individual practitioners and as a profession in
relation to any provision of care is vital if we are to learn from tragedies such as this one.
ADULT
Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis 2013)
The Mid Staffordshire Inquiry was set up following concerns with mortality rates and the standard
of care. This far-reaching report documents numerous examples of where care fell far short of what
should be expected. When you read the report you will see that there were failings in many areas
including continence, bladder and bowel care, safety, personal and oral hygiene, nutrition and hydra-
tion, pressure area care, and cleanliness and infection control. These are just some of the areas, and as
you can see, they have far-reaching effects on all aspects of the patient journey and standards of care.
MENTAL HEALTH AND ADULT

Starved of Care: Summary Investigation Report into the Care and Treatment of Mrs V (MWC 2011)
Mrs V was a woman with dementia who died in hospital in December 2008. The Scottish Mental Welfare
Commission (MWC) decided to investigate because there were concerns that her treatment had not
been as good as it should have been. The MWC findings show that Mrs V was treated poorly. Her prob-
lems were complex but not uncommon.
LEARNING DISABILITY
Review of Compliance: Castlebeck Care (Teesdale) Ltd (CQC 2011)
This review of services revealed a number of concerns including (but not restricted to):
poor and outdated practices in the care of patients across a variety of settings;
inconsistent practice in safeguarding;
problems with staff supervision;
inadequate quality assurance mechanisms nationally.
OLDER ADULT
Care and Compassion? Report of the Health Service Ombudsman on Ten Investigations
into NHS Care of Older People (Parliamentary and Health Service Ombudsman 2011)
This report provides evidence relating to 10 complaints against NHS Trusts and GP practices. The
particular cases are explored and the key message from the ombudsman is that people did not
receive the care that they expected and that the patient experiences did not relate to the core values
and principles of the NHS. What the ombudsman presents is a picture of an NHS that is failing in its
care for older people.
43
Box 3.2 Illustration of poor practice
‘Excellent surgical team let down badly by some’

‘Sadly some of the staff on ward let the hospital down badly. They were lazy and treated people with lack of
respect and dignity. This was my first time in hospital and I was horrified by what I witnessed on this ward.
I had an accident and could not clean myself, the nurse threw a box of wet wipes at me and said, “You have
get used to it, clean yourself up.” Food left for people to eat on tray when they could not feed [themselves].
Urine left on bathroom floor for long periods, patients walking into it without slippers.’
https://www.patientopinion.org.uk/opinions/58021
‘Concerned about poor communication and patient care’

‘I was horrified to witness some nurses treating other patients . . . with very little patience and occasionally
outright hostility. I soon became the object of the same treatment when I expressed my concern over the fact
that I was left waiting up to four hours each time I asked for pain relief.’
‘Very, very bad’

‘The nurse[s] and ward sister[s] never remembered a patient’s name. I saw no “basic care” given to patients
that needed it and some of these patients asked for help, it was not given. Staff told me they were too busy when
I said I was in pain. I was left without water and I could not get out of bed . . . All night staff were rude and gave
the impression they didn’t want to be there. Patients didn’t want to ask for anything because of the staff’s attitude.’
‘Compassion is sometimes lacking’

‘Upon arrival at A&E it was reported that I was just having a panic attack . . . I was then told to sit in a small
waiting area to be triaged. When the nurse came to triage me I was talked to with disdain and was asked the
circumstance of my being in A&E. I did my best to explain about being unwell and a passer-by calling 999 on
my behalf. The nurse stated that I was obviously just anxious and I was asked, “What made you think this is an
emergency?” I attempted to explain the situation again but I was dismissed to wait for a Dr. . . . When the same
nurse came to carry out some of the tests I . . . happened to ask what I do. I replied, honestly, that I am currently
awaiting treatment for a brain tumour . . . From that moment, the attitude of the nurse changed dramatically. On
discharge and recalling the nurse’s question to me about why I thought my situation that day was an emergency
I stopped and apologised for having wasted both the nurse’s and the Dr’s time. I really will never forget the
response which was “Oh, it’s fine, I didn’t realise you actually had something wrong with you.” ’
‘Elderly patient care’
‘My grandmother was admitted with a broken leg . . . on two days she was left for hours without water at her
bedside . . . I asked that she be given extra pillows from the nurses and while assured she would get some
she was never given any extra pillows to make her more comfortable . . . As her leg was broken, she was in a
lot of pain and need[ed] regular painkillers. One night she rang for the nurse and it took the nurse 30 minutes
to come to her bedside. She informed the nurse that she was in a lot of pain and asked if she could be given
more painkillers. The nurse said she was not sure what she could be given and said she would have to ask a
more senior colleague. However, the nurse did not come back to her bedside and she was left in pain until
her next round of painkillers was due. She was also distressed that it would take a nurse sometimes an hour to
come to her bedside when she rang the buzzer for help to go to the bathroom. This was very stressful for her
as the delay in time meant she was worried she would have an accident . . . Furthermore, some staff members
complained to her and other staff loudly in front of patients that they were not being paid enough and their
pensions were not good enough. Noise during the night was another issue, as some nursing staff appeared to
make no attempts to keep the noise down as they often talked to each other loudly during the night.’
44
2,178 allegations were made against regis-

Activity 3.2 tered nurses;
1,759 of these were investigated;
For each of the examples above, make
740 cases resulted in sanctions;
notes about:
210 nurses were struck off the professional
What you think was happening generally in register;
these situations? many allegations involved more than one inci-
Who was responsible for the patients’ or fami- dent and more than one type of allegation.
lies’ experiences in these cases?
How what was happening reflects your prin- The most common allegations were to do with:
ciples and values.
What decisions would you make about your physical and verbal abuse;
standards of care if you were on placement in failure to communicate;
these situations. failure to respect the dignity of patients;
incorrect administration of medicines (this
accounted for 11.7 per cent of cases);
dishonesty in 14 per cent of cases, involving,
among other things; theft, fraud, falsification
As individual nurses we are all accountable for of records, claiming sick pay dishonestly and
the decisions we make in the course of delivering sleeping on duty.
nursing care. Even as a student under the super-
vision of a named mentor, you are accountable You should take time to review these annual
for what you do. Thus, you need to be clear what reports as you progress as they make sober read-
your limitations are, about when you should seek ing and can help you consider and reflect on your
guidance and when you should not get involved own standards of care. When you have reviewed
in care which is not of the required standard and the reports, take some time to undertake
what you should do about it. This can be one of Activity 3.3.
the most challenging areas for students and you
will develop your skills as you grow as a profes-
sional in order to achieve progression as required
by the NMC in relation to: ‘Demonstrates poten-
Activity 3.3
tial to work autonomously, making the most of
opportunities to extend knowledge, skills and How do the statistics highlighted above
practice’. make you feel about the nursing profession? Who
The NMC has the protection of the public as its do you believe owns standards of care?
prime objective and it is the NMC that investigates The individual?
allegations made about registrants’ fitness to prac- The managers?
tise. With around 660,000 registrants, this is a huge The organization?
area of the NMC’s work and the number of alle- The profession?
gations is increasing annually. The 2008–9 annual
NMC report along with all previous and future
reports can be accessed at: www.nmc-uk.org/
Documents/Annualreportsandaccounts/FTPan- Now let us take the issues you have considered
nual Reports/NMC. back to your own practice. Begin with Activities
The key points are that: 3.4 and 3.5.
45
to be mindful that people with learning disabili-

Activity 3.4 ties or enduring mental illness can find it difficult
to assert their views and rights. Nurses need to
Using Gibbs’ reflective cycle (see p. 00), create opportunities for disclosure to occur in a
think of an experience in practice in which you felt safe environment. Therefore, nurses cannot be
that the standard of care was very good and work defensive, must be open to feedback and be non-
your way through the questions below. judgemental. The ability to accept and be non-
Description: what happened? judgemental is key to reflective practice.
Feelings: what were you thinking and feeling?
Evaluation: what was good and bad about the Student nurse behaviour
experience? It is important to note that there are sometimes
Analysis: what sense can you make of the situa- instances where student nurses’ behaviour during
tion? their course does not reach the standard required.
Conclusion: what else could you have done? For example, students may:
Action plan: if it arose again, what would you
do? lack the knowledge base to ensure their prac-
tice is competent because they are not engag-
You will find it useful to go through the reflec- ing with the theoretical learning;
tive cycle again, this time focusing on an issue fail to acknowledge their limitations and carry
from practice where the care was poor or not to out an intervention they are not competent to do;
the required standard. fail to seek appropriate guidance;
convey unacceptable attitudes to patients,
staff in clinical placements and academic staff;
falsify records such as time sheets and clinical
assessment documents;
Activity 3.5
fraudulently claim expenses associated with
Now compare the outcomes of these practice placements.
reflective activities and list the differences in each
case. Go back and review your learning from We raise these issues not because we think that
earlier in this chapter and make notes about the many students engage in behaviours that sit out-
factors that impact on the standards of care that the side the required standards, but because in such
public are subjected to from a macro level (e.g. instances the student may not be aware of or rec-
policy level) through to a micro level (e.g. at the ognize the impact of their behaviour. The chal-
level of interaction with the patient). lenge for the student in this position is how they
respond to the feedback provided. Students are
viewed as learners who require support and guid-
The impact of poor practice ance to take on board the standards of behaviour
on patient care and practice required. However, ultimately, the
The outcome of poor practice is distressing for all student must take ownership of their behaviour,
parties involved, whether it is recognized or not. demonstrate the standards required or accept the
Where poor practice is not disclosed but is expe- consequences where this does not happen.
rienced by patients, their carers and families who As you have worked your way through this sec-
are already vulnerable, we are failing in our duty tion, you will have identified the learning that you
of care as we have allowed them to go on with think is most relevant to you. We will refer back to the
their lives with their confidence in the services we relevant learning in the final section when we iden-
provide compromised. In particular, nurses need tify some of the key learning points for the chapter.
46
Learning to achieve high you to deal with them, but it is also about helping
standards of care you begin to explore the factors within yourself that
How you approach care delivery concerns the way impact on your ability to maintain your standards
you interact with patients, and any others involved, of care. The challenge is for you to begin to notice
as care is being delivered. Decisions about your and understand all of the things that affect you dur-
approach reflect your personal and professional ing ‘real time’ in practice. Mason (2002: 1) states:
values and influence your standards of care. They
are manifested through the nature of your presence At the heart of all practice lies noticing: noticing
at the point of delivery. Activity 3.6 is designed to as opportunity to act appropriately . . . [this] . . .
enable you to articulate the values that are impor- requires three things: being present and sensitive
tant to you, and their impact on how you work with to the moment, having a reason to act and having
patients and own your own standards. a different act come to mind. Consequently, one
important aspect of being professional is noticing
possible acts to try out in future, whether gleaned
Activity 3.6 from reading, from discussion, from watching
others or from personal reflection. A second
Note down the five things you value
important aspect is working on becoming more
most in your life at this time.
articulate and more precise about reasons for
Note down the five things you value most about
acting. The mark of an expert is that they are
being a student nurse.
sensitised to notice things that novices overlook.
Note down five things you value most about
being able to contribute to the care and sup-
Mason is highlighting the importance of the role
port of service users and their families during
of your underpinning knowledge which arises from
your course.
your theoretical and experiential learning. This
Note down five principles that you can use to
learning gives you options for making decisions in
guide your behaviour as you progress through
practice and in being able to explain the reasons for
your studies.
your decisions. He is also suggesting that the first
step in this process is being mindful within practice
situations. Thich Nhat Hanh (2012) describes mind-
Key learning
As a nurse it is important that you can
! fulness as the ‘energy of attention’. Being mindful
in a situation is about not thinking about the past
or future, what you did yesterday or what you still
identify the key principles and values that have to do today, or how you are going to manage
direct your standards of care. to complete everything you have to do, or whether
Be aware of any factors that might interfere you are going to fail or succeed: it is about putting all
with or compromise you maintaining your own of that aside and giving your full attention to what is
standards of care according to your values and happening in the present moment as it is happening.
principles and the formal standards that are You actually need to make the conscious decision
made explicit to you. to engage with patients in this way – a key decision
that affects the quality of the patient experience.
We become more ‘mindless’ when we are stressed
The importance of your and our minds get caught up in thinking about our
role as a nurse worries with the result that we do not pay attention
The key thing here is for you to become aware of to what is going on around us. Practice environments
the external things that affect you so you can begin are stressful for a whole array of reasons (Brown
to identify your learning needs in order to allow 2009) so it is easy to become distracted. There is
47
evidence that effective decision-making can be com- we use to guide it, and are used to measure
promised in dynamic environments where lots of our performance.
decisions have to be made within short periods of There are ways of doing things within clinical
time and the decision-makers are not taking in what settings that are customary and ‘standard hab-
is evolving as a situation unfolds (Gonzalez 2004). its’ need to be examined in the light of what is
To be mindful is to consciously train yourself to considered good and desirable. Students can
focus on the present moment and give it all your contribute to this examination of practice with
attention. In relation to delivering nursing care, fresh eyes.
this is about giving every patient your full atten- Implementation of evidence-based practice
tion as you work with them and consciously pre- involves ensuring that practice is informed by
venting your mind from becoming distracted by contemporary evidence that is discussed and
unrelated thoughts. Being a student nurse with 50 debated within the practice area so that prac-
per cent of your programme in a clinical setting tice develops consistently and appropriately.
allows you to take a bit more time when you are Understanding and being aware of your own
delivering care to begin to practise doing so in a values and principles, and those of others, and
mindful manner. how they impact on your behaviour, is impor-
tant for ensuring you maintain high standards
of care.
Conclusion Being present in the moment with the patient –
In concluding this chapter, we draw your attention being aware of how focused your attention
to the areas we have identified as being crucial to is on the patient at the time is essential. You
your developing an understanding of standards need to be able to judge whether you are giv-
of care. In turn, you will now be in a position to ing the patient your full attention.
clearly articulate how you, as a developing person Critical reflection on practice – at individual,
and professional, own your own standards. team and organizational levels – is crucial in
order to enable deep learning and the develop-
In summary: ment of practice.
Being open to and accepting of feedback as
Standards, codes of practice, guidelines and part of the learning and development process
similar statements of principles set out the val- will enhance your ability to deliver high stan-
ues that underpin our care and the principles dards of care.

www.institute.nhs.uk. The website for the NHS Institute for Innovation and Improvement.
www.mwcscot.org.uk/publications/investigation-reports. The website for the Mental Health Commission
(MWC) for Scotland.
www.scotland.gov.uk/Publications/2010/05/10102307/2. The website for the NHS Scotland Healthcare
Quality Strategy.
http://bit.ly/c7Dfen takes you to the Department of Health’s (DH) 2010 White Paper Equity and Excellence: Liberating
the NHS.
www.midstaffspublicinquiry.com. The website relating to the Mid Staffordshire NHS Foundation Trust Public
Inquiry conducted by Robert Frances, QC.
www.patientopinion.org.uk is a helpful site examining the experiences of service users.
References
Basford, L. and Kershaw, B. (2008) A Key Issues Paper: Underpinning the Future of Health Professional Education in the
UK. London: University and College Union.
48
Brown, C. (2009) Self-renewal in nurse leadership: the lived experience of caring for self, The Journal of Holistic Nurs-
ing, 27(2): 75–84.
CQC (Care Quality Commission) (2011) Review of Compliance: Castlebeck Care (Teesdale) Ltd. London: CQC.
Frances, R. (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office.
Gibbs, G. (1988) Learning by Doing: A guide to teaching and learning methods. Further Education Unit, Oxford Brookes
University, Oxford.
Gonzalez, C. (2004) Learning to make decisions in dynamic environments: effects of time constraints and cognitive
abilities, Human Factors: The Journal of Human Factors and Ergonomic Society, 46(3): 449–60.
House of Commons Health Committee (2003) The Victoria Climbié Inquiry Report. London: The Stationery Office.
Johns, C. (2010) Guided Reflection: A Narrative Approach to Advancing Professional Practice, 2nd edn. Chichester: Wiley-
Blackwell.
Johns, C. and Freshwater, D. (eds) (2005) Transforming Nursing Through Reflective Practice, 2nd edn. Oxford: Blackwell.
Kabat-Zinn, J. (2004) Wherever You Go, There You Are: Mindfulness Meditation for Everyday Life. London: Piatkus.
Kleinman, C.S. (2006) Ethical drift: when good people do bad things, Journal of Nursing Administration, Healthcare
Law, Ethics and Regulation, 8(3): 72–6.
Mason, J. (2002) Researching Your Own Practice: The Discipline of Noticing. London: Routledge Falmer.
McSherry, R., Pearce, P., Grimwood, K. and McSherry, W. (2012) The pivotal role of nurse managers, leaders and edu-
cators in enabling excellence in nursing care, Journal of Nursing Management, 20: 7–19.
MWC (Mental Welfare Commission for Scotland) Starved of Care: Summary Investigation Report into the Care and Treat-
ment of Mrs V. Edinburgh: MWC.
Scottish Government (2010) The Healthcare Quality Strategy for NHS Scotland. Edinburgh: Scottish Government.
Siegel, R.D. (2010) The Mindfulness Solution: Everyday Practices for Everyday Problems. New York: Guildford Press.
Taylor, R. and Brannan, J. (forthcoming) Interprofessional practice, in J. Lishman and C. Yuill (eds) Social Work: An
Introduction. London: Sage.
Thich Nhat Hanh (2012) The Art of Mindfulness. London: HarperCollins eBooks.
49
Section
Communication and 2
interpersonal skills
Developing effective
communication and
4
interpersonal skills
Mary Addo and Alison Brown
Chapter contents
Introduction Models for developing communication strategies
The importance of communication Six category intervention analysis
Developing your communication skills Brief, ordinary and effective (BOE) health
Defining communication communication
Types of communication The skilled helper
Non-verbal communication Relationship of communication to personal
Good and bad communication techniques values and professionalism
Interpersonal skills The importance of interpersonal communication
Barriers to effective interpersonal as a lifelong approach to delivering quality
communication patient care
Therapeutic communication strategies Conclusion
Interpersonal skills and qualities of an effective Further reading and resources
nurse helper References
Introduction evaluate your interpersonal communication skills

This chapter is primarily concerned with helping and their relevance in the context of your educa-
you to develop effective communication and tion for future professional nursing practice, as
interpersonal skills in the context of the Nursing well as emphasizing the need to commit to con-
and Midwifery Council (NMC) (2010) Standards tinuing future lifelong learning for your employ-
for Pre-registration Nursing Education skills clus- ability. The specific domain and the relevant out-
ters, required of the graduate nurse for nursing comes are summarized below.
practice. The skills discussed here are inherent All nurses must use excellent communication
in all domains and competencies regardless of and interpersonal skills. Their communications
your field of practice. Research, evidence and must always be safe, effective, compassionate and
health and social care policy are used to illumi- respectful. They must communicate effectively
nate the value of why you need to be confident, using a wide range of strategies and interven-
compassionate and clear in your communication tions including the effective use of communica-
to patients and their families, friends and carers. tion technologies. Where people have a disability,
The experiential exercises and case study exam- nurses must be able to work with service users
ples will enable you to practise, reflect on and and others.
53
Section 2 Communication and interpersonal skills
is the most pivotal, fundamental and important skill

Activity 4.1 that frames all you do as a nurse. Good, clear and
professional communication is important for the
Try to remember why you wanted to delivery of high quality care.
become a nurse in the particular field of nurs-
ing you are studying.
Reflect on what you thought would guide and
Activity 4.2
inform about how to communicate and relate to
service users, carers, families and professional You are on duty and Mrs Jones asks to talk
colleagues as a nurse. to you about her concerns regarding a new medi-
Take the time to write your reflections down as cation she has been prescribed. For three days
a way of clearly identifying them. she has been taking the medication but has had
no information about why she needs this drug. On
several occasions she has gathered the courage to
The importance of communication bring this to the attention of nursing staff. However,
the response she always gets is that ‘there is noth-
As social beings we are always communicating with
ing to worry about; the doctor said it is OK’.
others, be it our friends, families, peers, workmates
or even strangers. Nursing is fundamentally an What communication issues stand out for you
interpersonal profession because it concerns itself in this scenario?
with the health and nursing care needs of society How will you deal with this situation and sup-
through communication and relationship-building port Mrs Jones?
within a professional context. Peplau (1952) rede- Why do you think the nurses were behaving in
fined nursing as an interpersonal, interpretive pro- such a manner?
cess which laid the foundations for studying nursing
as a communicative process. As far back as the 1940s
Peplau was advocating that to achieve a therapeu- Faulkner (1998: 1) states that ‘to be able to com-
tic experience for patients, nurses need to actively municate effectively with others is at the heart of
work in partnership with them. She saw the crux of all patient care’. When effective communication
nursing as building on nurse–patient relationships occurs, it enables the establishment of therapeutic
in practice. This view is as relevant today as it was relationships with service users, their carers and
more than 70 years ago, and even more so now that families, and increases their understanding of the
the involvement of service users in the decision- treatment and care processes in which they find
making process regarding their care and treatment themselves (Silverman et al. 2005).
has become core to a raft of health care policies that How you respond to service users in the therapeu-
guide practice (e.g. Scottish Executive 2003, 2006a, tic relationship and dialogue with them indicates the
2006b; DH 2004, 2009, 2010; Scottish Government value that you place on them. The nurses’ response
2005, 2010; Welsh Assembly Government 2010). to Mrs Jones illustrates poor interpersonal commu-
Nurses cannot provide meaningful care to service nication skills and a lack of the expected graduate
users if they are poor communicators and incompe- attributes (NMC 2008; Griffiths et al. 2012). They
tent at relating to people. Griffiths et al. (2012) report appear dismissive of Mrs Jones’ concerns, appearing
that what service users and their carers look for in unprofessional, uncaring and lacking the required,
graduate nurses is a caring professional attitude, yet evidence-based responding qualities (Rogers 1951;
sadly poor communication by clinical staff remains Peplau 1952). An appropriate responding skill would
a major area of complaint within the NHS (Abraham have been to acknowledge Mrs Jones’ concerns by
2004; Giles et al. 2009). It is with this knowledge that saying, for example, ‘I can understand why you are
we would suggest that communication by the nurse worried; I will make time today so we can talk about
54
Chapter 4 Developing effective communication and interpersonal skills
this.’ A key communication issue in this scenario is Developing your

the nurses’ failure to listen actively to Mrs Jones’ con- communication skills
cerns and demonstrate that she has not just been
While your learning in the university setting will
‘heard’ but listened to and validated.
provide you with theories about and strategies
for developing interpersonal and communication
Key learning
It is vital to understand the importance
! skills, it is within clinical practice that you will learn
to apply these theories and strategies, and develop
your confidence in your own skills of communica-
of responding to patients and the significance of
tion. As you begin to develop your interpersonal
the attitude and behaviour of the nurse in this.
communication skills for professional practice, a
Effective communication is fundamental to the
phase of new nursing experiences will challenge
delivery of quality patient care.
those skills, which are the key determinant of
Nurses’ interpersonal communication skills
patient satisfaction, compliance and recovery
are essential for the implementation of health
(Chant et al. 2002; Barker 2009; Kozier et al. 2012).
care policy.
For example, as a nurse you will be required to
undertake an assessment of the service user’s
McCabe (2004) found that patients felt nurses needs and the first phase of the nursing process
spend more time on clinical tasks than talking framework. Not only will you have to demonstrate
to them and that nurses’ communication skills your theoretical knowledge and understanding
needed to be improved for delivering quality of health, disease and illness, but also of the care
patient care. This is a key point for you as a student and treatment interventions available that relate
to consider and reflect on, irrespective of what part to the particular service user’s condition. This
of your programme you are on. While clinical tasks will require effective interpersonal communica-
are clearly important in the delivery of patient care, tion skills, without which the information needed
they are required to be undertaken with effective to plan care will not materialize (Doenges and
communication that is both informative to the Moorhouse 2003; Arnold and Boggs 2007; Fawcett
patient and reassuring. and Rhynas 2012).
Case study 4.1: Sandy Reid and his family

Sandy Reid is a 61-year-old man with Down’s syndrome. Until recently he has been living in a
housing complex for those with learning disabilities but this care normally comes to an end at age 60. He
has now moved into a care home. His sister Jess, a widow, is 58 and comes regularly to visit him. However,
she has been increasingly confused lately and has now been diagnosed with early onset dementia. She
has one child, Anne, 32, who has two young children, Sophie, 4 and 18-month-old Ryan. Anne is mar-
ried to John who works long hours as an on-call gas engineer and in emergencies he has been asked to
travel across the country. John’s parents have recently retired and are living in Dubai. They visit every few
months, splitting their time between Dubai, visiting John and his family in the UK and their other son Peter
and his family who live in Australia. Anne has been discussing with her mother and John the possibility that
they might all live together so she can look after Jess, and maintain contact with her uncle Sandy. None-
theless, Anne has recently been diagnosed with bowel cancer, and is having surgery later in the month
for this, and has been told she will require chemotherapy. She is understandably worried not only about
her own health but about her mother and children, and who will look after them if John is away. Sandy is
struggling to settle himself in the care home and wants to see Jess quite often.
55
backgrounds and interpretations can all affect

Activity 4.3 the message we give to and receive from others
(Addo 2006; Addo and Smith 2008). However,
You are the allocated nurse meeting there are principles and strategies that you can
Sandy’s family for the first time. Identify the main learn and use in order to be therapeutically effec-
communication issues in this scenario, thinking tive in your practice (Heron 2001; Arnold and
about it in relation to your field-specific area. Boggs 2007; Crawford and Brown 2009; Egan
How would you communicate with the family? 2010), as outlined in the following sections of this
How would you communicate with the wider chapter.
members of the multidisciplinary team?
What communication skills do you need in this
sort of situation? Types of communication
Can you address the needs of all the family Verbal communication involves all aspects of
members? Explain your answer. language: words, style, grammar, content, pitch,
What do you think your responses to this sce- volume, tone, pronunciation, pace, timing and
nario and these questions say about you and the clarity and use of voice. Most of your ver-
your values? bal interactions when you engage with others
What advice and support would you put in constitute a small part of the message you are
place for this family? sending: a significant part of your message is
How do you communicate these values and conveyed through your body language, and this
beliefs to others? is known as non-verbal communication. Personal
styles of communication are the ways in which
Now reflect on your responses to these questions.
we prefer or like to communicate, and are impor-
What have you learned about how you commu-
tant in enabling facilitation of effective partner-
nicate and relate to different people, in different
ship working and mutual understanding in the
situations?
helping process. Awareness of your preferred
communication style will help you to prevent
misunderstandings and conflicts, which can
Defining communication impact on teamwork, and eventually the quality
Communication is important in nursing practice of the helping process.
and is the method by which nurses do what they
do. The process for establishing, maintaining
and improving human contact is interpersonal
communication. Communication is an exchange Activity 4.4
between two or more people that involves the
exchange of information. It also requires a How would you assess your interper-
sender, the message, a mode of transmission, sonal skills at this point in your nurse training?
the receiver, feedback to the sender, and can be Are there aspects of your communication and
linear, circular or both (Kozier et al. 2012). Com- interpersonal skills that you need to further
munication is a complex concept with many develop?
dimensions, and therefore is not something that It is important that as part of your ongoing learn-
you can simply memorize and perform. In coming as a professional you are able to reflect on
municating with others meaning cannot just be your practice, learn from it and make changes to
transferred, but should be mutually negotiated, develop your skills, professionalism and approach
because it is influenced by many factors (Forchuk to your role as a nurse.
and Boyd 1998). Our perceptions, values, cultural
56
Non-verbal communication
Non-verbal communication is more powerful Activity 4.5
than the spoken word as it communicates the
meaning behind the message being sent, the real
In relation to your meeting with Anne:
meaning intended by the sender. It is also worth What initial preparation should you make?
noting that non-verbal communication can often Think about your approach, style and any non-
carry more social meaning than verbal commu- verbal cues that may be important at this stage
nication, due to individuals making inferences of Anne’s care.
from your non-verbal communication when you
are interacting with them (Beebe et al. 2011).
For example, when listening to the concerns Good and bad communication techniques
of a patient, your body language, eye contact Here are some examples of communication tech-
and general way in which you conduct yourself niques, most good, some poor.
while listening will communicate important sig-
nals. When we perceive information as giving Active listening. This is the sort of listening
‘mixed messages’, we tend to use the sender’s which demonstrates your participation and
non-verbal cues such as their appearance, pos- that you are attending to what is being said.
ture, gaze, touch and mannerisms to help vali- It involves using verbal and non-verbal cues
date what is being said, and what we think we such as ‘mmmh’ and ‘uh’ and ‘OK’, while
have heard (Kozier et al. 2012). This is because also nodding, smiling or shaking your head
non-verbal messages are the way we communi- appropriately. This sort of listening allows you
cate our attitudes and feelings, and it therefore to build a relationship with the service user
requires high self-awareness on the part of the by demonstrating your interest in them. This
nurse in relation to any non-verbal messages leads to a trusting and respectful relationship.
they may be sending when dealing with service Reflecting. This helps to focus on the ser-
users, patients, colleagues and members of the vice user’s perspective and promotes person-
public. centred communication by identifying the core
message and offering it back to them in your
own words. Used effectively, reflecting facili-
tates service user/patient interaction, and
Case study 4.2 builds trust, understanding and acceptance.
Imagine you are on a clinical place- Paraphrasing. Expressing the information
ment and as part of your learning your men- received from the service user in your own
tor asks you to arrange a meeting with Anne words. Here the meaning remains the same
from the first case study in this chapter. She but the words are different. Paraphrasing can
has had her surgery and made a good recov- be used to check clarity and mutual under-
ery, and preparations are being made for her standing of what is being communicated.
discharge. You will need to elicit important Silence. This helps you communicate respect
information from Anne regarding her views to the service user, confirms your validation of
about her impending discharge and feed this their worth, and gives you an opportunity to
back at the weekly multidisciplinary team gather your thoughts and reflect on how best
meeting. Your feedback will help inform the to proceed in responding to the immediacy of
decision-making process about the care the issues at hand.
management support Anne will need when Summarizing. An accurate summary of what
discharged. has been said to you will demonstrate to the
service user that you have understood them
57
correctly. It also allows them to address any into the care home with Sandy?’ Or, ‘John, you
misconceptions you may be under. are probably thinking about cutting down on
Open questions. These are where you allow your hours and asking your parents to come
the person you are communicating with the home aren’t you?’ This sort of question should
opportunity to explain things to you. They be avoided if possible as it may compromise
normally begin with phrases such as ‘What do the other person’s values and beliefs.
you think . . .’, Why did this . . .’ or Tell me
about . . .’. Such questions encourage the

sharing of the individual’s own story.
Closed questions. This type of questioning
Key learning
Verbal and non-verbal communication
!
only provides a ‘yes’ or ‘no’ response. It is used
compliment each other, and are interdepen-
when seeking factual responses. For example,
dent in aiding meaning-making and under-
‘Are you in any pain?’
standing.
Probing. This involves the use of a combination
In order to communicate with service users
of questions in order to gain in-depth informa-
and others we need to prepare ourselves for
tion and properly understand the service user’s
our interactions and work on all aspects of our
needs. For example, ‘Could you just describe
communication skills.
that for me?’ or ‘ It will help me plan how to care
for you if you tell me a bit more about that.’
Open-ended questions. Such as those be-
ginning with ‘when’, ‘how’, ‘who’, ‘what’ and Activity 4.6
‘where’. This approach promotes a more de-
tailed, descriptive response: ‘How long have The aim of this activity is to help you
you been feeling like this?’ or ‘When did this review your use of any of the communication
start?’ skills described in this chapter in your own clini-
Clarifying. You ask the individual to enlarge cal practice to date. Begin by identifying a recent
on their answer. For example, in the case study interaction you had with a service user/patient, a
Anne may say that she feels guilty about not carer or a member of staff. Now reflect on the inter-
being able to look after everyone. Asking her action, and answer the following questions. It will
why she feels like this should provide deeper help your learning if you add your answers to your
insight into the values of the family and what reflective journal and share them with your mentor.
is important to them. Such questions also help What was the key intention of my interaction?
you to clarify things if you have been puzzled What communication skills did I adopt during
by an answer. the interaction?
Use of touch. Touch may be used to reassure Which communication skills was I comfortable
and comfort a service user where verbal com- with and which did I find challenging?
munication is insufficient. For example, holding Which communication skills did I not use, and
their hand, or a gentle touch on the shoulder. for what reasons?
However, you must be mindful of factors such What factors do I think influenced my interac-
as age, ethnicity, gender, cultural differences, tion? How? Why?
children, elderly and vulnerable persons. What have I learned from this interaction?
Leading questions. These are questions you What further communication skills do I need to
use to gain the answer you want, rather than develop?
the one the person wishes to give. For example What strategies will I adopt to help develop
you might say to Anne, ‘So you would agree these skills?
that until you are better your mum should go
58
Interpersonal skills S – sitting facing the client squarely promotes

involvement and interest.
Interpersonal skills are all the activities, verbal
O – adopting an open posture, with arms and
and non-verbal, that people use when interacting
legs uncrossed. Crossed arms and legs can be
directly with others (Rungapadiachy 1999; Mallik
a sign of defensiveness and unwillingness to
et al. 2009). Despite variations in the literature over
engage.
the actual skills that fit under this heading (Chant
L – leaning towards the person conveys to
et al. 2002), various authors (e.g. Dickson et al. 1989;
them your interest and willingness to get to
Rungapadiachy 1999; Hayes 2002; Burnard 2003)
know them and help.
agree on the core attributes that are essential for
E – maintaining good eye contact, without star-
effective interpersonal interaction: self-awareness,
ing. Avoidance of eye contact can signify a lack
effective listening, questioning, helping or facili-
of confidence in your self or your abilities. Bal-
tating, reflecting, assertiveness and non-verbal
ance the frequency and intensity of eye contact
cues. For example, a nursing ward report handover
so that the service user does not feel threatened.
involves a range of different communication skills,
R – a relaxed posture enables you to appear
many of which fall within the interpersonal domain,
natural in your interaction, yielding a commu-
requiring the nurse to engage in active listening,
nication.
discussions, monitoring the reactions of colleagues
and responding appropriately to their contributions. By using this strategy you are more likely to
hear what patients and service users are saying,
Barriers to effective interpersonal
clearly and accurately (Hamilton and Martin 2007).
communication
Nurses work with people from different social and
!
cultural backgrounds and therefore it is important
to be aware of barriers to effective interpersonal
Key learning
communication (Luckmann 1999; Narayanasamy When interacting with others you should
2003; Addo 2006). For example: draw on a range of communication skills.
When communicating we need to not only con-
Language: technical and professional jargon, sider our verbal messages but utilize SOLER
use of slang and metaphors. when developing a therapeutic relationship.
Cultural and gender issues: customs and In any relationship you need to be aware of
beliefs of a particular people or group, gender, the barriers to communication exhibited and
preconceived beliefs. inherent both within yourself as a nurse and the
Personal values: emotions, ignorance, ethno- individual you are communicating with, and
centric views. the impact of the environment on you both.
Unsuitable environmental context: lack of pri-
vacy, noise, organizational climate.
Inconsistencies, mistrust, power, feeling op- Interpersonal skills and qualities of an
pressed, not feeling valued. effective nurse helper
Attitudes, past experiences, perceptions, fear, Responding with empathy is the nurse’s
stereotyping, stigma, defensiveness. ability to connect with service users and vali-
Health condition of individual, disability, trauma. date their worth, which is fundamental to the
helping process (Rogers 1951).
Therapeutic communication strategies Responding with respect is about showing
Egan (2010: 135) provides a communication strat- how much you value the integrity, autonomy
egy called SOLER, comprising five key non-verbal and informed choices of the service user, and
‘micro skills’, summarized below. accepting that with appropriate person-centred
59
Activity 4.7
Look at the following scenario and decide which is the most empathic response, and which response
lacks empathy.
A substance misuser talks to a nurse.
Service user: I feel like everything is piling on top of me. The only way I can handle it is by getting my usual
fix. I know it doesn’t solve anything, but it takes away the pain for a while and makes me feel in control.
Nurse:
a) Having a fix seems to be your way of dealing with life’s ups and downs.
b) I know what you mean about life getting on top of you. I used to get like that a lot of years ago. It’s awful,
isn’t it? How do you get your fix?
c) When you feel as though everything is piling on top of you, like carrying the world on your shoulders,
misusing substances like drugs seems like your only answer to the problem.
d) You’re lucky not to be in serious trouble with the law. Have you been checked and had an HIV test yet?
help based on involvement in the decision- These qualities fit with many of the values under-
making process about their care and treat- pinning current health care policies in the UK.
ment, they will be able take control of their cir-
cumstances (Watkins 2001). Models for developing
Responding with genuineness is your abil- communication strategies
ity to be authentic, who you really are, trans-
There are various theoretical models to guide how
parent, open and honest in your interactions
you initiate, sustain and end a therapeutic dia-
with people. A genuine nurse is one who
logue with service users. For example:
works with difference of all kinds in a positive
manner in order to enhance the service user’s interpersonal relations model (Peplau 1952);
care experience (Scottish Executive 2006b). client-centred therapy (Rogers 1951);
Responding to immediacy relates to attend- six category intervention analysis (Heron 2001);
ing to the here and now issues occurring for the skilled helper (Egan 2010);
the service user within the therapeutic working the brief, ordinary and effective (BOE) model
relationship. This can be challenging at times, (Crawford et al. 2006).
especially when negative feedback is provided
by the service user on their experience of the Early seminal work on client-centred therapy
quality of care received. How you respond will (Rogers 1951) articulated the core conditions of
either strengthen or weaken the working rela- acceptance, unconditional positive regard, empa-
tionship (Watkins 2001). thy, genuineness and congruence as underpinning
Responding with warmth is closely related any helping relationship. Despite the passage of
to empathy and respect, as you cannot show time the values described by Rogers are still rel-
warmth in any human interaction in the evant and pertinent to you as a professional nurse,
absence of empathy and respect being pres- and clearly at the heart of the thinking of today’s
ent. The warmth that is articulated here is not NHS. Here we provide you with three of the mod-
‘friendly chit-chat’, but rather warmth con- els you can adopt as strategies to help facilitate
veyed in the manner in which you communi- effective therapeutic dialogue within your role as
cate respect and empathy (Rogers 1951). a nurse. There are, of course, others.
60
Six category intervention analysis empowering the individual to become more able
Heron’s (2001) six category intervention model to help themselves in their everyday lives. This
identifies six styles of helping interventions that requires the nurse to demonstrate the responding
you can adopt with service users and others. and communication skills described earlier in this
There are two basic approaches in Heron’s model: chapter. Egan’s model has three stages which are
‘authoritative’ and ‘facilitative’. These are further briefly described below.
broken down into six core responding categories
to show how you can intervene when helping a Stage 1: the present – where you are at now
service user, their family or carer. We would sug- 1 Help the client tell their story (prompts, active
gest that to help you develop your communication listening, open questions, SOLER).
skills you review Heron’s work, read around the
2 Help the client break through any blind spots.
subject further and start to practise your skills.
Practising communication skills in our view is 3 Help the client find the right problem/oppor-
as essential as practising and refining a clinical tunity to work on.
‘tasks’ – so take the time to practise with a peer
and then try out the approach with different cli- Stage 2: preferred – where you want to be
ents. You may want to talk this through with your 1 Help the client use their imagination to spell
mentor so that you can gain feedback and support out possibilities.
in your development. 2 Help the client chose realistic and challeng-
ing goals.
Brief, ordinary and effective (BOE) 3 Help the client to find incentives that will
health communication
help with commitment.
The BOE model for communication in health care
(Crawford et al. 2006) helps nurses adapt their
Stage 3: strategies – how are you going to get
communication within the busy dynamics of the
where you want to be?
setting. The BOE model helps to address the time
constraints that often prevent nurses from spend- 1 Help the client find possible actions.
ing quality time with patients when undertak- 2 Help the client to find ‘best-fit’ strategies.
ing interventions and tasks. At the heart of this 3 Help the client to draft an action plan.
model is the understanding that short periods of
communication can be valuable and have a big These helping models are relevant to all areas
impact. It identifies for us as nurses the impor- of nursing practice. The NMC generic standard for
tance of avoiding meaningless communication competence for nursing practice and communica-
and demonstrating value in our patients and the tion (2010: 24) states that:
communications we have with them. While this
model is not ideal for all situations, it does pro- All nurses must use excellent communication and
vides one of a range of flexible approaches and interpersonal skills. Their communications must
tools that can be used. A link to a useful paper always be safe, effective, compassionate and
by Professor Paul Crawford is provided in the respectful. They must communicate effectively
resources section (p. 63). using a wide range of strategies and interven-
tions including the effective use of communica-
The skilled helper tion technologies. Where people have a disability,
Egan’s (2010) skilled helper is a useful framework nurses must be able to work with service users
for support the patient on issues that may have and others to obtain the information needed to
had an impact in their recent past or currently. It is make reasonable adjustments that promote opti-
a person-centred model and has an emphasis on mum health and enable equal access to services.
61
Relationship of communication As nurses we are expected to abide by the NMC

to personal values and Code but are also guided in our actions by various
professionalism policies which detail the values we should demon-
strate. Yet, if we do not subscribe to the values and
The values we hold are based on the fundamental
beliefs shown by others, including those we look
beliefs we have and we use them to guide our
after, then conflict can arise.
actions. Beliefs can be thought of as those things
In the first case study of this chapter we saw the
which we hold to be true. Values are those beliefs
conflict that can often arise within a service user’s
we consider to be important (refer to Chapter 2).
family. However, such conflict resolution can be
The values we adopt give us guidance in deter-
achieved with effective interpersonal and com-
mining right from wrong, good from bad. They
munication strategies between the health profes-
become our standards as to how we behave, and
sionals and the family, requiring that you develop
how we expect others to behave. However, we
awareness and clarification of your personal and
all have different kinds of values, and here we
professional values and those of others. Reflecting
will focus on those which are personal or pro-
on your practice gives you the opportunity to disas-
fessional in their nature. Our personal values
semble and examine a situation to make sense of
come from a variety of sources: our parents, our
it, in light of your own values and those of others.
upbringing, our schooling, our religion, our polit-
ical beliefs, our peers and the media. Horton et al. The importance of interpersonal
(2007) have identified the core values of a nurse communication as a lifelong
as being: approach to delivering quality
respect;
patient care
caring; The importance of teaching and learning about
responsibility; communication with patients is well established
honesty; within nursing (Chant et al. 2002). According to
patient participation; Sheldon et al. (2006: 141) ‘communication is a cor-
preservation of wholeness and humanity; nerstone of the nurse-patient relationship’. The
patient autonomy; value of effective interpersonal communication
dignity; skills in health care practice has been extensively
making a difference; researched and evidenced (Hack et al. 2005; Thorne
versatility; et al. 2006). However, most complaints consistently
altruism; made against the NHS in the UK relate to poor
nurturing; interpersonal, inter- and intraprofessional commu-
integrity; nication skills, as reflected in the investigation of
supporting and empowering individuals; The Bristol Royal Infirmary Inquiry (2001) regarding
reciprocal trust; the high mortality rates in a paediatric surgical unit,
sound knowledge; where ‘strained’ communication was a key factor.
clinical competence; Compassionate engagement with service users
relationships; and maintaining their dignity cannot be achieved
continuity; where nurses remain incompetent in their inter-
homogeneity; personal and communication skills (RCN 2008;
self-sacrifice; NMC 2010; Scottish Government 2010; Sharples
hard work; 2011). Therefore your commitment to lifelong
control; continuing professional development to maintain
diversity; your credibility and integrity for practice as a nurse
patient choice. remains paramount.
62
Conclusion In summary:
This chapter has emphasized the importance and Be self-aware in your approach and keep the
relevance of the graduate attributes of an effective patient as the central point for all you do.
communicator and interpersonally skilled nurse in Effective communication and interpersonal
the context of health care delivery, and in uphold- skills are essential for quality patient care.
ing nursing’s professionalism. It is important that Be active in your listening to service users to
developing your communication and interper- explore how you can work with their views.
sonal skills is perceived as a lifelong commitment Adopt effective communication skills in your
to quality enhancement in your professional nurs- work with peers, colleagues and external
ing practice. Remember that it is only by practis- agencies.
ing these skills and obtaining feedback that you Be aware of the barriers to effective commu-
will perfect their use. You will know how effective nication in the work environment and seek
you are from feedback given by service users. appropriate support.

We suggest that you look at the following material to enhance and develop your knowledge and awareness of com-
munication and interpersonal skills.
Bach, S. and Grant, A. (2009) Communication and Interpersonal Skills for Nurses. Exeter: Learning Matters Ltd.
Hamilton, S.J. and Martin, D.J. (2007) Clinical development: a framework for effective communication skills, Nursing
Times, 103(48): 30–1.
Harrison, A. and Hart, C. (2006) Mental Health Care for Nurses: Applying Mental Health Skills in the General Hospital.
London: Blackwell.
A useful paper by Professor Paul Crawford can be found at www.wales.nhs.uk/sites3/docopen.cfm?orgid=

415&id=162430.
You can learn more about Herons’ six category intervention analysis at: www.mindtools.com/CommSkll/
HeronsCategories.htm.
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351–3.
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Mental Health Nursing: Interventions with People with ‘Personality Disorder’. London: Quay Books.
Addo, M. and Smith, I. (2008) Equality and diversity: respecting the person with a learning disability, in Forensic
Mental Health Nursing: Capabilities, Roles and Responsibilities. London: Quay Books:
Arnold, E. and Boggs, K.U. (2007) Interpersonal Relationships: Professional Communication Skills for Nurses.
Philadelphia, PA: W.B. Saunders.
Barker, P. (2009) Psychiatric and Mental Health Nursing: The Craft of Caring. London: Arnold.
Beebe, S.A., Beebe, S.J. and Redmond, M.V. (2011) Interpersonal Communication: Relating to Others, 6th edn.
San Marcos, TX: Pearson.
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Infirmary 1984–1995: Learning from Bristol. London: DH, available at: www.bristolinquiry.org.uk/final_report/
report/, accessed 14 April 2012.
Burnard, P. (2003) Ordinary chat and therapeutic conversation: phatic communication in mental health nursing,
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Chant, S., Jenkinson, T., Randle, J. and Russell, G. (2002) Communication skills: some problems in nursing education
and practice, Journal of Clinical Nursing, 11: 12–21.
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Crawford, P. and Brown, B. (2009) Communication, in M. Mallik, C. Hall and D. Howard (eds) Nursing Knowledge and
Practice: Foundations for Decision Making, 3rd edn. London: Elsevier: London.
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The Stationery Office.
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Dickson, D.A., Hargie, O. and Morrow, N.C. (1989) Communication Skills Training for Health Professionals: An Instruc-
tor’s Handbook. London: Chapman & Hall.
Doenges, M.E. and Moorhouse, M.F. (2003) Application of the Nursing Process and Nursing Diagnosis, 4th edn.
Philadelphia, PA: F.A. Davis.
Egan, G. (2010) The Skilled Helper: A Model for Systematic Helping and Interpersonal Relating. Pacific Grove, CA: Brooks
Cole.
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Contemporary Practice, 4th edn. Philadelphia, PA: Lippincott.
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NHS, Clinical Risk, 15(4): 146–50.
Griffiths, J., Speed, S., Horne, M. and Keeley, P. (2012) ‘A caring professional attitude’: what service users and carers
seek in graduate nurses and the challenge for educators, Nurse Education Today, 32: 121–7.
Hack, T.F., Degner, L.F. and Parker, P.A. (2005) The communication goals and needs of cancer patients: a review,
Psychooncology, 14(10): 831–45.
Hamilton, S.J. and Martin, D.J. (2007) Clinical development: a framework for effective communication skills, Nursing
Times, 103(48): 30–1.
Hayes, J. (2002) Interpersonal Skills at Work, 2nd edn. Hove: Routledge.
Heron, J. (2001) Helping the Client – A Creative Practical Guide, 5th edn. London: Sage.
Horton, K., Tschudin, V. and Forget, A. (2007) The value of nursing: a literature review, Nursing Ethics, 14(6): 716–40.
Kozier, B., Erb, G., Berman, A., Snyder, S., Harvey, S. and Morgan-Samuel, H. (2012) Fundamentals of Nursing –
Concepts, Process and Practice. London: Pearson.
Luckmann, J. (1999) Transcultural Communication in Nursing. New York: Delmar Publishers.
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Elsevier.
McCabe, C. (2004) Nurse–patient communication: an exploration of patients’ experiences, Journal of Clinical Nursing,
13: 41–9.
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12(3): 185–95.
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Mifflin.
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Practice. Edinburgh: Butterworth-Heinemann.
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ing in Scotland. Edinburgh: Scottish Executive.
Scottish Executive (2006b) The 10 Essential Shared Capabilities for Mental Health Practice. Edinburgh: Scottish
Executive.
Scottish Government (2005) Delivering for Health. Edinburgh: Scottish Government.
Scottish Government (2010) The Health Care Quality Strategy for NHS Scotland. Edinburgh: Scottish Government.
Sharples, K. (2011) Successful Practice: Learning for Nursing Students. Exeter: Learning Matters Ltd.
64
Sheldon, L.K., Barrett, R. and Ellington, L. (2006) Difficult communication in nursing, Journal of Scholarship in Nurs-
ing, 38(2): 141–7.
Silverman, J., Kurtz, S. and Draper, J. (2005) Skills for Communicating with Patients. Oxford: Radcliffe Publishing.
Thorne, S.T. Gregory, H., Kuo, M. and Armstrong, E.A. (2006) Hope and probability: patient perspectives of the mean-
ing of numerical information in cancer communication, Qualitative Health Research, 16: 318.
Watkins, P. (2001) Mental Health Nursing: The Art of Compassionate Care. Oxford: Butterworth Heinemann.
Welsh Assembly Government (2010) Doing Well, Doing Better: Standards for Health Services in Wales. Cardiff:
Quality Standards and Safety Improvement Division.
65
Developing skills
in solution-focused
5
interactions
Steve Smith
Chapter contents
Introduction If it’s working, do more of it
Domain 2: Generic standard for competence If it’s not working, stop doing it
Analysing the conversation Big problems don’t need big solutions
The background to solution-focused interactions Solution-focused interactions in the
Values and principles of solution-focused ‘non-clinical’ setting
interactions Conclusion
Some key principles of solution-focused Further reading and resources
interactions References
If it’s not broken, don’t fix it
Introduction 4 All nurses must recognise when people are

anxious or in distress and respond effec-
This chapter discusses solution-focused inter-
tively, using therapeutic principles, to pro-
actions, a specific approach to communication
mote their wellbeing, manage personal safety
which is based on ‘solution-building’ (as opposed
and resolve conflict. They must use effec-
to ‘problem-solving’), which you can utilize across
tive communication strategies and negotia-
all fields of nursing and implement within your
tion techniques to achieve best outcomes,
clinical practice. It will explore the theory and
respecting the dignity and human rights of all
skills of solution-focused interactions and provide
concerned.
an understanding of how they can be used. The
chapter will draw on examples from various fields 5 All nurses must use therapeutic principles to
of nursing, including from a public health con- engage, maintain and, where appropriate,
text, to demonstrate the strength of this approach disengage from professional caring relation-
across a range of settings. In addition it builds on ships, and must always respect professional
the core skills from the previous chapter. boundaries.
This chapter is relevant to the following Nursing 6 All nurses must take every opportunity
and Midwifery Council (NMC) competencies. to encourage health-promoting behaviour
through education, role modelling and effec-
Domain 2: Generic standard for competence
tive communication.
1 All nurses must build partnerships and thera-
peutic relationships through safe, effective We begin with a case study which will help to illus-
and non-discriminatory communication. They trate the communication skills and approaches
must take account of individual differences, required to understand and adopt a solution-
capabilities and needs. focused approach to nursing care.
67
Case study 5.1: Mark and Janeczka

Mark is 24 and suffered a traumatic amputation of his lower left leg in a motorcycle accident. He
also sustained a complicated fracture of his left wrist. His girlfriend, Debbie, was killed in the accident. He
is currently being cared for in a surgical ward, as his stump wound is infected and failing to heal. Mark is
frequently verbally aggressive and abusive towards nursing staff; at other times he complains of extreme
pain in his wrist and phantom pains in his leg. He does not get on with other patients and is being nursed
in an individual room.
Janeczka is a nurse working on the surgical ward where Mark is being cared for. On this particular
morning she is re-dressing Mark’s stump wound. She is aware that he is ‘difficult’ to work with; today he
has sworn at her several times, complained she is causing him pain, and insulted her East European heri-
tage. Janeczka is on the verge of walking away from Mark, casting the experience off as ‘just another failed
attempt to help him’; however, in desperation and frustration she suddenly asks him, ‘What is wrong with
you?’ The following conversation ensues while Janeczka gathers together the equipment used for Mark’s
dressing.
: What do you think’s wrong with me?

M
J: I don’t know; there are so many things that could be wrong with you, I can’t begin to imagine. But if
I don’t know what it is, I can’t do anything to help.
M: Yeah, and what are you gonna do?
J: I don’t know what I can do.
M: Exactly; just more goody-goody claptrap. Just leave me alone, I don’t need your help.
J: If there was something I could do, just one thing, what would it be?
M: I don’t know!
J: Suppose you did know . . . what would you say?
M: [pause] Bring Debbie back . . . that would be it.
J: How would that help?
M: It would just be . . . I feel so guilty. I’ve never seen her mother . . . I wouldn’t know what to say to
her . . . just her face . . . would kill me. She always said Debbie shouldn’t ride on the back; she
never liked the bike at all. ‘If Mark had an accident, he could be injured and you could be killed’
she used to say, and we laughed, ‘How come Debbie was always the one that got killed and I only
got injured’; that seemed funny at the time . . . Now who’s got the last laugh? Nobody, nobody’s
laughing now . . .
J: What difference would it make if Debbie was here now?
M: I’d have something to get better for, I’d have a reason to get out of here.
J: Hmmn . . . what else?
M: I’d be looking forward to seeing her, and getting out, and doing things.
J: What sort of things?
M: I dunno, just getting out, getting back on a bike, getting . . . I don’t know . . . just getting back to nor-
mal; maybe yeah, getting back on a bike someday, or going to rallies, or just doing stuff . . . going
to the pub, y’know, normal stuff.
J: Yeah. What else would be different?
M: I wouldn’t feel so guilty all the time.
J: What would you feel?
68
Chapter 5 Developing skills in solution-focused interactions
: Determined . . . Strong. Like I was gonna get out of here.

M
J: What would be different about you? What would I see different?
M: Oh, I don’t know. How do I know what would be different?
J: Okay, yeah. Let me ask you this though. How close are you to feeling like that? Say ‘10’ stands for
you’re feeling strong and determined, and ready to fight your way back out of here, and ‘0’ is sort of
the exact opposite; you’re just gonna surrender and give in to everything. Where are you just now,
between ‘0’ and ‘10’?
M: [sigh] . . . I dunno . . . about ‘2’ I’d say.
J: Okay . . . how have you managed that?
M: I dunno, I just block the whole thing out my mind sometimes.
J: And that helps?
M: Well, for a little while . . .
J: What else have you done?
M: Nothing, I don’t think . . .
J: So you’ve just got to ‘2’ by blocking things out for a while and letting things happen?
M: Yeah, I guess.
J: How will you know when you’ve got to ‘3’?
M: I dunno . . . I’ll be able to think about it without blocking it out.
J: What will you do instead . . . instead of blocking it out?
M: I dunno, just accept it, accept that it’s happened.
J: And would that help?
M: Yeah, I suppose it must. [pause]
J: Is that what you’re doing now?
M: Yeah, I suppose it is . . .
J: How have you managed to do that?
M: I dunno, just you asking these questions . . . I don’t want to do this . . .
J: What do you want to do?
M: I dunno, I suppose I have to . . .
J: So . . . if you’re thinking about this just now, and accepting how it is . . . is this you at ‘3’ at the
moment?
M: Yeah, I suppose it is. [ looks vaguely surprised at this]
J: Well done. ‘3’.
M: Hmmn!
J: Look; if you want to talk again, give me a shout. In the meantime . . . what would ‘4’ look like?
Analysing the conversation

Activity 5.1 In the above conversation there are several points
Consider how you might have responded where Janeczka may have regretted getting into
to Mark’s initial outburst in the conversation above. the conversation, and felt like running away from
If you were in Mark’s position, what do you think ‘4’ Mark’s pain. Having taken the plunge and asked
would look like? Mark, in realistic terms, what was wrong with
him, Janeczka could easily have been swamped
69
by the enormity of his answer. Given his situa- knows that she is not offering to ‘solve’ Mark’s
tion, where would she begin to list his potential problems, she’s only asking ‘what she would
problems? However, Janeczka did something have to do’ to solve his problems; in other words,
that nurses (and most other health professionals) her question is a hypothetical one aimed at dis-
rarely do: she admitted that she ‘didn’t know’. We covering what it is Mark wants. Mark, naturally
are, as a profession and as professionals, ‘trained enough, finds it very difficult to answer this ques-
to know’. Our knowledge base is the root of our tion, and so Janeczka, bearing in mind the hypo-
professional identity, and as professional practi- thetical nature of the conversation, encourages
tioners it is the application of our knowledge to a him to use his imagination, to ‘think outside of
given situation that defines our practice. So it often the box’.
goes against all we have been taught, and all we Sometimes, gently asking someone, ‘Suppose
have learned from practice, to say ‘I don’t know’. you did know?’ allows them to think things they
Which is unfortunate, because in most situations have not been allowing themselves to think about
(or at least in most situations involving subjective previously; sometimes it’s just such a strange
experiences) we don’t know what our patients are question that prompts the person to look afresh
experiencing. So, in this situation, Janeczka admit- at the situation being discussed; either way, it can
ted that she ‘didn’t know’, which was not only an gently encourage someone to look beyond ‘I don’t
honest response, but invited Mark to continue in know’.
the conversation. When Mark does look again at what would
help, his answer could well have left Janeczka
stuck in her tracks. Bringing Mark’s girlfriend back
to life is an understandable response, but one that
Key learning
By adopting a ‘not knowing’ position
! is clearly beyond Janeczka’s power to deliver,
and one that conveys some of the enormity of his
loss and grief. Janeczka is able to ‘hold’ Mark’s
in our conversation we can often encourage
grief for a moment, because she knows that she
patients to give us more information, and in
doesn’t have to ‘sort it out’; instead, she continues
greater detail, about how they are feeling and
to ask Mark what difference that would make. In
what they are thinking, than if we assume that
all of this, Janeczka is asking rather than telling,
we know what they mean.
and in the asking she is enabling Mark to begin
‘Not knowing’ is a technique used by skilled
to describe the world as he would like it to be.
practitioners to enable patients to explore their
Clearly, Debbie is not going to come back, but
own thoughts and feelings; it doesn’t neces-
there may well be a time at some point in the
sarily reflect what the nurse actually knows or
future where Mark begins to feel more able to
understands about a particular situation.
confront the world and begin to move forward.
This is in essence what Mark is describing – a
future in which things are more positive. Note that
Again, Janeczka may have felt overwhelmed in all of this conversation, Janeczka only makes
when Mark asked her directly what she was three statements; everything else she says is a
going to do to help him. Given his list of poten- question. By asking ‘not knowing’ questions, Jan-
tial problems, where could she begin to help him? eczka encourages Mark to explore his own solu-
In light of this (so far) brief interaction, Janeczka tions, rather than those which she might try to
might well have felt that Mark’s derisive com- offer up to him in response to her understanding
ments were justified, and again felt some regret of his problem. Because the focus of this type of
at rushing into this conversation. However, she communication is on the patient’s description of
70
their solution (rather than their problem) it is often selling work, group work and self-help books, as
described as a ‘solution-focused’ conversation. well as settings such as social care, education,
prison populations and business systems (Iveson
2002; Trepper et al. 2006; Walsh 2006).
In particular, nurses quickly recognized the
Activity 5.2 potential benefits from this approach and began to
incorporate solution-focused interactions in nurs-
Watch Insoo Kim Berg, one of the found-
ing practice (Webster 1990; Wilgosh et al. 1993;
ers of the solution-focused approach, working with
Montgomery and Webster 1994; Iveson 1995;
a teenage girl and her parents via the video link
Hillyer 1996). Webster (1990) argued that SFBT
given below. Notice how she listens to the mother
provided a framework that was congruent with
using only minimal ‘not knowing’ questions,
both traditional nursing values and feminist ethics.
and changes the focus of the conversation from
Montgomery and Webster (1994) developed this
Sarah’s deficits to her assets by asking what she
further when they argued that solution-focused
has ‘going for her’ at the end of the first session.
approaches provide a framework to promote a
You can access the video on YouTube at: http://bit.
shift from a cure-orientation to a care-orientation
ly/YDyR8L.
in health care, and particularly in nursing. They
argued that brief therapeutic approaches enabled
nurses to re-engage with their patients, concluding
that working within a solution paradigm, nurses
The background to solution- could respond to their patients’ vulnerability, as
focused interactions opposed to their pathology, and could reduce ‘the
Solution-focused interactions developed out of mystique of our own power and knowledge’, in
the work in solution-focused brief therapy (SFBT) order to ‘give them a sense of their own power
of a husband and wife team, Steve De Shazer and help them rediscover their resources’ (p. 296).
and Insoo Kim Berg, and their colleagues at McAllister (2007) takes this further, and argues
the Brief Family Therapy Centre in Milwaukee, that solution-focused nursing represents a ‘prac-
Wisconsin (De Shazer and Dolan 2007). De Shazer tical philosophy’ emphasizing the importance of
and Berg’s background was in problem-solving; exploring solutions as well as problems, a focus
however, they came to realize that the people on strategies for working with patients and not
they were working with made quicker progress on them, and the need to be cautious of dominant
the less they spoke about their problems. In other ways of thinking. Bowles et al. (2001) found that
words, less time spent talking about problems, nurses working in a solution-focused way experi-
and more time spent on talking about what people enced less stress and anxiety, and reported being
wanted out of life, made for more effective com- more confident in their work. Similar outcomes
munication. Where the typical number of sessions were reported by Boscart (2009) for nurses work-
required for other forms of therapy was between ing in a continuing care setting, and by Neilson-
12 and 20 (and sometimes many, many more) the Clayton and Brownlee (2002) and Smith et al.
average number of sessions required by the team (2011) for nurses working in cancer care and sur-
at the Brief Family Therapy Centre was less than gical care respectively. In all these papers, nurses
5 (De Shazer et al. 1986). Although SFBT origi- utilizing a solution-focused style of communica-
nated in family therapy, it was quickly adopted by tion were able to care for their patients in a less
other practitioners in a variety of fields. It has been authoritative manner, giving patients more oppor-
utilized in settings as diverse as couples therapy, tunity to take responsibility and make decisions
substance misuse, sex therapy, individual coun- about their health care.
71
Values and principles of solution- seen to operationalize some of the NMC compe-
focused interactions tencies relating to communication and interper-
sonal skills. In particular, nursing from a solution-
Some of the values and principles which underpin
focused perspective enhances the nurse’s ability
solution-focused interactions are:
to ensure that communication is ‘safe, effective,
sensitivity to individual and cultural differences; compassionate and respectful’. We have seen how
maintaining human dignity; Janeczka used solution-focused skills to listen to
promoting self-care; Mark in an empathic way. This is central to the
recognizing and enhancing patients’ strengths; NMC expectations, and indeed Domain 2, Com-
a health, rather than illness, focus; petency 1 states that all nurses ‘must build part-
endeavouring to reduce pain and discomfort; nerships and therapeutic relationships through
reintegrating patients into helpful social sys- safe, effective and non-discriminatory commu-
tems; nication’. In the example above, it can be seen
emphasizing the pragmatics; that Janeczka’s practice met these standards, in
promoting a safe environment; that she didn’t tell Mark what to do, rather she
mobilizing patient hope and agency. facilitated a conversation that helped him iden-
tify his ‘problem’ and begin to build a solution to
Webster (1990) argues that these same prin- it. This principle crosses all domains of nursing;
ciples underpin traditional nursing values. Given in the next conversation note how Anne, a chil-
the very close links between the ethics and prac- dren’s nurse, enables David, an 8-year-old boy
tice of nursing and the principles underpinning who has Type 1 diabetes, to maintain his sense of
solution-focused interactions, it is not surprising independence and engage in the decision-making
that working in a solution-focused way can be process.
Case study 5.2: David and Anne

David’s previously well managed diabetes has become unstable in the last year. It is thought this
is due to his increasing reluctance to follow a regular dietary regime, which he is unable to do as he is
spending more time with friends from school than he did previously. While his family are keen to promote
normal social interactions, they are worried that David’s desire to be ‘the same as everyone else’ is at odds
with his diabetes management.
Anne works in a unit specializing in the care of children and young people with diabetes. David has
been referred by his GP to a nurse-led clinic within the unit. Anne begins by talking to David about his life:
what he enjoys, his favourite sports and his favourite television programmes. In carrying out this ‘problem-
free talk’ Anne is both learning something about David’s wider life, and letting him know that she sees him
as more than just a problem or just another case. She then goes on to ask David how he sees the problem.
In this period of ‘problem talk’ Anne listens to David describe how he sees the problem from his perspec-
tive. David talks at some length about how his mum gets onto him for not eating the ‘right food’ at the ‘right
time’ and how it’s not fair, because all he wants to do is play with his school friends and it’s not his fault
about the diabetes. Throughout this period, Anne simply listens and acknowledges that she understands
what David is telling her; specifically, she offers no opinions or advice on what David is telling her. In this
respect, solution-focused communication differs from other forms of professional communication Anne
might employ as a nurse, in which she might provide health education information, or take the opportunity
72
to explore David’s feelings more deeply. Here, she simply listens (T.K., one of my students on a solution-
focused training course, described the approach as ‘more of a listening therapy than a talking therapy’,
which I thought very apt). Anne then asks David how she can help him deal with his problem – i.e. how can
she help him stop his mum ‘getting on to him’. In doing this she is both addressing David’s problem (as
opposed to his doctor’s problem or his family’s problem) and using the words that David used to describe
the problem to her. Not surprisingly, David doesn’t have many ideas how she could do this. Here’s an
extract from their conversation.
:
D You could tell her she doesn’t need to worry about me.
A: Would that help, do you think?
D: Probably not.
A: Let me ask you a question then, David. [Anne pauses] Suppose . . . just suppose that later . . . after
you leave here and go home and do the things you’re going to do for the rest of the day . . .
:
D I’m going out to play with Gavin at the park.
A: Right; so you go out to play with Gavin at the park . . . and then you come home . . . and when
it get’s to bed-time, you go to bed. Now . . . while you’re sleeping . . . something amazing hap-
pens . . . and the problems you’ve been telling me all about . . . are gone. Just like that! You don’t
understand how it’s happened, but they’re gone. But . . . you’re asleep, right?
:
D Yeah . . .
A: So . . . because you’re asleep, you don’t know that this thing has even happened. So . . . what will be
the first thing that tells you in the morning that something is different? Can you draw me a picture of
what it will be like when things are different, and this problem’s gone? [Anne then provides David
with paper and a large selection of coloured pencils and pens]
It can be seen here that Anne and David are

essentially ‘telling a story’; Anne is providing most
of the story but readily incorporates the parts Different media for scaling questions
David provides. She makes good use of pauses;
allowing David time to imagine what that part of 0 10
the story is like. In asking David to draw a picture Typical adult scale / numeric scale
of his ideal day rather than describing it in words,
Anne is recognizing that it is often easier for young ☺
children to use visual communication, as opposed
Emotive / child friendly scale
to verbal communication, to express their ideas.
This approach can also be used when asking scal- Bad Good
ing questions (Figure 5.1). Simple construct scale
Note also that Anne doesn’t say, ‘Can you draw
me a picture of what it would be like when things
are different’, or ‘what it will be like if things are Simple visual scale
different’, instead she uses pre-suppositional lan- Note that in all cases the nurse must define what each
guage to suggest that things not only can be dif- end of the scale represents.
ferent, but will be different. David then goes on to
Figure 5.1 Different media for scaling questions
draw a picture of his family in the kitchen on the
morning after his problem is gone.
73
Case study 5.2: continued

A: So, what’s here?
D: This is me, sitting in the kitchen, and I’ve got my football top on.
A: Right, so, what day is it?
D: It’s Saturday, ’cause I’m going out to play. I’m going to play football with Gavin and Tom, and we’re
going to the park.
A: Right. What else?
D: We’ll buy sweets.
A: Okay; what else is happening in the picture?
D: The dog’s wagging his tail, ’cause he’s happy . . . and I’m smiling ’cause I’m happy too. And Mum’s
smiling, ’cause she’s happy.
A: Right! So everyone’s happy. What else is happening?
D: I’m having my breakfast, I’m having sausage and eggs, that’s the egg there, and I’m having juice to
drink.
A: Wow, okay. What else is there?
Anne goes on to get David to describe how this particular story ends and David, knowing the rules
about stories, provides a suitable happy ending as he sees it. In doing this, Anne is helping David describe
his ‘positive future scenario’. The capacity to tell a story with a happy ending is something that is not lost
to us as we grow older; we can all describe a positive future scenario given the right encouragement.
However, no matter how happy the ending, this is still just a story. Anne continues to encourage David to
add detail to his story by asking him what his mum would notice different about him on this day (‘I’d be
all happy and talking to her’) and eliciting detail about this, and what his Dad would notice different about
him (‘I’d finish my breakfast quick, and clear away the plates’); even what the dog would notice different
about him (‘Ha ha; he’d get a really big walk and we’d go to the park, and he’d get a bone. He’d know I
was happy ’cause I’d give him a big hug’). In every case, Anne elicits as much detail from David as he can
provide about what would be happening and what each person (or pet) would notice. In doing this, David
creates more and more detail, and his story becomes more and more ‘real’ as a result. It is though, still a
story; which is why Anne then brings the story back to reality.
A: Wow . . . what a great picture. But, I’m wondering . . . have there been any times you can remember
when any of that’s actually happened? Any time you’ve all been happy, or you’ve gone out with the
dog, or even given him a big hug?
D: Well . . . we’re happy sometimes . . . and the dog’s always wagging his tail, and we take him out for
walks and stuff.
A: Wow . . . how do you manage to do that? I mean with all these problems you were telling me about;
with all that going on, how do you manage to be happy sometimes and take the dog out?
D: Well . . . it’s not always like that . . . Mum’s not always getting on at me . . . mostly she’s okay.
A: How do you manage that . . . how do you get your mum not to be getting on at you?
D: I don’t know . . . it’s only when I’m messing about with my diet that she gets mad . . .
A: So what do you do to stop her getting mad?
D: Well . . . I just keep to my diet really.
A: Oh right . . . Okay . . . How do you do that?
D: Well, it’s quite easy really. I’ve got a thing here, look . . .
74
David then goes on to explain his diet regime to Anne. Note that throughout Anne is asking ‘not-knowing’
questions, using David’s words wherever possible, and looking at the situation from his point of view. In
doing this she helps David create a meaningful positive future scenario, and then helps him to recognize
that parts of it are happening already; not only does he not need a miracle to bring about his positive future
scenario, but parts are already happening and he wasn’t even aware of it! This highlights a basic principle
of solution-focused interactions; it’s not our job to change the patient’s life. Our job is to help the patient
recognize where change is already happening in their life, and they haven’t noticed it yet, and to do more
of what has helped bring about that change. Most of the key principles of solution-focused practice can
be grouped under four interconnected headings, which we examine in the next section after Activity 5.3.
competent, and having the necessary resources to

Activity 5.3 change and adapt to whatever problems are occur-
Consider for a moment how solution- ring in their lives. Therefore we focus on what is
focused interactions might enable you to prac- going well in the patient’s life (while not ignoring
tise in accordance with the NMC competencies their presenting problem) and what they have at the
within your own area of practice. moment that they would like to keep in the future.
Make a note of a recent clinical situation you These are the patient’s assets and strengths, and
were involved in, and think of how you could these are the things that they are going to have to
have applied solution-focused interactions in rely upon in order to overcome whatever difficulty
that situation. they are experiencing at the moment.
Make links from this to the specific NMC com-
petencies you would be demonstrating were
you to have responded in that way.
Activity 5.4
Take a piece of A4 paper and fold it in half.
On the left-hand side write down any problems you
Some key principles of solution- have been experiencing recently (equally you can
focused interactions note any problems a patient you have been working
If it’s not broken, don’t fix it with has been experiencing); make a list of between
Patients come to us with problems; they are not three and five aspects of the problem. On the right-
the problem themselves. We often hear other prac- hand side of the paper, write down opposite each
titioners (and, truth be told, we sometimes do it part of the problem the skills, strengths or attributes
ourselves) speak about ‘problem patients’ or refer which you (or your patient) have brought to bear in
to patients using a diagnostic label; in other words, dealing with that problem. Now tear the paper in half
defining patients by what is wrong with them. along the fold you made earlier. Throw away the left-
While there is, obviously, an element of logic to hand panel, and look at the right-hand panel; where
this process, it is very likely to encourage us to see did you get these strengths and abilities from? Con-
our patients in terms of their deficits, and to focus sider how they have helped you in the past, and
our attention on what they can’t do. In solution- think of how they might be useful in helping you in
focused interactions we make a deliberate attempt the immediate future. What other strengths, skills
to build on what is healthy and functioning about and positive attributes do you possess?
the patient. We see patients as being inherently
75
If it’s working, do more of it is that good for you?’ we can encourage our
This might seem like a really obvious statement, patients to explore the impact of what they are
but very often people respond more to what doing, and to recognize that if something isn’t
they think they ‘should be doing’, rather than helping the first time you do it (or certainly by
what they know to work. In order to know if the third or fourth time), it’s unlikely to help at
something is working, we have to know where all. We can then ask, ‘What else can you do that
we are going or what it is that we want to hap- will be helpful?’ It’s important to recognize that,
pen. Often, particularly in times of distress, we sometimes, a patient might benefit from permis-
focus on feelings of ‘I don’t want this to hap- sion from a nurse, or other perceived authority
pen’ without necessarily thinking what it is ‘I do figure, to stop doing something that isn’t work-
want’ to happen. In Mark and Janeczka’s story, ing (e.g. to stop responding to a violent part-
Janeczka helps Mark move from what he doesn’t ner, or to stop ‘grieving’ for a loss); however,
want to be happening to what he does want, by the recognition that it isn’t working must come
asking him ‘What would you feel?’. Mark then from the patient before we can respond to it in a
begins to describe what it is he would like to be helpful way.
happening instead. Janeczka then helps him mea-
sure how well his efforts at getting to where he Big problems don’t need big solutions
wants to be are working by asking him to scale Most people are pretty good at solving the prob-
his progress, and even to identify a ‘next step’. lems of daily life; we regularly overcome any
Similarly, Anne enables David to describe what number of problems on a daily basis. ‘Where are
he wants to be happening and then helps him to my shoes?’, ‘How do I address this assignment?’,
describe what it is he is doing already ‘that works’. ‘How can I tell my friend that I can’t meet her
Again, it is not Anne’s or Janeczka’s job to tell their tomorrow night?’: these are all the types of prob-
patient what they should be doing, it’s their job to lems that most of us deal with every day. How-
help their patient identify what they are already ever, the problems that our patients often bring
doing that works, and then to encourage them to to us are of a different order: ‘How can I live my
do more of it. life with the impact of injury, disease, disability
and loss?’ These are the kinds of problems that
If it’s not working, stop doing it can feel overwhelming to us as nurses, and we
If the previous point seemed pretty elemen- often resort to ‘on the surface’ responses that
tary, this key principle should be even clearer. fail to respond to the patient’s underlying need
However, there are many times when we all for help. However, from a solution-focused per-
continue to do things that aren’t helping us, even spective we take the view that problems and
when we are clear what we want from a situa- solutions are not as closely connected as we
tion. Sometimes we are unaware of the connec- might think. We don’t have to ‘solve’ the patient’s
tion between what we are doing and a lack of problem; we only have to help them see it in a
positive change, sometimes we tend to think different way, in order that they can find their
that we’re just not doing what we think will be own way of dealing with (or solving) their prob-
helpful ‘hard enough’, and sometimes we just lem. In helping people see things in a different
like doing something even though we know it way, encouraging them to make a small change
isn’t helpful. In all three cases it isn’t our role in their lives is often more effective that asking
to lecture our patients on what they should, or them to make a major change. A small change
shouldn’t be doing, but rather we can take a ‘not in the way a person behaves is frequently enough
knowing’ posture and ask them to explain to us to bring about further changes in their life and
how what they are doing is helpful to them. By in the way people around them behave towards
asking questions like, ‘Does that help?’, or ‘How them.
76
Activity 5.5
The diagram below describes the solution-building process. See if you can link the parts of the
process to what you have learned about solution-focused interactions so far.
Scaling
0 10
Validate
Positive
Future
Scenario
Reinforce
Problem Situation/
Assessment
Figure 5.2 The solution-building process
Solution-focused interactions in
Key learning
The process of solution building begins
! the ‘non-clinical’ setting
Some of these key principles have been seen in
the clinical scenarios presented above. However,
with hearing the patient’s account of ‘the prob-
solution-focused interactions can also be used in
lem’. We then help the patient describe their pos-
non-clinical situations such as team meetings, staff
itive future scenario, and scale how close they are
appraisals and planning meetings. The same tech-
to achieving that goal. We then validate the steps
niques of ‘not knowing’, ‘asking rather than tell-
the patient has taken towards achieving their
ing’, ‘focusing on assets rather than deficits’, and
goal and reinforce the things that are ‘working’. In
the use of scaling and a ‘positive future scenario’
doing this we are guided by the principles of:
can all be utilized in moving professional conver-
if it’s not broken, don’t fix it; sations away from a problem focus to a solution
if it’s working, do more of it; focus. The NMC generic standard for competence
if it’s not working, stop doing it; in communication and interpersonal skills states
big problems don’t need big solutions. that, ‘all nurses must use excellent communication
and interpersonal skills. Their communications
77
must always be safe, effective, compassionate and crosses communication with patients and clients,
respectful’. This standard does not only apply to relatives, colleagues, and anyone the nurse comes
communication with patients but equally to pro- into contact with. Solution-focused interactions
fessional communications – for example, with provide a framework for nurses to communicate
members of the multiprofessional team. Solution- in a safe, respectful, compassionate and effec-
focused interactions can provide a framework for tive manner, recognizing the traditional values
engaging in effective communication in a range of of nursing and promoting patient independence
difficult situations. Where, increasingly, the regis- and well-being. Several examples of the tech-
tered nurse’s role encompasses that of mentor and niques being used in clinical practice have been
coach to junior staff, the skills of solution-focused discussed, and further reading is suggested below.
interactions can be utilized to facilitate respectful,
yet effective, coaching across the domains of pro- In summary:
fessional practice.
It can be seen that solution-focused interac-
tions are structured around a process of:
Conclusion ■■ hearing the client’s definition of their par-
No single approach can be seen as a panacea for ticular problem;
all nursing practice; however, solution-focused ■■ helping the client construct a positive future
interactions are an important addition to the scenario;
‘tool-box’ of knowledge and skills possessed by ■■ scaling how close the client is to achieving
the contemporary nurse practitioner. Whether their goal and their next small step;
practising in adult, children’s, learning disabili- ■■ delivering a solution-focused intervention.
ties or mental health nursing, all practitioners are These questions provide a structure within
required to demonstrate competency in communi- which we can then address the NMC com-
cation and interpersonal skills. This requirement petencies in relation to communication and
not only crosses all domains of practice, but also interpersonal skills.

Connie, E. and Metcalf, L. (eds) (2009) The Art of Solution Focused Therapy. New York: Springer.
De Shazer, S. and Dolan, Y. (eds) (2007) More than Miracles: The State of the Art of Solution-focused Brief Therapy.
London: Routledge.
Hanton, P. (2011) Skills in Solution Focused Brief Counselling and Psychotherapy. London: Sage.
MacDonald, A. (2011) Solution-focused Therapy: Theory, Research and Practice. London: Sage.
McAllister, M. (ed.) (2007) Solution-focused Nursing: Rethinking Practice. Basingstoke: Palgrave Macmillan.
References
Boscart, V. (2009) A communication intervention for nursing staff in chronic care, Journal of Advanced Nursing, 65(9):
1823–32.
Bowles, N., Mackintosh, C. and Torn, A. (2001) Nurses’ communication skills: an evaluation of the impact of solution-
focused communication training, Journal of Advanced Nursing, 36(3): 347–54.
De Shazer, S. and Dolan, Y. (eds) (2007) More than Miracles: The State of the Art of Solution-focused Brief Therapy.
London: Routledge.
De Shazer, S., Berg, I.K., Lipchik, E., Nunnally, E., Molnar, A., Gingerich, W. and Weiner-Davis, M. (1986) Brief therapy:
focused solution development, Family Process, 25(2): 207–22.
Hillyer, D. (1996) Solution oriented questions: an analysis of a key intervention, Journal of the American Psychiatric
Nurses Association, 2(1): 3–10.
Iveson, C. (1995) Solution focused brief therapy: a tool for health visitors, Health Visitor, 68(6): 236–8.
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Iveson, C. (2002) Solution-focused brief therapy, Advances In Psychiatric Treatment, 8: 149–57.

McAllister, M. (ed.) (2007) Solution-focused Nursing: Rethinking Practice. Basingstoke: Palgrave Macmillan.
Montgomery, C. and Webster, D. (1994) Caring, curing and brief therapy: a model for nurse psychotherapy, Archives
of Psychiatric Nursing, 8(5): 291–7.
Neilson-Clayton, H. and Brownlee, K. (2002) Solution-focused brief therapy with cancer patients and their families,
Journal of Psychosocial Oncology, 20(1): 1–13.
Smith, S., Adam, D., Kirkpatrick, P. and McRobie, G. (2011) Using solution-focused communication to support
patients, Nursing Standard, 25(52): 42–7.
Trepper, T.S., Dolan, Y., Mccollum, E.E. and Nelson, T. (2006) Steve De Shazer and the future of solution-focused
therapy, Journal of Marital and Family Therapy, 32(2): 133–9.
Walsh, T. (2006) Two sides of the same coin: ambiguity and complexity in child protection work, Journal of Systemic
Therapies, 25(2): 38–49.
Webster, D.C. (1990) Solution focused approaches in psychiatric/mental health nursing, Perspectives In Psychiatric
Care, 26(4): 17–21.
Wilgosh, R., Hawkes, D. and Marsh, I. (1993) Session two and beyond – or, ‘what do you say after you say “hello”
again?’ Context, 9: 31–3.
79
Com munication in
difficult situations
6
Kay Townsend, Beth Sepion and Delia Pogson
Chapter contents
Introduction What to tell children who are dying
Domain 2: Communication and interpersonal skills The power of language
Communication and end-of-life care Impact of difficult communication situations on
Caring and communication emotions
Caring, but difficult, conversations Communicating and giving emotional support
What contributes to difficulty in conversations? The shape of the conversation
Communication difficulties for the person you are Breaking bad news
speaking to How can I manage to do all of this?
Conversations about dying: fears, misconceptions Conclusion
and beliefs Further reading and resources
Finding the words References
Introduction consider how you can develop your competence

in communication we will use end-of-life care as
It is possible to argue that communication under-
the theme for this chapter. There is no one, single,
pins the majority of the Nursing and Midwifery
way to communicate with people who are com-
Council (NMC) competencies. However, we
ing to the end of their lives. Just as all end-of-life
have identified the key issues in each domain
situations are unique, so is the way that you will
and competency that we think are significant
feel.
when discussing communication in difficult situ-
However, the following three things can help
ations. While other chapters in this book focus
you deal with difficult situations:
on highlighting specific aspects of communi-
cating in practice situations, this chapter focuses thinking about these situations before you find
on the difficult conversations that patients and yourself in them;
carers face throughout their care experience with having good practice knowledge to fall back on;
us. Of course these conversations are difficult for being able to reflect on them afterwards.
us too.
No matter which field of nursing you are study- This chapter is not a recipe for success, it’s a
ing, you will on occasions find yourself in situ- resource to allow you to improve your practice. It
ations where you feel that you just don’t know is also not an in-depth analysis of communication
what to say. The situation we think most likely at the end-of-life – for this we recommend Duke
to prompt this reaction, and one which is com- and Bailey’s chapter in Payne’s book, Palliative
mon to all fields of nursing, is when someone Care Nursing: Principles and Evidence for Practice
is dying or has been bereaved. To enable you to (Payne et al. 2008).
81
Communicating in difficult situations: NMC record their knowledge and understanding

competencies (NMC 2010) of people’s needs. They must be aware
of their own values and beliefs and the
Domain 1: Professional values
impact this may have on their communica-
2 All nurses must practise in a holistic, non- tion with others. They must take account
judgemental, caring and sensitive manner that of the many different ways in which people
avoids assumptions, supports social inclusion, communicate and how these may be influ-
recognises and respects individual choice; and enced by ill health, disability and other fac-
acknowledges diversity. Where necessary, tors, and be able to recognise and respond
they must challenge inequality, discrimination effectively when a person finds it hard to
and exclusion from access to care. communicate.
The key issues for communication in difficult The key issues raised here are understanding the
situations raised by this competency include impact of illness on the whole person and their
avoiding assumptions, respecting choice and indi- family, the impact of your own values and beliefs
viduality, and challenging others. on your attitudes and behaviours, and the wisdom
to make a decision based upon another individu-
Domain 2: Communication and interpersonal al’s values rather than your own.
skills
4 All nurses must recognise when people are
1 All nurses must build partnerships and thera- anxious or in distress and respond effectively,
peutic relationships through safe, effective using therapeutic principles, to promote
and non-discriminatory communication. They their wellbeing, manage personal safety and
must take account of individual differences, resolve conflict. They must use effective com-
capabilities and needs. munication strategies and negotiation tech-
The key issues raised here are the virtues of care niques to achieve best outcomes, respecting
and compassion, the moral wisdom you use to the dignity and human rights of all concerned.
make judgements and the account you take of They must know when to consult a third party
another person’s values (which may be different and how to make referrals for advocacy,
to your own). mediation or arbitration.
2 All nurses must use a range of communi- The key issues here are acknowledging and
cation skills and technologies to support responding to distress, and understanding and
person-centred care and enhance quality and acknowledging your own limitations.
safety. They must ensure people receive all 5 All nurses must use therapeutic principles
the information they need in a language and to engage, maintain and, where appropri-
manner that allows them to make informed ate, disengage from professional caring
choices and share decision making. They relationships, and must always respect pro-
must recognise when language interpretation fessional boundaries.
or other communication support is needed
The key issues here are sensitivity, understanding
and know how to obtain it.
the limits of the relationship, and the need for
The key issues here is the variety of ways informa-
‘closing’ in conversations and relationships.
tion can be provided and the wisdom to choose an
appropriate method of communication with each
individual. Communication and
3 All nurses must use the full range of com-
end-of-life care
munication methods, including verbal, non- Why use end-of-life care as the theme for this
verbal and written, to acquire, interpret and chapter? ‘How we care for the dying is an indicator
82
Chapter 6 Com munication in difficult situations
of how we care for all sick and vulnerable people. communication in end-of-life care it is worth
It is a measure of society as a whole and it is a revisiting the five interrelated concepts of caring
litmus test for health and social care services’ (Morse et al. 1990):
(DH 2008: 2). In the next 20 years, with an increas-
ingly elderly population, the health care workforce a human trait;
will be more involved in end-of-life care (National an ideal;
End-of-Life Care Programme 2011a), and as an interpersonal relationship;
nurses spend more time with patients than any a therapeutic intervention;
other health care professionals, you are likely to an affect.
be present when someone is facing death. While
caring for dying patients, and their families, can be The way that we value others and the way that
a stressful experience for student nurses (Cooper we are with others have an impact on the way peo-
and Barnett 2005) it can also be a profoundly ple feel cared for. Research and literature about
influential experience (DH 2008). Thinking about what are important characteristics for nurses help
end-of-life care, how you support others and what us understand the things that we should reflect upon
makes you anxious can help reduce the stress as we engage in care: moral behaviour, ethical rea-
of these situations, and improve your own well- soning and decision-making (Skisland et al. 2012);
being as well as the care you give (Melo and Oliver being (not acting) virtuous (Putman 2012); comfort-
2011). ing and encouraging (Hwang et al. 2012); integrity
There are other chapters in this book that will (Ekeberg 2011); respect for equality (Kangasniemi
help you to think about some important con- 2010); moral courage (LaSala and Bjarnason 2010);
cepts with respect to communication in different being ‘amenable’ (Jonasson et al. 2010); and com-
practice settings and we suggest that you refer passion (McLean 2012). How many of these things
to these as well. Chapter 2 looks at professional featured in your reflection about what makes you
values and this strongly links to how we commu- feel cared for?
nicate and interact with others. Chapters 4 and
5 explore other specific practice opportunities
!
related to you developing effective communica-
tion, interpersonal skills and competencies. Key learning
Nurses are likely to care for people
Caring and communication who are dying or are bereaved.
Being caring is fundamental to the experience
other people have in any situation, including
Activity 6.1 end-of-life care.
Think about what makes you feel cared

for and cared about. How does the way someone
behaves, what they say and what they do, convey
this to you? Caring, but difficult, conversations
Theories about caring in nursing emphasize the Activity 6.2

importance of the relationship between the nurse With your field of nursing in mind, make
and the person being cared for, as well as har- a list of conversations that you consider being
mony, wholeness, comfort and the broad spectrum difficult, or have seen as being significant.
of human living beyond health. When considering
83
The situations you have listed in Activity 6.2

will in all likelihood have a common feature of Activity 6.3
very significant change: difficult conversations are
often about telling someone that the future they With your field of nursing in mind, talk to
pictured is not how they have been picturing it a family member, friend or neighbour about their
or hoping it will be. This is often called ‘breaking experience of a health care conversation. What
significant news’, and a model that may help you helped them and what did not?
with this is discussed later in the chapter. Models Try writing about this experience in the form
are very useful, but they do depend on the person of a short story and share it with your tutor group.
using them having some key skills, and these will Are there common themes that you notice that you
be explored first. could explore in the literature?
Earlier chapters, in particular Chapter 4, have
explained that communication difficulties are not
only about what is said, either by you or by the per-
The person you speak to in Activity 6.3 may
son being cared for or their family members, but
have mentioned:
are also about the non-verbal messages. Although
body language has been discussed, we think it is
facial expressions (movement of eyebrows,
important, and want to remind you about some
frowning, smiling, crying);
key facts. According to Donnelly and Neville
eye contact (contact or not, staring);
(2008), approximately:
voice (volume, rate of speech, silence, tone);
posture (sitting or standing);
7 per cent of what we communicate relies on
body movements (fidgeting, nodding, gestures);
the words being used;
proximity (physical closeness or distance).
38 per cent is communicated by the tonality of
the voice; Being aware of your own body language and
55 per cent is communicated by body language. the often unintentional signals it sends is part of
the emotional labour of nursing that creates a
We rely very heavily on our body language, clear message that ensures people feel safe and
particularly in situations such as the end-of-life. cared for (Horschild 1983, cited in Gray 2008).
We rely on active listening skills and empathy, so
it is helpful to more consciously consider what
these mean to us. Body language is an aspect of
!
our behaviour that we often forget about until, or
after, we are in a difficult situation. Many com- Key learning
munication models describe the components of Thinking about the way that you are
body language or non-verbal communication will help convey that caring to another person.
(e.g. Donnelly and Neville 2008; Atherton and Thinking about the things that make you
Crickmore 2011; Hannon and Clift 2011), but con- anxious about end-of-life care can help
sider Activity 6.3. We think that theory is useful improve the way you feel as well as the care
and necessary to appreciate why things happen you give.
the way they do. The only way you can appreci- It takes energy (emotional labour) to create an
ate the reality for people you speak to is to listen outward expression of caring in your facial
to them and think about the impact that good and expressions, tone of voice, posture and
bad communication skills have on the way they positioning.
feel.
84
What contributes to difficulty not be so obvious and you will be in a position

in conversations? of trying to identify whether the person has a
specific difficulty. Hannon and Clift (2011: 104)
Communication difficulties for the
suggest some possible indicators when commu-
person you are speaking to
nicating with people with learning disabilities, but
A difficulty when communicating with individu-
these could apply equally when communicating
als, in particular on first meeting them and when
with other individuals, such as children, people
forming new relationships, is finding out how
with cognitive impairments, people with sensory
much the person understands and if they have
impairments, people experiencing mental health
any existing communication difficulties (Hannon
difficulties and people whose first language is not
and Clift 2011). Their level of understanding or
English.
any existing communication difficulties may
make the communication interaction more com-
plex, for you or for the other person. On first Conversations about dying: fears,
meeting with someone it may be obvious that misconceptions and beliefs
they have an existing communication difficulty, As well as specific difficulties in their communica-
such as lack of or altered speech, or expressing tion, people also have to overcome other barriers
difficulty in understanding you (‘Say it again?’ to communication. These barriers are faced by all
or ‘Oh yes’ in response to an open question). people in the conversation and are put there by
There will be many other situations where it may both the person and the professional. For the per-
son in the end-of-life situation there are all sorts of
reasons that make it difficult for them to approach
you and share their worries and needs. The chal-
lenges for a person needing care in end-of-life
Activity 6.4 situations are compounded by the challenges the
With your field of nursing in mind, consider professional feels (see Table 6.1 next page).
the following and reflect on those occasions when
you have experienced similar situations in your Finding the words
practice. Consider whether those situations were A difficulty for many nurses when communicat-
well managed, and if not, why not? ing to patients that they are dying is deciding
The person you are speaking to: what to tell everyone involved. There is a natural
initial response to ‘not tell’ as a means of protect-
has difficulty in finding the right words to
ing them. Much can be learned from the literature
express their thoughts and emotions;
about communicating about dying in children’s
uses words but does not appear to fully under-
nursing. This knowledge can be transferred into
stand them;
many adult, mental health and learning disability
demonstrates confusion, especially when more
nursing situations.
than one person is talking – for example when
staff and family members are present;
is acquiescent – giving you the answer they What to tell children who are dying
think you want; The evidence indicates that children are never
repeatedly asks the same question; too young to be told what is happening to them
talks about everyday things but not about emo- (Silverman 2000). Children of all ages are astute
tions; observers who pick up on parents’ emotions and
has family members that talk instead of them. anxieties. They read non-verbal communication,
compare it with the verbal and try to make sense
85
Table 6.1 Common fears, beliefs and challenges that hamper effective
communication (adapted from National End of Life Care Programme 2011b)
Fears of people being cared for Fears of professionals

Of being stigmatized Unleashing strong emotions
Of being judged ungrateful or inadequate Making things worse
Breaking down and crying Saying the wrong thing
Burdening health and social care staff Facing difficult questions
Causing distress to others Taking up too much time
Not being able to find the words Facing our own failure
Beliefs of the person being cared for Beliefs of professionals
Problems are an inevitable part of illness so Emotional problems are inevitable and
health and social care staff should anticipate them nothing can be done about them
Problems cannot be alleviated It’s not my role to discuss such things
Professional people are only interested in certain There’s no point talking about problems that
types of problems cannot be solved
This is not the ‘right’ professional person to talk with They don’t understand what’s happening
Professional staff are too busy They don’t need to know
Challenges perceived by the person being
cared for Challenges perceived by professionals
It’s hard to find the right words Lack of skills or confidence
The right questions weren’t asked by the Starting end-of-life discussions
professional Exploring concerns
Problems hinted at are not picked up by the Handling difficult questions – saying the ‘right’ thing
professional Closing the conversation sensitively
Not communicating in first language
Cognitive impairment Workplace
Lack of support from colleagues or managers
Lack of privacy
Time constraints
Noise and distractions
Nowhere to refer to for psychological support
No training or supervision in communication skills
of it. Piaget (1929) describes this as ‘accommoda- or distress holds them back from talking to the
tion and assimilation’: comparing what is known child about the potential of death or the serious-
and matching the unknown within this to make ness of the situation. Recognizing the distress,
sense. However, some things will not make sense the child attempts to protect the parents by not
and will be interpreted as being ‘at odds’, caus- asking questions that they think may cause fur-
ing children to feel concerned and not involved ther distress. The parents interpret this as ‘they do
(e.g. when the parent is crying and distressed but not need to know’ and thus a situation of mutual
says everything is fine). This can lead to a con- pretence, that both are ‘OK’, develops (Bluebond-
cept of ‘mutual pretence’: the parent’s reluctance Langner 1978).
86
However, we know that children have to make

sense of everything (see Case study 6.1). Asking Case study 6.1: Ben
questions is how they learn and fantasy and make-
believe are tools that children use to help make Ben was 8 years old and had been
sense of unfamiliar, unknown or frightening situ- diagnosed with an osteosarcoma when he was
ations. When did I last see my mummy cry? What aged 7. A routine follow-up scan three months
makes daddy so angry? At a time when they would after the completion of treatment confirmed
ask mummy or daddy they feel unable to do so. that the tumour had regrown. The results of this
Understanding why parents try to avoid these con- test were shared with his parents and a deci-
versations, and what benefit the conversation may sion regarding no further active treatment was
have for a child, can help you support the parents agreed upon. However, Ben’s parents requested
in their decision-making (see Table 6.2). that he should not be told the results as they felt
The nurse is in a challenging situation when he would not be able to cope with this news.
supporting and communicating with a family While the team were with his parents Ben
where a child is dying. It is necessary to be able asked a nurse who was recording his observa-
to act as the patient’s advocate while at the same tions, ‘Am I dying?’ She sat next to him and asked
time meeting the needs of the family. Kübler-Ross why he had asked this question. He described
(1969) states that everyone has a right to know that how, when he was diagnosed, it was explained to
they are dying but not everyone needs to know, him that he had a tumour, that it would not get bet-
and the thing to bear in mind is that parents know ter on its own but there was treatment to help. He
their child best and therefore their views must be continued, ‘I have had the treatment but it has not
taken seriously. The parents’ decision to not tell gone away so I must be going to die.’ The nurse
their child needs to be explored sensitively, utiliz- explored this with him and he told her that he had
ing the skills explored in this chapter. Whatever things that he wanted to do, and asked how long
decision is made, it is important that parents are he had to live. He didn’t want to ask his parents
encouraged to respond to a child’s questions in a because he knew that they would be upset. He
composed and relaxed manner. This can help the was relieved that the nurse suggested sharing
child to feel secure and supported (Faulkner 1998). this with his parents, and together they were able
Honesty is a key element when communicating to plan his end-of-life care.
with family members (Heyland et al. 2006).
Table 6.2 Understanding parents and children in end-of-life care
Why parents may be reluctant to

tell their child that they are dying Why children need to know
Impression of giving up on their child They may have questions
Need to maintain hope They may be frightened
Don’t know what to say They may already have an idea (expert patient)
Child doesn’t need to know They may have unfinished business – things they want to do or say
They won’t understand They may want to make a will if they are over the age of 12, or
give instructions about their belongings in a less formal way
They wouldn’t be able to cope They may want to plan their funeral
They might ask difficult questions They may want to say goodbye
87
mass’ – but that’s not cancer! There are many

Key learning
The fears and beliefs of people both
! more examples like this, and you should try
to avoid them. Most people can identify their
own difficulty when trying to talk about dying
being cared for and acting as the carer will and death, in particular with specific individu-
create barriers and challenges in end-of-life als such as children and people with cognitive
care conversations. impairments, but there are some other situa-
Situations of ‘mutual pretence’ and collusion cre- tions we want you to prepare for, and these are
ate tensions in care for all concerned and need addressed in Activity 6.5.
to be managed with honesty and sensitivity.
Activity 6.5
With your field of nursing in mind, think
The power of language
about some of the ways that ‘dying’ and ‘dead’ are
Reluctance to communicate due to fear, having
explained and the possible difficulties these terms
false beliefs and misconceptions, or assuming that
may pose. Write down (and try saying out loud)
you know what the question is about are some of
the exact phrase you would use to explain some-
the reasons that communication can break down.
one is dying if talking to:
If such problems are not identified and resolved
it can lead to a chain reaction of communication an elderly relative with a hearing impairment;
breakdown between yourself and the person or a school-age child, grandchild or sibling
family members (Bunning 2011). This is described (5–10-year-old);
as a breakdown process – from the initial com- a pre-school age child, grandchild or sibling
munication struggle through to the outcome and (2–4-year-old);
possible social implications, such as withdrawal a teenager with a cognitive impairment;
and social isolation. This chain reaction and the someone with dementia;
potential outcomes highlight the crucial nature someone with a learning disability;
of consciously reflecting upon all aspects of any a son or daughter with a mental health difficulty.
communication interaction, and this includes the
words that you choose to use. Thinking about
The key thing you are trying to achieve is mutual
these before the situation arises can help you to
understanding – do you and the other person
be a little more prepared and to feel a bit more
understand what is being communicated? Remem-
confident.
ber that in practice settings, communication is
Euphemisms can make communication more
not only about the person understanding you and
complex or distressing, either at the time or
other staff, but also about you understanding the
subsequently when the true meaning becomes
other person and their family members.
clear. Euphemisms can represent a struggle to
express ideas; they can create a complex start-
!
ing point when we consider all the terms and
euphemisms that are associated with dying
Key learning
and death. Some euphemisms that have led to A person’s current level of understand-
distressing conversations include ‘he went to ing or difficulties in communicating must be
sleep’ which resulted in a fear of falling asleep; assessed.
‘he’s gone to heaven’ which raises questions Indicators may help you identify those who
about heaven and hell; ‘he’s with the angels’ – have a communication difficulty.
so why them and not me?; ‘the tumour/lump/
88
Impact of difficult communication unconditional positive regard;

situations on emotions warmth and genuineness;
empathy.
If communication breaks down, you must con-
sider how this makes the person and yourself feel
and behave. Behaviours demonstrated in difficult
situations are often a way of expressing one’s Activity 6.6
underlying emotions (e.g. frustration, anger, anxi-
ety, fear, sadness, disappointment, grief). At times What is meant by the three qualities
like this, we are once again in a position of consid- below suggested by Carl Rogers?
ering the expression of communication by means Unconditional positive regard means . . .
of our body language and trying to understand the Warmth and genuineness means . . .
underlying communication message (Donnelly Empathy means . . .
and Neville 2008).
Emotions are a normal physiological and psy- With your field of nursing in mind, identify a prac-
chological reaction to many complex health care tice experience that you have been involved in or
situations, and that means our own emotions as observed where these qualities were evident.
well as those of others. The following points may
What was it about this experience that high-
help you in complex situations such as end-of-life
lighted unconditional positive regard for the
care.
other person?
How did you or another person demonstrate
Consider your own emotional state and your empathy, warmth and genuineness?
response to the other person’s emotions – are
you feeling upset, anxious, frightened, angry,
sad, worried? How are you displaying these
feelings to the other person? Communicating and giving
Acknowledge the emotion – recognize it and emotional support
try to support, manage or diffuse it – emotions Thinking about and adopting a humanistic model
should not be ignored. For example, strong can help develop skills of emotional support,
negative emotions such as anger may need to which along with information is one of the two
be diffused. essential elements of a health care conversation
Try to find out the cause of the emotion – it (Duke and Bailey 2008). These will depend on
may not be what you think it is. the context of the situation and the nature of the
Empathize with the other person – imagining problem, but both must be there in the conver-
what it must be like to be in their situation. sation to some degree or another for it to be a
Use your body language and speech – remember successful one. And another consistent feature
that earlier we mentioned that the largest part of end-of-life conversations is the courage to be
of what is communicated is by body language with people in distress, to offer empathy and try
and then by voice, with only a small percent- to ‘hold’ the distress with the person. It may seem
age by our actual words. obvious to say that you need to be kind, yet this
Draw upon the humanistic models, such as is one of the things that patients and relatives
Rogers (1951), Egan (1986) and Heron (1999). complain about – that empathy is apparently
The three qualities advocated by Rogers are lacking in their relationships with nurses (Kunyk
evident in humanistic models and highlight the and Olson 2001). Stories about lack of compas-
complexity of interpersonal interactions, par- sion or care make devastating reading (Triggle
ticularly in difficult situations. They are: 2011).
89
The shape of the conversation for supporting people in distress (Connolly et al.
The structure of the conversation is as important 2010), and using a model like this in one of the
as the tone. The shape of a good conversation licensed training sessions can help staff develop
contains a greeting, a farewell, an ending. Have confidence in emotional situations (Box 6.1).
you ever felt upset about someone walking away
before the conversation seemed to have ended, or
when someone has hung up the phone without Box 6.1 Sage and Thyme model
saying goodbye? Again, it seems obvious, yet sto-
ries of poor practice – such as the visitor who asks Setting – If you notice concern – create some
a patient ‘Who was that?’ after a doctor’s round privacy – sit down
only to be told ‘I don’t know’ – are common. And
Ask – ‘Can I ask what you are concerned
nurses are no less guilty – we start conversations about?’
with ‘I’m just here to take your blood pressure’
without saying ‘Hello’ or ‘How are you’, or ‘May I?’ Gather – Gather all of the concerns – not just
As well as the greeting and the farewell, there the first few
are other interconnected stages in a health care Empathy – Respond sensitively – ‘You have a
conversation that will help to make it successful. A lot on your mind’
good conversation will normally have five stages
AND
(Duke and Bailey 2008):
Talk – ‘Who do you have to TALK to or to help
greetings and introductions; you?’
listening to and understanding the other per-
Help – ‘How do they HELP?’
son’s story;
exploring how this story might change and You – ‘What do YOU think would help?’
what this possibility feels like;
Me – ‘Is there something you would like ME to
agreeing a plan to manage the things that
do?’
might cause the story to change;
summarizing, providing follow-up and contact End – Summarize and close – ‘Can we leave it
details, saying goodbye. there?’
A good starting point when you are communi-

cating with a patient about end-of-life care is to
!
use some open-ended questions, but not too many.
This enables you to develop an understanding
Key learning
about the person’s perceptions and views. These Conversations should contain the five
are the sort of questions you can ask: essential elements: greeting, listening to the
story, thinking about how things may change,
What do you think might help the situation? agreeing a plan and summarizing the conver-
What would you like to do? sation before saying goodbye.
Conversations need to contain both emotional
The answers to such questions can help you as support and information.
the professional to avoid assuming that you know Emotions are a normal reaction, but thinking
what the person is feeling or needs, or jumping about and recognizing the emotion before,
in with an unwelcome or untimely suggestion. during and after a conversation can help in the
These key supportive strategies are incorporated delivery of good care.
into models such as the Sage and Thyme model
90
Breaking bad news is not where this conversation was going at all!
While standard answers are not suitable for these
The Sage and Thyme model is useful when
situations there are certain skills that will help.
acknowledging, managing or containing distress,
Figure 6.1 offers examples of how these might
but is not a model for the breaking of significant
be phrased.
bad news. For this, the SPIKES model (Baile et al.
2000) is the appropriate one. While the intent of
!
these two models is different and they should not
be confused with one another, they both con- Key learning
tain the essential components of a good health Thinking about the words you choose
care conversation identified by Duke and Bailey to use before a situation arises can be helpful.
(2008). Avoid euphemisms, which can cause misun-
derstandings and anxiety in others.
Finding out what the person wants or thinks is
Box 6.2 The six steps of SPIKES key to supporting them.
Using a model for a particular situation may
STEP 1: S – SETTING UP the interview be helpful in guiding the conversation and
ensuring all the key things are thought about
STEP 2: P – Assessing the patient’s and addressed.
PERCEPTION
STEP 3: I – Obtaining the patient’s

INVITATION How can I manage to do all of this?
STEP 4: K – Giving KNOWLEDGE and infor- Nurses’ emotional commitment to their patients
mation to the patient goes beyond what they may feel personally,
and this contributes to the quality and excel-
STEP 5: E – Addressing the patient’s
lence of nursing care . . . Experiencing emo-
EMOTIONS with empathic responses
tions is considered essential for nurses to cope
STEP 6: S – STRATEGY and SUMMARY with morally difficult clinical situations (e.g.
patients who refuse medical treatment) and to
interact ethically and meaningfully with people
in distress.
Using models such as Sage and Thyme and (Huynh et al. 2008: 196)
SPIKES assumes that you have some key skills such
as being able to reflect questions back to the per- What you will find is that this all takes effort, and
son so that you can be certain the answer to their the concept of emotional labour is wisely named,
question really is what they’re after. This is par- for labour it is. It can certainly be very demanding
ticularly important when being asked a question or draining to maintain an outward expression of
such as ‘Am I dying?’ You may want to respond to calm safety while feeling uncertain and out of your
this question by asking, ‘Can you tell me why you depth (Gray 2008). Spontaneous emotional reac-
ask that?’ This can help to clarify what is actually tions to a situation need to be transformed into
being asked. When the reply is ‘I’m scared to go expressions of emotion that are acceptable both
to sleep’ or ‘I need to make things better with my to society and the organization you are working
brother who I haven’t spoken to for 20 years’ you in. This should lead you to think about the way you
might find the response you were rehearsing (‘Yes, present yourself as a professional person, your
I’m sorry but I think you have less time now than ‘work personna’, and the way you express not just
when we spoke at the end of your treatment’), reactions to circumstances but also the deliberate
91
People respond to people who respond
STOP, LOOK, THINK

Resist the temptation to run!
Make eye contact and pay attention - you are important
Negotiate: ‘Are you able to say what’s worrying you?’ = I am willing to listen, but I can see it’s hard and I don’t want to distress you
LISTEN, RESPOND
Silence: don’t be afraid to be quiet and let the person gather their thoughts
Open questions: ‘How are you feeling/what do you think about that?’ = I am interested/concerned
Educated guesses: ‘I imagine that came as quite a shock’ = I have an idea about how you might be feeling, do you want to
talk to me about it?
Prompt: ‘Yes, go on’ = I’m still listening
Acknowledge and reflect: ‘You’ve had a rotten time by the sound of it’ or ‘You look/sound upset’ = how you feel matters, I can
see you’re upset, it's OK to tell me about it, I want to help
Clarifying: ‘What are the things about it that upset you?’ = I”d like to understand exactly what the problem is
MAKE A PLAN, END THE CONVERSATION

Paraphrasing to sum up: ‘Being ill has been really distressing/you really want to get some answers about this’ = I want you
to know I’ve heard and I’m checking I’ve got it right
Open directive questions: ‘What’s most important to you right now?’ = I think you might have concerns/needs and I want to help
Summarizing: ‘So what’s most important is ... [list of things said]’ = I’ve heard you, have I got it right, have I missed anything out?
Permission: ‘Can I talk to someone about this?’ = I think you need more help than me, but I’d like your permission first
Remember to close: ‘I’m glad you talked to me, would you like me to come back/let you know when I’ve done...’ = it was all
right to talk to me, you’ve given me things to do on your behalf and I know that you need to know when I do them
©Kay Townsend, University of Southampton, 2011. Adapted from National End of Life Programme Finding the Words
Figure 6.1 Managing difficult conversations
expression of more deeply felt emotions (Huynh A work ‘persona’ helps nurses engage in emo-
et al. 2008). This concept is relatively underdevel- tional labour (Truc et al. 2009). Knowing what
oped in nursing, but having a sense of what it is your work persona is like, that is, how it appears
about may help you manage the labour it entails. to others, what helped to form this ‘nurse version’
of you, and what influences the way your persona
manages situations, will all help you develop your
Activity 6.7 ability to labour emotionally. Social norms in work
and the support you receive will help your per-
Who helps you think about your work
sona develop, as will your work experience, your
persona?
skills, how you view the nursing profession and
Make a list of the people that you talk to about
of course the situation you work in, what sort of
difficult situations, and how they help (e.g. lis-
demands are made of you, how much you work
ten, challenge, guide).
alone or in a team and how complex your work is.
Who do you help and support with their devel-
oping work persona?
Conclusion
How often do you reflect on difficult situations
from practice? What guides your reflections? The guidance in this chapter has aimed to help
guide your practice in difficult times. Remember
92
that it takes courage to just ‘be with someone’, the expression of these thoughts and feelings in
not talking or carrying out tasks. One of the most the words you use and your body language. It’s not
complex and difficult areas of practice is end- just what you say but the way that you say it. Body
of-life conversations. Such communication can language is a major element in communication
provoke a range of emotions both for you and and your tone of voice and facial expressions will
the other person/people involved. The difficulties be remembered. Prevent confusion and misunder-
may be around fears, beliefs and misconceptions; standing by avoiding euphemisms.
both yours and the other person’s. Having good Make sure you greet people, listen to their story
conversations with those facing death and dying and consider how their life is changing and how
requires both preparation beforehand and reflec- that makes them feel. Leave people with a sense
tion during and after the conversation. Commu- that there is a plan, then summarize the conversa-
nication is not only about you being understood tion and make sure you say goodbye.
by others, but about you understanding other Importantly, look after yourself. Consciously
people. think about your ‘work persona’, how it is per-
Communication involves the synchronization ceived, how it is developing and how it helps you
of what you are thinking, how you are feeling, and in your emotional labour.

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94
Section
Nursing practice and 3

decision-making
An introduction to
clinical decision-making
7
in practice
Mary-Jane Baker
Chapter contents
Introduction Identifying available sources of knowledge
Domain 3: Nursing practice and decision-making Using evidence in decision-making for care
generic competence Decision-making: being organized in your
What is clinical decision-making and what is thoughts and actions
the decision-making process? Setting priorities and making choices
The complexity of the context of Communication, reflection and
decision-making decision-making
Reflecting on your decision-making processes Moving forward
Picking up cues Further reading and resources
Having a sense of purpose/being clear References
in your plan
Introduction carefully and think hard about what is going on

and what you and others need to do. Making
People make decisions all the time. What to eat,
the right decision is very important as decisions
when to go to bed, what to wear . . . the list is
have consequences – not only for you but also for
endless. Some decisions we make without really
colleagues and most importantly for those you
thinking about them, but others prove more dif-
care for.
ficult, prompting us to consider options and make
In this chapter the NMC generic standard for
judgements about what might be the best deci-
competence in decision-making will be explored.
sion in the circumstances presented.
Professional health care practice requires much
Domain 3: Nursing practice and decision-
decision-making and when you first start a pro-
making generic competence
gramme of study leading to registration as a nurse,
it can seem complex and confusing. It may be All nurses must practise autonomously, com-
reassuring to understand that even experienced passionately, skilfully and safely, and must
practitioners have difficulty in deciding what the maintain dignity and promote health and well-
right course of action might be at times, because being. They must assess and meet the full range
caring for people can be complicated. However, of essential physical and mental health needs
complicated does not mean impossible, or even of people of all ages who come into their care.
difficult – it just means that you have to observe Where necessary they must be able to provide
97
Section 3 Nursing practice and decision-making
safe and effective immediate care to all people What is clinical decision-making
prior to accessing or referring to specialist ser- and what is the decision-making
vices irrespective of their field of practice. All process?
nurses must also meet more complex and co-
To decide something means that you have reached
existing needs for people in their own nursing
a conclusion or determined an end point to your
field of practice, in any setting including hospi-
deliberations. According to Gambrill (1990), clinical
tal, community and at home. All practice should
decision-making is concerned with managing a
be informed by the best available evidence and
range of information from diverse sources, to make
comply with local and national guidelines.
professional judgements. Dowie (1993: 8) puts it
Decision-making must be shared with service
more simply by explaining that judgements are ‘the
users, carers and families and informed by
assessment of alternatives’ whereas decisions require
critical analysis of a full range of possible inter-
that one ‘chooses between the alternatives presented’.
ventions, including the use of up-to-date tech-
A variety of models which explain and clarify the
nology. All nurses must also understand how
decision-making process are available (Banning
behaviour, culture, socioeconomic and other
2008). Of these, the hypothetico-deductive model
factors, in the care environment and its loca-
described by Taylor (1997) has been a popular choice
tion, can affect health, illness, health outcomes
in nursing. It offers decision-making as a process in
and public health priorities and take this into
four stages, as shown in Box 7.1 opposite.
account in planning and delivering care.
A different model for clinical decision-making
is offered by Junnola et al. (2002) who indicate that
Regardless of your field of practice, this chapter
clinical decision-making is a process operating in
will facilitate your understanding of the value of
two phases, starting with a diagnosis of a problem
making appropriate decisions in clinical settings
and moving on to problem management or action
and what resources need to be accessed to help
(see Box 7.2 opposite).
you make the best decision in the many and varied
Whatever model is used, it is clear that collect-
situations you will come across. It is not the inten-
ing information, assessing that information and
tion to give you a series of answers to all clinical
making choices for action are all key aspects of the
problems, but rather a toolkit for you to use as a
clinical decision-making process. See Junnola’s
professional resource for action. It may be use-
2 phase process.
ful to have a pencil and paper handy as you work
through the chapter as you may wish to record
your responses to the exercises offered. Indeed, if
The complexity of the context of
you have not already started to record your nurs-
decision-making
ing activities, feelings and thoughts in a reflective The number of activities involved in clinical deci-
log or journal of some kind, now may be a good sion-making, together with the added dimensions of
time to begin. critical thinking and problem-solving (Wainwright
Remember that this is a generic domain but it et al. 2011) give some insight into the breadth of
takes on field-specific qualities when applied to skills required to do it well. Also, it must be remem-
the needs of the particular client group you will bered that decisions are made in a specific context
encounter in your field of practice: child, adult, and the influencing factors of any practice situation
mental health and learning disability – as speci- offer additional information, but with that, addi-
fied by the Nursing and Midwifery Council (NMC tional complexity. Gillespie (2010) helpfully divides
2010). Additionally, further scrutiny of the other the contextual influencing factors which are
NMC domains will identify that decision-making is encountered when making nursing decisions into
a core component of practice and central to the three levels (see Box 7.3 p. 100). When starting
provision of excellent care. out as a student nurse, it is likely that you already
98
Chapter 7 An introduction to clinical decision-making in practice
Box 7.1 The four stages of the hypothetico-deductive model (Taylor 1997)
1 Picking up available cues: for example, this may include observing the patient for signs that tell you
something about them, noting their age, facial expression, how ill they appear, any disabilities and how
dependent or independent they are. In addition, patients can report symptoms to you, such as thirst or
pain.
2 Making hypotheses from those cues: as your experience in clinical practice grows you will be able
to make use of multiple cues to assess what is going on. You may begin to be able to assess what the
underlying problem or issue is, or at least consider one or two possibilities which may be causing the
patient’s problem.
3 Obtaining further information about each hypothesis to validate or invalidate them: for
example, while taking routine post-operative observations, you might note that a female patient has dry
lips and looks flushed. She may be in pain and feeling nauseous and therefore unable to drink, making
her become dehydrated. Questioning can help you better assess the situation, along with observations,
noting fluid chart data and when analgesia was last given to the patient. Together this information will
help you to form an idea of what is happening to the patient.
4 Evaluating each hypothesis and then reaching a final diagnosis: at this point you may decide the
patient requires pain relief and an antiemetic that has been prescribed to solve the problems you have
noted. As a student nurse you may find it helpful to check your diagnosis with your colleagues, mentor
or a qualified practitioner.
have some experience of all these factors but per- Looking at decision-making, in practical terms,
haps the area where you feel most ‘comfortable’ the key stages of the process are summarized in
and ‘independent’ initially is at the micro level. Box 7.4 opposite.
By virtue of the fact that all interventions of care
are derived from the decision-making process, it
!
is easy to see why it has been described as the
Key learning
‘cornerstone of practice’ (Flannery et al. 2011). To
care for patients safely and effectively, it is essen- An understanding of how decision-
tial that health care professionals understand the making is defined, the process involved in
component parts of the decision-making process, reaching a decision and evaluating that deci-
their role in that process and the means to improve sion are central to providing effective and high
or attain skills to complete the process well quality care.
and in different situations, time and time again.
Box 7.2 Clinical decision-making as a two-phase process (Junnola et al. 2002)
Phase one Diagnostic Observation of the patient episode

Collection of data
Processing of data
Diagnosis or identification of the problem
Phase two Management Draw up a plan of action
99
Box 7.3 Influencing factors (Gillespie 2010)
Micro level The nurse–patient relationship

All patients are individuals and knowing about the person, their preferences and
responses to care, including their own resources, will be important and impact on clinical
decisions made. In addition, as a student, your own experience, confidence, along with
knowing your own strengths, limitations and learning needs will be significant in how you
approach making decisions.
Meso level The working environment and other personnel

As a student, communicating and collaborating with other appropriate staff in the work-
ing environment is important and an understanding of the clinical environment and
culture will be needed. There may be challenges in terms of constraints, such as work-
load and other interruptions, or limitation of time and resources which will impact on
what decision is possible to carry through.
Macro level Professional and political factors

As a student you will need to be aware of the NMC competencies and code of practice
(NMC 2008) which impact on what you do in practice and on the decisions you make.
It is worth remembering that there are many factors which will impact on and influence
priorities in health care decision-making which relate to other professional, political and
social drivers.
Box 7.4 Key stages of the decision-making process
Interpret the context (i.e. ask ‘What is happening?’)

Identify the purpose or goal (i.e. ask ‘What do I want to happen?’)
Consider what resources are available (i.e. ask ‘What do I already know about the person/the
context/the situation?’)
Clarify what other resources you need (i.e. ask ‘What else do I need to know and where can I get this
information/help?’)
Gather your resources together
Evaluate your resources (i.e. ask ‘Is this evidence relevant to the situation and if it is relevant, is it
useful?’)
In cases where you have more than one useful resource, decide which resource/piece of evidence is
most useful now to attain your goal/purpose
Confirm to yourself why this is the case
Inform the patient and everyone else involved what you intend to do
Receive feedback and adapt your actions accordingly
Reflect on the decision-making process (i.e. ask yourself ‘Did that event go well/badly/as expected?’)
100
Perhaps your process includes the factors and

Activity 7.1 considerations suggested in Table 7.1 on the
next page.
Consider an activity in which you
made some decisions today and involved other
people (such as a conversation, a journey or a
Reflecting on your
shared meal).
decision-making processes
Can you frame that activity so that it becomes In your response to Activity 7.2, you may have
a scenario with a beginning and an end (e.g. I given some rationale for your thoughts (as in the
felt hungry, I ate something and I did not feel example) but it is interesting and important to
hungry any more)? note what factors influence your decision-making.
Now, apply the stages Box 7.1 to your scenario What you have just done in the activity is a process
and see what you come up with. called ‘thinking aloud’ (Ness et al. 2010) which is
a particularly useful way to clarify your purpose,
the situation and your resources and consider
how they fit together. Interestingly, the process of
In Activity 7.1 it is likely that the first two
decision-making in this scenario necessitated a
stages did not take you very long to do, but what
change of purpose from the original one planned.
about the others? The first two stages are in the
This, in turn, meant that pre-planned resources
diagnostic phase of decision-making and the
needed to be altered and new ones added to
rest are in the management phase. In a situation
ensure the best outcome at this time. This ‘shift-
where something is so familiar, like having a meal,
ing situation’ can often happen in clinical practice
it may be strange to break down the activity in this
and the speed with which you decide to act in such
way but hopefully you defined some actions that
circumstances is dependent on your skills and
uncover the intricacies of the decisions we make
experience in considering the factors influencing
without really thinking about them (e.g. what you
the situation and in doing a number of activities,
ate, why you ate the amount you did at the time
seemingly simultaneously (see Box 7.5 p. 103).
you did, and so on).
Activity 7.3
Activity 7.2
In considering your ability in each aspect,
Now look at the following scenario and
try to offer an example from your practice that
apply the stages again.
supports your assertion. How skilled are you at
Catherine Lessing is a 62-year-old who was admit- changing practice situations? Look at Box 7.5,
ted earlier today on your ward. You are asked to p. 103 and take a few moments to give yourself
take and record Mrs Lessing’s observations. You a score out of 10 for each of the activities listed,
have not met Mrs Lessing before. When you go up where ‘10’ means that you have considerable skill
to see her, she is sitting on her own by her bed and ‘1’ denotes an area that you feel you do not
and you notice that she is crying. do well at the moment. If you give yourself a score
of 70 (i.e. 10/10 for each activity) you have done
very well. However, there is always something new
In applying the stages in Activity 7.2 you may and useful to learn and everyone can extend their
have come up with a number of alternative plans competence in decision-making, so please com-
of action and also have some questions that need plete the activity honestly and then read on.
to be answered with more detailed information.
101
Table 7.1 Possible stages of decision-making
Level of influencing
Stage Thoughts factors (Gillespie 2010)
Interpret the context: what do The patient is crying. I do not know the Micro
you observe and what does reason for this.
it mean? (i.e. ask ‘What is
happening’?)
Identify the purpose or goal I want to introduce myself and find out why Micro
(i.e. ask ‘What do I want to the patient is crying. I want to take and
happen’?) record her observations.
Consider what resources I know the name and age of the patient and Micro and meso
are available (i.e. ask ‘What what she has been admitted for (as I heard
do I already know about the this at handover). I know that she has been
person/context/situation?’) admitted today. She is sitting on her own
but her bed is in a six-bedded area and
other patients occupy the other beds.
Clarify what other resources I need to know why she is crying to see if I Micro and meso
you need (i.e. ask ‘What else can help her. I need to give the patient some
do I need to know and where privacy. I may be able to ask the patient. I
can I get this information/ may be able to find information out from her
help?’) charts and care plan at the end of the bed. I
still need to do her observations so should I
get the equipment for this ready? I may need
to get the help of another member of staff.
Gather your resources I am a resource as I have a legitimate Micro, meso and some
together reason to talk to and have some limited macro (with professional
knowledge of the patient. The patient is accountability issues
distressed but appears able to speak. There acknowledged)
is a box of tissues on the patient’s locker.
There are curtains that could be pulled
around the bed space. The patient’s care
plan and charts are available at the end of
the bed. The necessary equipment to take
and record the observations is with me.
There is a call bell by the bed. My mentor
knows that I am with this patient.
Evaluate your resources (i.e. All the resources I have identified are relevant Micro and meso
ask ‘Is this evidence relevant to to the situation but I am not sure how useful
the situation and if it is relevant, the equipment for taking and recording the
is it useful?’) observations is at this time. I do not think that
this is an emergency at the moment so I may
not need to use the call bell.
In cases where you have more I think that there are a few very useful Micro and meso
than one useful resource, resources at this time: the patient, myself
decide which resource/piece and the curtains around the bed.
of evidence is most useful now
to attain your goal/purpose
102
Table 7.1 Possible stages of decision-making (Continued )
Level of influencing
Stage Thoughts factors (Gillespie 2010)
Confirm to yourself why this is The resources are helpful because my Micro
the case overriding purpose now is to find out why
the patient is crying and to try to help her
Inform the patient and I will approach the patient gently, asking if I Micro and meso
everyone else involved what can sit with her. I will introduce myself and
you intend to do state that I have noticed that she appears
to be upset. I will offer to close the curtains
around her bed. I may hold the patient’s
hand.
Receive feedback and adapt Hopefully the patient will acknowledge Micro
your actions accordingly and accept my presence but if not, I would
have to act on her cues and take action
accordingly (go back to the beginning of
the decision-making process)
Reflect on the decision-making If the patient is able to tell me what is Micro, meso and macro
process (i.e. ask yourself upsetting her I may be able to help her
‘Did that event go well/as and I would say that the process had gone
expected?’) well, particularly if I knew I had given her
the required privacy, listened to her, acted
professionally and with kindness and
taken further action as a result of what she
told me.
Box 7.5 Skilled activities in changing practice situations
Your score
Picking up cues by making detailed observations of the situation (the scenario

started with these).
Having a sense of purpose (your intervention intention/tentative hypothesis).
Clarifying what resources are available to you – what you know, what you may know
and what you need to know (about the situation, the possible outcomes and the sub-
sequent possible course(s) of action).
Focusing on the specifics of the situation and organizing your resources into some
order.
Setting priorities and making choices with confidence.
Practising skilled two-way communication.
Reflecting on (in or before) practice.
Total score =
103
mation and your first action would probably be

Key learning
Understanding what you are already
! to find out more by assessing the situation with
the patient (Standing 2007). That includes talk-
ing and listening to them, looking at patient notes
good at and what you might do better at is the and records and conferring with other members of
first step to understanding how to make good staff. This highlights the value and importance of
decisions in clinical practice. communication as a skill to access and share the
information you require.
However, it is also possible to have too much
The chapter now explores some of the specific
information. Certainly when you start your nurs-
concepts already outlined, offering practical tips
ing career, you may feel bombarded with informa-
which will support you in clinical practice and
tion and until you get to a point where you can
help you consider what can be improved when
discriminate between useful and non-useful infor-
you have clinical decisions to make.
mation, the number of cues or data you collect
can be vast and confusing. Being discerning with
Picking up cues cue collection is an important skill but one that
The clinical decision-making process is initiated must be balanced with care, so that you collect
when the nurse recognizes or picks up cues from enough information and avoid jumping to conclu-
a patient or clinical situation. These can take the sions. For instance, as a nurse, I may have omitted
form of something expected or unexpected and to note that the medication taken by the patient
provide data for the nurse to process. Cues enable had been newly prescribed (and nausea may be
a situation to be understood more fully and it may a common side-effect) or that I was unaware that
sound easy, but consider Activity 7.4 and identify the patient was anxious about an expected visit of
the important cues or information for you to be a relative.
able to decide the best course of action. In practical terms then, to maximize your ability
for cue collection, you need to use skills of com-
munication to collect as many cues as you can, but
Activity 7.4 try to place these into some semblance of order of
importance based upon:
A patient complains of feeling nauseated
and seems distressed and agitated. From what you where you got the information from (the
already know about the patient, this is unusual. source);
They have no dietary or fluid restrictions and whether the cue has the breadth to encompass
appear to have eaten a normal lunch. They have the activity in the scenario (the scope);
taken their prescribed medication. It is visiting whether the cue is relevant; and
time on the unit. whether the cue reminds you of a previous
List the pieces of data you can gather from this experience (pattern recognition) to help you
scenario. assign meaning to the current situation.
What do you consider the possible reasons for
the patient’s condition?
Having a sense of purpose/being
From the information you have, what would you
clear in your plan
do next?
Florence Nightingale identified the essential
nature of knowing the outcome of each inter-
The problem with the scenario in Activity 7.4 vention to be able to plan effective care (1946).
is that, of course, you do not have enough infor- The hypothetico-deductive model described
104
earlier identifies this stage of the decision-making how knowledge is classified. A seminal paper by
process as hypotheses formation. An hypothesis Carper (1978) described that nurses knew more
is a proposal or something you believe may be a than they could communicate to others. Carper
possible outcome to a situation. Previous experi- was doubtful that scientific or factual knowledge
ence of a similar situation may help you here but alone could explain all aspects of nursing prac-
you cannot experience everything, therefore you tice. Recognizing that the complexities of nurs-
require skills to be able to build a picture of pos- ing practice had not been well explained in the
sibilities (Huckabay 2009). past, Carper offered a new way to illuminate the
At a basic level you may only be able to offer patterns of knowing that nurses operated within.
a ‘best guess’ in a situation but even in these cir- Although Carper’s paper is dated, the patterns of
cumstances you must ensure that a safe outcome knowing in Table 7.2 (on the next page) have
results. To do this you must, wherever possible, been added to by authors such as Munhall (1993),
involve the patient and/or others in the plan to White (1995) and Chinn and Kramer (2008), and
get guidance and support that the chosen action still reflect contemporary practice.
is acceptable and patient focused. Involvement
of others offers the opportunity for more options In summary these ideas are intended to high-
(which you may or may not think you want), but light the fact that when decisions are
as a collaborative process is one that enables the made in clinical practice, you will have a
acknowledgement of the ethical requirements broad range of knowledge bases on which to
of decision-making (Trede and Higgs 2003) and draw. Sometimes this can make it feel diffi-
keeps the process ‘real’ (Elwyn and Miron-Shatz cult to know what is the ‘best action’ in any
2009). It also gives the opportunity for ‘rehearsal’ particular situation. There may also be times
(Ness et al. 2010) which diminishes aspects of risk when as a student you may be challenged to
through trial and error and promotes the choice of appreciate the decisions made by patients,
safe options. relatives, professional colleagues and even
government policies. For example, the deci-
sion of a patient to refuse treatment such as
!
a blood transfusion, or the difficulty of decid-
Key learning ing how best to provide care for a group of
When making any decision it is helpful elderly clients when there is a limited financial
to clarify your purpose, the situation and the budget.
available resources and to consider how they
fit together.
Key learning
Knowledge acquisition, utilization and
!
Identifying available sources of recognition is complex.
knowledge Nurses must personally declare what knowl-
Botti and Reeve (2003) support the work of edge they use, identify if the use of any
Tanner et al. (1987) who suggest that knowledge sources of knowledge has been neglected and
is the best resource that one can access when consider how they can enhance the utilization
making clinical decisions and the more knowl- of new/different forms of knowledge to nurture
edge one has the better should be the skills in clinical curiosity and engender confidence
both cue collection and hypothesis formation. in using resources effectively within clinical
However, there are different types of knowl- decision-making processes.
edge; so you need to have an understanding of
105
Table 7.2 Patterns of knowing
Pattern of knowing Description Author(s)

Empirical Based on the assumption that what is known can Carper 1978
be measured and tested scientifically. Reality
exists and can be demonstrated through
observation. When making decisions in clinical
practice nurses can draw on factual information
such as that derived from research studies and
theory.
Ethical Based upon experiential knowledge of social Carper 1978
values and ethical reasoning that guides and
directs the conduct of practice. Ethical knowing
requires nurses to have an understanding of ethical
matters (e.g. obligation and consequentially) and
the philosophical positions of deontology (duty),
autonomy and social justice.
Personal Nurses have personal knowledge based on Carper 1978
self-awareness and use of self in practice. It is
dynamic and continues to be developed and
extended through reflection on their practice, and
remains open to learning more about ourselves
through new experiences. Personal knowledge
is demonstrated in nurses’ personal attitudes and
attributes.
Aesthetic Nurses have a deep understanding of the whole Carper 1978
situation, and can develop the ability to bring
together both the science and the art of care and
interaction to implement confident, competent and
skilled performance.
Unknowing Unknowing specifically concerns the Munhall 1993
understanding of the patient’s perspective and a
setting aside of personal beliefs and values until
the patient’s view is known.
Sociopolitical This pattern of knowing was added by White White 1995
to acknowledge the political and social context
of care influenced by economic constraints
and government policy. Issues of power are
involved, not only in whose voice is heard but
whose voice is silent. When a decision is made,
do you acknowledge the patient voice or the
governmental voice?
Emancipatory Based on the assumption that, through critical Chinn and Kramer 2008
reflection, nurses can understand and use all the
patterns of knowing to deliver and achieve holistic
patient care.
106
best practice (NMC 2010: 26). The move towards

Activity 7.5 evidence-based practice (EBP) in health care is dem-
onstrated in the evidence used to underpin protocols
Consider a scenario from your recent and procedures and this is seen as a positive means
practice where you were caring for a patient or to offer equitable and safe care for all patients. With
client. Write it down as a story about what hap- regard to decision-making, the use of protocols
pened (taking care not to mention the names of has been found to be most helpful for novice/new
patients or clinical settings). It does not need to be nurses in making decisions, as it enables standard
very long, in fact limit your writing to just one inter- hypotheses or diagnoses to be described for specific
vention/episode of care that you were involved in. cases, together with accompanying guidance for
Now look at what you have recorded. the access, choice and use of resources in the form
What was the intervention? of knowledge and evidence (Manias et al. 2005). As
How did you ‘decide’ what to do? such, these standard cases and responses limit the
Identify how you ‘knew’ what was the correct range of possible options for action (cue acquisition,
course of action hypothesis formation and resource/evidence selec-
Was it because you had been taught what to tion) and provide novice nurses with ‘certainty’ and
look out for? confidence to proceed. This is understandable given
Did you use a specific type of knowledge or that errors in decision-making usually occur in pre-
way of knowing? viously unknown situations and without specialist
What were the ethical dimensions in the deci- knowledge and experience (Flannery et al. 2011).
sion-making process? Nevertheless, nurses must be aware of the
How did you collaborate with the patient? dangers of following protocols and procedures
How did you use yourself (your personal knowl- unthinkingly, for in so doing may lie the road to
edge) in the interaction? complacency and a lack of awareness of con-
founding factors that make a usual situation unex-
Now decide which form of knowledge you used pected or unusual. Unthinking decision-making
most and which form you used least, or not at all. denies the nurse the opportunity for taking the
If there are aspects of knowledge that you do not wider view (Manias et al. 2005; Kinchin et al. 2008)
regularly use when making clinical decisions, and complacency is the enemy of skilled nursing
write these down to act as an aide-mémoire and in that it can stifle clinical curiosity and diminish
think how you might incorporate different ‘ways of the ability to problem-solve. Nurses have access
knowing’ to build your knowledge repertoire. to many different forms of knowledge which they
It is hard to analyse one’s own practice but in should utilize to care for patients holistically. You
doing so one can discover areas that require fur- must access and use these to keep an open mind
ther attention in order to offer a balanced approach and to provide the breadth of care options that
to making decisions confidently and competently. best benefit the patients in your care (Kinchin et al.
2008; Thompson and Kagan 2011).
Using evidence in decision-making

for care
Key learning
Using best evidence to inform decision-
!
In making person-centred judgements, nurses must making in practice can be supported by the
use up-to-date knowledge and evidence to assess, use of protocols and procedures when used
plan, deliver and evaluate care, communicate find- appropriately.
ings, influence change and promote health and
107
Decision-making: being organized If you find it hard to ‘see the wood for the trees’,
in your thoughts and actions ask for help (Ladyshewsky 2002). Peer and men-
tor support can help you to organize your thoughts
In clinical decision-making, being organized is
and actions, for example to clarify the scope of
largely dependent on clear thinking about the spe-
a problem and identify the specific resources
cifics of:
required to resolve it. This can be invaluable while
why you are doing something; you develop your own portfolio of experience and
what needs to be done to complete the task; confidence in this area. Meanwhile, consider the
and organizational attributes you already hold and
what constraints (such as time or concurrent those you need to hone.
activities) may impose upon the situation.
Setting priorities and making choices
This clarity of thought is what makes the dif- Deciding on what to do first indicates that there
ference between those who are organized and is an order of activity in all situations. When you
those who are disorganized – being single-minded are caring for a number of patients or clients your
about a specific goal and the actions to achieve it. caseload or list of activities needs to be organized
However, the unpredictable and fast-paced envi- and prioritized in some way. Even when you are
ronment of clinical practice offers a different arena caring for one client at a time, the care they require
where ‘clear thinking’ may be hard work for every- will need to be managed in a way that makes best
one, particularly when, as a student, you are trying use of the resources available and provides effi-
to learn the ropes. Translating actions to be taken cient, effective and safe care.
into problems to be solved has been suggested as The parameters for applying priorities to care
a useful mechanism to throw specific situations are usually influenced by two main factors: the
into relief and provide some shape and boundary critical nature of the situation and time (Hendry and
to them (Standing 2007), thus providing a more Walker 2004). In an emergency situation, these
manageable structure within which to arrange two factors are synonymous as the overriding pri-
one’s thoughts. ority is patient safety and the order and timeliness
Experienced practitioners or ‘experts' who have of nurses’ interventions take on particular signifi-
been working in practice for some time may seem cance. However, considerations of time can have
to be ‘more organized’ than less experienced col- individual significance for care, even when the
leagues or student nurses. Sometimes student situation is not critical – i.e. when getting a patient
nurses are referred to as ‘novices’ or ‘advanced bathed and dressed. Deciding upon priorities of
beginners’ and certainly there is a wealth of lit- care in a clinical situation requires skill in assess-
erature and much debate on this subject (Benner ing risk and the ability to take appropriate steps
1984; Rashotte and Carnevale 2004; Bakalis and to minimize the predicted risk by timely interven-
Watson 2005; Flannery et al. 2011). For the pur- tion. When setting priorities it is important to rec-
poses of relating it to decision-making here, it is ognize that practice will always have elements of
understood that experienced practitioners are certainty and uncertainty. Where there is certainty
usually more able to see problems clearly and and risk may be accurately predicted, protocols
quickly because they recognize them as similar to, and procedures may objectify the logical reason-
or reminiscent of, something they have encoun- ing process and assist in setting priorities of care,
tered before. This ‘pattern recognition’ or intuitive however, where the clinical situation is less cer-
practice is something that you may have witnessed tain, individual and locally tailored clinical judge-
or indeed experienced yourself, and its benefits ment may need to operate.
include the ability to clarify specific problems and To enhance your skills for accurate risk
quickly identify the resources needed. assessment and sound clinical decision-making
108
it is important to be aware of your personal For collaboration to be achieved successfully,

attributes – strengths and shortcomings that you clear two way communication is key.
bring to the decision-making process – and learn The systematic processes offered by models
to identify opportunities that help you make of reflection offer practitioners the opportunity
good decisions in clinical practice (e.g. people, to articulate, scrutinize and document their deci-
clients, research, evidence or experiences). sion-making practice in detail. The relevance of
This self-knowledge of what might influence this activity is illuminated by Boud et al.’s (1985)
your decision-making is important, but remem- definition of reflection as an opportunity to turn
ber that seeking and using help and support to experience into learning, a sentiment that is
build your confidence is invaluable, not only as echoed by the work of Johns (1995). According
a student but during your professional career to Rashotte and Carnevale (2004) this notion of
(Thompson et al. 2007). transformational learning for individuals who
have had clinical experience is fundamental for
good decision-making in practice. The practical
benefits of reflection are outlined by Huckabay
Key learning
While developing your skills in making
! (2009), who highlights that nurses cannot experi-
ence every situation, yet working in the chang-
ing context of practice they must develop a reper-
clinical decisions you can always invite others
toire for transferring learning from one situation
to support you by asking them for comments
to another. Reflection offers you an opportunity
on your diagnosis of the situation and your
to build a portfolio of experience as a means of
plan for action.
surfacing and articulating experiential knowledge
that may be recorded and reviewed. It is always
valuable to reflect on cases where your decision-
making has resulted in positive outcomes for the
Communication, reflection and patient and/or others, in order to critically anal-
decision-making yse and learn from them and apply that learning
It is assumed that you come to this section of the to future situations.
chapter with knowledge of both the theory and There are a number of models of reflection
practice of skilled communication as detailed in which take you step-by-step through the decon-
earlier chapters. The emphasis of communica- struction, scrutiny and reconstruction phases
tion in relation to clinical decision-making is one at varying levels of complexity. The model by
of collaborative working and inclusivity where Driscoll (2000) operates within a simple frame-
all parties involved in the situation should also work using three headings, as illustrated in
be involved in the decision-making process. The Table 7.3.
involvement of patients and your ability to work By engaging with reflective processes, your prac-
with them in the decision-making process is vital tice will enter a new domain, for by constantly
for the following key reasons: scrutinizing and questioning your own practice
you will develop the clinical curiosity and obser-
it allows you to gain necessary consent for vational skills that are so vital to decision-mak-
procedures; ing. Also, deeper engagement with practice may
it enables cooperation when giving care; provide you with the realization that, as a health
the patient can contribute to goal-setting and care professional, at whatever stage in your pre-
achievement; registration programme, you are playing an inte-
the patient can offer their own knowledge and gral and vital role in increasingly complex health
expertise. care situations.
109
Table 7.3 Stages of reflection model (Driscoll 2000)
Stage Explanation
What Description of the details of what happened in the scenario Deconstruction
So what? Critical exploration of the details described (feelings/actions/ Investigation
consequences)
Now what? Identification of the implications for future practice (learning) with Reconstruction
rationale
Moving forward Consolidate what you know. Getting to know a

clinical setting and the associated care options
Looking back at your progress through the chap-
of patients within that setting enables nurses to
ter, I hope you can see how gaining competence
focus and add depth to their knowledge of par-
in clinical decision-making involves understand-
ticular specific clinical situations (Bakalis and
ing yourself, understanding how you learn and a
Watson 2005). Consolidation of knowledge in
rehearsal of the component parts of the decision-
a setting can offer personal and professional
making process. To take this work forward you
confidence in decision-making in that setting.
may find the following suggestions helpful.
Look after yourself. Bakalis and Watson (2005)
propose that psychological stress is potenti-
Consider how you learn; your personal learn-
ated in high stress areas such as critical care
ing style.
where decisions are high risk due to the com-
Hone your skills of patient observation and
plexity of illness, new technology (keeping up
clinical assessment in practice.
to date) and increased morbidity and mortality.
Don’t jump to conclusions. Take time to con-
Keep a reflective journal or log. Use a mind
sider the possibilities and options open to you
map within your reflective log to identify the
and the care of your patients.
influencing factors involved in the scenarios
Get help if necessary but don’t necessarily go
(Kinchin et al. 2008). Journal entries will help
for the quickest option.
to build a record of experience. Reflection on
Use your peers. Problem-solving, particu-
these entries will assist you to uncover the
larly priority-setting, is often better done in a
knowledge sources you access and the subse-
group.
quent outcomes from action.
Choose to work with people who challenge
and test you. Mentors are very important to
In summary:
help you hone your decision-making skills –
try to get a good one who you may observe in This chapter has offered you the opportunity
action making sound decisions and then ask to review the component parts of clinical deci-
them to uncover why they chose the decision sion-making as a process.
they did. It has enabled you to consider your own deci-
Keep up to date with new developments and sion-making abilities in relation to each com-
nurture a critical stance. Botti and Reeve ponent part.
(2003) linked academic achievement with Your use of the activities within the chapter will
better ability to reach a reasonable and swift start, or maintain and continue, your reflec-
decision – certainly in simple cases but par- tive journey through understanding what you
ticularly in complex ones where confounding know and what you need to know to develop
factors were present to ‘test’ the decision- and nurture your increasing competence and
making process. confidence in decision-making in practice.
110

Standing, M. (2011) Clinical Judgment and Decision Making for Nursing Students. London: Sage.
http://shareddecisionmaking.health.org.uk. This resource centre is designed to support individuals and

teams to put shared decision-making into practice through systems and processes, skills and behaviours of
staff, social marketing and patient support. It offers a ‘one stop’ portal for shared decision-making, and advice
on navigating these resources, based on learning from the UK and linked to international research.
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112
Advanced decision-making:
involving patients and
8
relatives in decisions on care
Jackie Bridges
Chapter contents
Introduction
Advocating for patients who are making
Domain 3: Nursing practice and decision-making
decisions
How experts make decisions
Patients who are unable to be fully involved in
Recognition-primed decision-making
making decisions
Bias and its impact on decision-making
Conclusion
Common pitfalls for decision-making when
making assessments
References
Involving patients and relatives in decisions
Introduction prone to errors, regardless of how experienced we

become. In addition, we need to consider how to
When confronted with complex or unfamiliar
effectively involve patients and their families in
clinical situations, novice nurses frequently
decisions about their care and treatment, and not
respond by drawing on theoretical knowledge
just assume that we know what is best for them.
and psychomotor skills, rather than enacting
Throughout this chapter, you will be able to
decision-making that addresses the complex
build on what you have read and learned in Chap-
and multidimensional nature of the situation.
ter 7 and specifically can:
Further, when novices lack confidence in the
clinical setting, they may rely excessively on find out how experts make decisions;
more experienced nurses and avoid situations explore the concept of bias and how it can
that require them to make decisions. influence your clinical decision-making;
(Gillespie and Paterson 2009: 164) identify how you can effectively involve
patients and families in decisions about treat-
If this passage rings any bells with you and reflects ment and care.
in any way your own experiences in decision-mak-
This chapter addresses Nursing and Midwifery
ing, be assured that with time and effort clinical
Council (NMC) competencies 1, 2, 3, 4, 8 and 10.
decision-making will get easier. As your experience
grows, and as you effectively draw out learning Domain 3 Nursing practice and decision-
from reflecting on your experiences, your own skills making (NMC 2010: 17–19)
will improve, enabling you to make the best deci-
sions for, and with, your patients and their families. 1 All nurses must use up-to-date knowledge
However, the way we make decisions can remain and evidence to assess, plan, deliver and
113
evaluate care, communicate findings, influ- 10 All nurses must evaluate their care to improve
ence change and promote health and best clinical decision-making, quality and out-
practice. They must make person-centred, comes, using a range of methods, amending
evidence-based judgements and decisions, in the plan of care, where necessary, and com-
partnership with others involved in the care municating changes to others.
process, to ensure high quality care. They
must be able to recognise when the com- How experts make decisions
plexity of clinical decisions requires special-
ist knowledge and expertise, and consult or Much has been made in the professional nurs-
refer accordingly. ing literature of the ‘intuition’ that expert nurses
use in making decisions. However, studies that
2 All nurses must possess a broad knowledge
have looked closer at this intuition have identi-
of the structure and functions of the human
fied that there is in fact a logic underpinning such
body, and other relevant knowledge from
apparently seamless decisions. Experts do not
the life, behavioural and social sciences as
instinctively know what to do but through their
applied to health, ill health, disability, age-
experiences have learned how to rapidly and
ing and death. They must have an in-depth
unconsciously process the available cues to select
knowledge of common physical and mental
the option that is likely to create the best out-
health problems and treatments in their own
come (Elstein and Bordage 1988; Harbison 2001;
field of practice, including co-morbidity and
Bond and Cooper 2006). There is no consensus
physiological and psychological vulnerability.
in the nursing literature on the model that best
3 All nurses must carry out comprehensive, describes how expert nurses make decisions, but
systematic nursing assessments that take in this section the concept of recognition-primed
account of relevant physical, social, cultural, decision-making (Klein 1993) is used to explain
psychological, spiritual, genetic and environ- expert decision-making.
mental factors, in partnership with service
users and others through interaction, obser-
Recognition-primed decision-making
vation and measurement.
The recognition-primed decision-making model
4 All nurses must ascertain and respond to does not reflect that experts consider the full range
the physical, social and psychological needs of available options before acting (Klein 1993).
of people, groups and communities. They must Instead it reflects that they use prior experience to
then plan, deliver and evaluate safe, com- recognize and classify a situation and they then
petent, person-centred care in partnership know from the classification they make what the
with them, paying special attention to chang- most workable option for action is. Any available
ing health needs during different life stages, time is then used to evaluate how feasible that
including progressive illness and death, loss selected option is before they implement it. If they
and bereavement. foresee problems, then they modify the option or
8 All nurses must provide educational support, implement the next most workable option. This
facilitation skills and therapeutic nursing model strongly focuses on assessment of the situ-
interventions to optimise health and well- ation and Klein (1993: 142) notes four important
being. They must promote self-care and man- aspects of this assessment:
agement whenever possible, helping peo-
ple to make choices about their healthcare 1 Understanding the types of goals that can be
needs, involving families and carers where reasonably accomplished in the situation.
appropriate, to maximise their ability to care 2 Increasing the salience of cues that are impor-
for themselves. tant within the context of the situation.
114
Chapter 8 Advanced decision-making
3 Forming expectations which can serve as a

check on the accuracy of the situation assess-
ment.
Key learning
Expert nurses use their experience to
!
4 Identifying the typical actions to take.
recognize and classify a situation and to use
this classification to select the most workable
While the recognition-primed decision-making
option.
model is based on research from outside nursing,
Bond and Cooper (2006) have identified it as a rel-
evant model to explain decision-making in nurs-
ing. The model highlights the value of experience
Bias and its impact on
in informing decision-making and sets out the
decision-making
steps that experts take to make decisions, often Judgement errors are ‘a natural consequence of
in urgent or emergency situations and over a very limitations in our cognitive capacities and of the
short space of time see example in Box 8.1. human tendency to adopt short cuts in reasoning’
A final point to make here is that experience (Elstein and Schwarz 2002: 732). Making decisions
does not necessarily equal expertise (Bond and rapidly can be helped by cognitive shortcuts known
Cooper 2006). Just because someone has many as heuristics, but these shortcuts can make deci-
years of nursing experience, it does not automati- sions prone to errors (Klein 2005). In addition, bias
cally mean that they make good decisions. The can also limit our ability to make the best decision.
next section looks more closely at the errors that This section looks more closely at the cognitive
can be made by decision-makers, regardless of errors that decision-makers are prone to, and offers
length of experience. suggestions on how to minimize their impact.
Box 8.1 Example of recognition-primed decision-making
John, who is a fragile elderly patient, is observed slipping off his chair onto the floor. The ward man-
ager, Sue, sees this happening.
1 GOALS. Sue knows what needs to be achieved in terms of limiting damage and injury to John – the
goals. The fall may not be prevented and intervention during John’s slipping to the floor may cause
further damage to anyone intervening. Instead John could possibly be helped to slowly descend to
the floor and possibly a blanket or pillow could be used to soften the fall. The aim is to avert or deal
with any adverse impact of the fall.
2 CUES. Sue will recognize the pain, anxiety and distress John will experience physically and mentally
and begin to observe and monitor these.
3 EXPECTATIONS. It is likely that Sue will anticipate the worst possible outcomes resulting from
the fall for John in order to prepare for action to manage and deal with all possible injuries
occurring.
4 ACTIONS. Sue will ask for assistance and ensure she has resources brought to John to monitor his
condition, assess the pain and manage any bleeding, bruising or other injury sustained. Intervention
may be required but she will not rush to lift him off the floor until his condition is assessed and he is
safely stabilized.
115
weighting we give to certain information can lead

us away from taking the right decision. This sce-
Activity 8.1
nario is a good example of a pitfall known as the
Take a look at the following two scenarios ‘representativeness heuristic’ (Klein 2005) or, in
(Brannon and Carson 2003: 202) and follow the other words, the assumption that if A is similar to
instructions. things in category B, then it can be categorized as
You are working in a hospital and you notice B. In the scenario, we see the tendency for peo-
a male lying down in the waiting room. When ple to attribute all of the symptoms to inebriation
doing your assessment you notice the following: just because of the piece of information about
slurred speech, uneven gait and a weakness in the smell of alcohol. While this example seems
his right arm. What is your best diagnosis (list most relevant to adult nursing, nurses in all fields
only one, no combinations or qualifications)? You of practice are susceptible to the representative-
may focus on whatever information you want. If ness heuristic. Nurses can counter it by being
you’re not sure, please make your best guess. aware of how common particular events are and
You are working in a hospital and you notice to avoid giving undue weight to single pieces of
a male lying down in the waiting room. When information. This links to the NMC requirement
doing your assessment you notice the following: that nurses ‘have an in-depth knowledge of com-
smell of alcohol on his breath, slurred speech, mon physical and mental health problems and
uneven gait and a weakness in his right arm. treatments in their own field of practice, including
What is your best diagnosis (list only one, no co-morbidity and physiological and psychological
combinations or qualifications)? You may focus vulnerability’ (NMC 2010: 17).
on whatever information you want. If you’re not
sure, please make your best guess. Common pitfalls for decision-making
when making assessments
Klein (2005) usefully outlines five pitfalls in deci-
sions about diagnosis and prescribing, the first of
You’ll notice that the scenarios in Activity 8.1 which is the representativeness heuristic. Klein’s
are identical except for the presence or absence paper is primarily directed at a medical audience,
of the information about the smell of alcohol but all practitioners in health care are equally
on the man’s breath. Nurses and student nurses prone to the pitfalls. The second pitfall identified
(n = 182) were presented with one of the above by Klein is the ‘availability heuristic’. This is the
scenarios in the study by Brannon and Carson tendency to use recently encountered or easily
(2003). Of the participants who read the scenario remembered information to make assumptions
that included the smell of alcohol on the man’s about a current situation. Klein gives the example
breath, 72.73 per cent attributed the symptoms to of people choosing to travel by car after a major
inebriation and 27.27 per cent to a physical ill- train crash because they incorrectly believe it is
ness. Just 1.96 per cent of participants who read safer. The availability heuristic means that the risk
the scenario without the mention of the smell of of something occurring, such as being involved in
alcohol attributed the symptoms to inebriation, a train crash if you travel by train, tends to be over-
with 98.04 per cent attributing them to a physical estimated and wrongly used to inform the course
illness. A similar pattern was seen with a different of action. Nurses can counter the availability heu-
scenario, participants being more likely to give ristic by being aware of what information may be
less weight to the physical symptoms when con- influencing a decision, and questioning whether
textual information was provided. These findings that information is representative of the current
are reflected in other studies and throw impor- situation, or if it just reflects recent or memorable
tant light on how we make decisions and how the experiences.
116
The third pitfall identified by Klein is overcon- being very painful against excoriated skin, also
fidence. There is a human tendency to overesti- have probably dried the skin out leading to fur-
mate what we know and this can give us mis- ther breakdown, but if nurses were using illusory
placed confidence in our judgements. This means correlation to guide them, they would have dis-
we are less likely to seek alternative explana- counted the harmful effects of the treatment in
tions or to ask for help when we need it. It also favour of the perceived benefits. Illusory correla-
underlines the importance of making decisions in tion can be minimized by being aware of avail-
teams, a point covered in the previous chapter. able evidence as to cause and effect of particular
Overconfidence can be countered by being aware interventions. Klein also recommends keeping a
of your shortcomings, and seeking the opinion of written record of events that you believe to be
colleagues. correlated.
Confirmatory bias is the fourth pitfall. Klein So there are a number of pitfalls which can
(2005: 782) defines this as ‘the tendency to look make nurses prone to errors in interpreting a situ-
for, notice, and remember information that fits ation and in identifying the right course of action.
with our pre-existing expectations’ and also points People who are prone to these cognitive biases
out that information that contradicts these expec- are also more likely to believe that they are good
tations can be ignored or dismissed. This can decision-makers, so self-awareness is key here!
mean that gathering information can be used to Being aware of what these pitfalls are can help
confirm the expectation that a particular problem to avoid them. This remains the case, however
exists and that information-gathering can cease experienced you are as a practitioner. In Brannon
too early before key information is identified. Klein and Carson’s (2003) study, qualified nurses were
recommends countering confirmatory bias through as prone to representativeness bias as student
remaining vigilant to information that may contra- nurses. If you are aware of your own particular
dict your interpretation of what is happening and pitfalls, whatever your level of experience, you
giving such information careful consideration. Be are more likely to question your decisions, to seek
aware of alternative explanations for a situation alternative explanations and more information,
and challenge your interpretation to check that it’s and crucially to ask for help in making decisions
the best interpretation of the evidence available when you need it.
(Klein 2005). Thorough assessment is clearly key
here, taking account of ‘relevant physical, social,
!
cultural, psychological, spiritual, genetic and envi-
ronmental factors’ (NMC 2010: 18). Key learning
The fifth pitfall is illusory correlation, defined Even experienced practitioners are
by Klein (2005: 783) as ‘the tendency to perceive prone to errors in judgement but there are
two events as causally related, when in fact the methods that nurses can use to reduce the
connection between them is coincidental or even likelihood of errors.
non-existent’. One example of this from nurs-
ing would be the use of brandy and egg white
by nurses to treat nappy rash in infants. Nurses
who used this treatment believed that the brandy
Involving patients and relatives
would clean the skin and the egg white would
in decisions
provide a protective barrier. When the nappy Now let’s take a look at a case study to try and
rash healed this provided evidence to the nurses apply some of the principles outlined in the above
that the treatment apparently worked, thus section. The true story below is told by a patient
increasing the likelihood that they would use in her own words, although her name has been
it again. The brandy used would, in addition to changed.
117
Case study 8.1: Anna Brown

My name is Anna Brown and I am 92. I live on my own at home and since my stroke have a home help
and meals-on-wheels. Five weeks ago, I tripped at home and hurt my wrist. The doctor visited and said I’d
broken it and needed to go to the hospital. He arranged for a taxi to take me there. The taxi driver helped me
out of the taxi and walked me into the hospital . . . I walk so slowly without my frame and that was at home. You
will have to excuse me, since my stroke it’s affected my speech you see. Oh, I was lost without my frame really.
Then I think they came and took me along then to the receptionist. She asked me some questions, I
cannot remember everything, there was lots of noise. I could not hear the lady very well. I don’t think she
understood me very well either, but she was in a rush . . . I think you can understand me because I can take
my time. If I get flustered it seems worse. I waited and waited and then I was taken in my chair into another
department. Eventually the nurse came and took me into the room. She looked at my wrist and asked me
questions. I had taken the list of my tablets that the doctor prepared for me . . . I gave the paper to the
nurse. She said she was pleased I had taken it. Oh . . . I was tired but she was kind and she wanted me to
have some pain tablets but I said no, they make me feel unwell and I did not want to have nausea. She said
I had to have an X-ray. The young lady . . . she pushed me in the chair and I had to wait and wait again.
Then I went in for the test and then they told me I would have to wait again . . . then have another X-ray. I
was taken back to the first department or was it the second? She looked at my tests and said it was broken
and I had to go back to the first place, so I was pushed back there and I was waiting and waiting . . . again.
The problem was I did not know what was going to happen . . . it was the noise . . . lots of rushing about
and people talking . . . lots of people everywhere . . . I can’t explain it somehow . . . Just before they came
to get me, I heard a voice behind me say ‘What are you doing here?’ and it was the man from next door.
He was told I was there you see. He was going to visit his cousin in the hospital, so he came to find me. He
stayed with me and brought me home in the afternoon. I was so pleased. I was feeling very anxious and so
very frustrated not knowing what was happening . . . I had been there for hours. Straight away it was better.
He stayed with me for a long time . . . we waited and waited. After some time I was seen again and a doctor
looked at the test . . . he said I had a clean break . . . across here . . . and that I would have to have a plaster
on my wrist, he said I had to go to another department for that. They told my neighbour where to go . . .
he had to push me up a long corridor in the wheelchair . . . ohh it was a long, long, long way and up a hill
too. Then we had to stay by some green chairs to have the plaster put on . . . we had to wait and wait again.
At the time I just wanted to go home, I was so tired and thirsty . . . I had not had anything all day. I hurt
my wrist early in the morning and the doctor came after half past twelve you see. I didn’t think about how
much more difficult it would be to manage at home at the time, to use my frame and pick things up, and
turn the tap on and things like that, I am right-handed you see . . . and you do not think how much you use
this hand . . . even when I cannot do an awful lot anyway. Anyway . . . finally I had my plaster put on. The lady
was nice. She smiled at me. It was nice, made me feel better. By then, I was worried about my neighbour
because he had been with me for such a long time . . . and he had to go back to his family. I was tired. I
needed to go to the toilet. I didn’t want to be a nuisance, everyone was rushing about and I could not ask
my neighbour. So I tried to hold on until I came home. It was alright. When we got home my neighbour
looked after me. He made me a sandwich then and a cup of tea. After he left, I managed to get to the toilet.
I didn’t use my frame. I held onto whatever I could. I had a sling around my neck you see. The doctor said
I had to keep it on for a few days. I had a slight accident, but I managed with this hand and the home help
came in the morning and was able to do the laundry.
(Bridges 2008)
118
feelings of being disempowered and make it too

Activity 8.2 difficult for them to ask for help.
Now answer these questions:

What information does Mrs Brown provide that Activity 8.3
is relevant to decisions about her treatment and
Think about a time when you or someone
care during and after her hospital visit?
close to you was a patient.
What information about Mrs Brown did staff
appear to use when deciding on her care while Did you know who each member of staff was
she was in the department, her treatment and who you met?
her discharge? What information did not appear Did you feel you understood what was hap-
to have been used? pening?
What pitfall(s) do the staff appear to have been Did staff keep you informed of what would be
prone to? happening next?
Can you identify an incident from your own Did you feel you had an opportunity to share
field of practice that you have witnessed or relevant information or to ask questions?
read about where staff took too narrow a focus Did you feel able to ask for help if you needed it?
with regard to a patient’s care and treatment? If there were key decisions to be made, how
Identify the related pitfall(s). involved did you feel?
Using Mrs Brown’s story or your own example, If there were shortcomings in your experi-
identify what decisions and actions would have ence, list the staff actions that could have made
optimized the patient outcomes. a difference.
If you felt involved by staff throughout your expe-
rience, list the staff actions that enabled this.
Let’s stay with Mrs Brown for a while longer.
From her account of events, it appears that she
had rather a passive role during her hospital visit. Advocating for patients who
She took along a list of her medications which are making decisions
was welcomed but she didn’t feel able to ask for a As patient advocates, nurses have an important
cup of tea or help in going to the toilet. Being in a role to play in helping patients feel in control of
hospital environment or other health care setting, what is happening. The NMC competencies spec-
especially in conjunction with a worrying illness ify the need for nurses to empower children and
or injury, can make patients of any age feel disem- young people to express their views and prefer-
powered. Even if they are confident people outside ences, but this need applies to patients and ser-
of the health care environment, many patients feel vice users across all fields. Many people will need
unable to express important needs, share perti- nurses to use proactive measures to help them be
nent information, ask questions or disagree with in control of their care and treatment. This may for
what is being proposed. Their reliance on relatives example include issuing explicit invitations such
and friends is often very important and you may as ‘It might seem that I’m busy today, but please
often find out there is a problem when approached stop me and ask if you need my help getting to the
during visiting hours by a relative concerned for toilet or if your glass needs filling up. That’s what
their next of kin. Both patients and their relatives I’m here for.’ Understanding how best to involve
depend on nursing staff to sort out their illness someone can mean putting yourself in their shoes
or injury and keep them informed and involved to anticipate their needs or preferences. It means
in decision-making. Too often an appreciation establishing a relationship with them so they feel
of high staff workloads can compound patients’ able to be open with you. And it means negotiating
119
with them each step of the way what information that person’s health and well-being. Some nurses
they need and supporting them to make the deci- are very skilled at making relatives feel a part of
sion that feels right to them. what is happening, and in drawing on the expertise
These principles don’t just apply to the big deci- of patients and their relatives, especially for patients
sions such as a significant change in the medi- with a long-term condition. When people cannot
cal management of a mental health need, but to communicate their wishes themselves, then their
everyday decisions such as what time an indi- relative or loved one can be an important consultee
vidual would like to wake up, what they like for for what the patient would want if they were able to
their breakfast, how much milk they like in their make a decision, and communicate it.
tea, when they have a wash, or what clothes they’d
like to wear. Being in receipt of nursing care can
mean that people’s ability to be in control of these Activity 8.4
everyday things can be disrupted by, for instance,
Think about your most recent clinical
having to wait in for the community nurse to visit,
placement and the patient that you had the most
or being subject to ward routines. Again, as patient
involvement with.
advocates, nurses have to proactively address this
risk in order to preserve the patient’s control. This Who were the important people in that patient’s
involves providing and honouring choice whenever life?
this is possible and challenging aspects of health What involvement did they have in maintaining
care such as routine or traditions that unnecessarily that person’s health and well-being?
disrupt an individual’s needs being met. If they were a carer for the patient (or the par-
In a systematic review I carried out with col- ent of a child patient or young person), what
leagues, we looked at qualitative research that strategies were used by you or other nurses to
reported older people’s experiences in acute care acknowledge and draw on their carer or par-
hospitals (Bridges et al. 2010). The review identified ent role, to establish their support needs, to
the importance of the interactions between staff enable them to ask questions and ask for help,
and patients in shaping patients’ experiences. It also to help them feel involved? What other strate-
reported that what older people want is for staff to: gies would have helped?
‘See who I am’: recognize and acknowledge

who I am as a person and what is important to
me.
‘Connect with me’: establish a warm and car-
Key learning
It is really important to involve all
!
ing connection with me that makes me feel patients in decision-making as it acknowl-
respected and enables me to be open with you. edges and recognizes their personhood.
‘Involve me’: establish what involvement I
want, and support and advocate for my choices.
Patients who are unable to be fully
While the review focused on research with older involved in making decisions
people, these messages apply across client groups Involving patients in decision-making is not
in health and social care. The review also looked at always straightforward, especially if the person
research that reported older people’s relatives’ expe- has impaired communication or capacity, or if they
riences and found that they also need staff to see are judged too young to make a decision for them-
who they are, to connect with them and to involve selves. Have a look at the resources in Activity 8.5
them. Relatives or other important people in the that provide some useful guidelines, including for
patient’s life can play a crucial role in maintaining making decisions with children and young people.
120
Activity 8.5
Review the following information on capacity and consent.
Resources on capacity and consent

NMC advice on consent, including consent for people aged under 16 years can be found at:
http://bit.ly/9bnNhQ.
The British Medical Association (BMA) has also produced some detailed guidance on working
with children and young people that includes guidance on consent and capacity issues. You can
find this guidance at: http://bma.org.uk/practical-support-at-work/ethics/children/
children-and-young-people-tool-kit.
The Department of Health (DH) has produced a useful guide on capacity and consent for people
working with people with learning disability: http://bit.ly/14oeqxL.
The Social Care Institute for Excellence (SCIE) website has a range of resources on the Mental
Capacity Act: http://www.scie.org.uk/publications/mca/index.asp.
Talk to your mentor in your current/next clinical placement about how decisions are made in that clinical
setting for people who lack capacity (or who are deemed by law to lack capacity such as those aged
under 16 years), and ask to see any local policies and procedures related to this.
Participate in the care of a patient who has impaired, fluctuating or absent capacity to consent, and evalu-
ate how decisions are made as their care and treatment are planned and delivered. Note when decisions
are straightforward to make and when they are more difficult. Helpful questions to ask yourself about this
patient’s involvement might be:
What do I or others do to help this person understand what is happening (e.g. verbal/non-verbal
communication, actions)?
How do I or others know the person has understood what is happening?
How do I or others know that what is happening is what the person wants or what they would want if
they were able to make a decision?
What happens if the person resists the planned care or treatment?
Make a written note of your observations in practice and discuss them with a fellow student.
Some health care professionals take decisions to the best course of action). You will come across
on other people’s behalf if they think they know such individuals in your clinical placements and in
what’s best for them or if finding out what they your practice after qualifying. Ask to shadow them,
want takes time and skill they feel they don’t have. encourage them to talk about how they do what
Some avoid getting involved in difficult situations they do, watch them at work and learn from them.
or talking about difficult things with patients and
!
families. Others recognize their shortcomings and
work hard to establish the best course of action. Key learning
Some health care professionals are enormously Nurses need to take proactive steps to
skilled at talking about difficult subjects (such as empower patients to express their needs and
death and dying) with patients and families and at preferences and to help them to feel in control
handling complicated family situations (e.g. when of what is happening.
there is disagreement among family members as
121
Conclusion Being aware of shortcomings and seeking

other opinions in complex situations.
We have seen in this chapter how experts use
Revising plans in the light of further relevant
their experience to recognize and classify a situa-
information becoming available, including
tion and to use this classification to select the most
information about an individual’s response to
workable option. Regardless of previous experi-
an intervention.
ence, the chapter has also identified strategies that
nurses can use to reduce the likelihood of making The chapter has also illustrated that nurses
errors in decisions: need to take proactive steps to empower
patients to express their needs and preferences
Carrying out comprehensive and systematic and to help them feel in control of what is hap-
assessments. pening. Involving relatives or other important
Being knowledgeable about the likelihood of people in the patient’s life is also an important
different patient problems. part of ensuring the best patient outcomes and
Avoiding giving undue weight to single pieces of making sure that carers get the right support.
of information. The chapter has reflected on the importance of
Being aware of what information is influenc- nurses understanding how to work with issues of
ing a decision and questioning whether the capacity and impaired communication. Finally,
information represents the current situation. the chapter has underlined that nurses can build
Being knowledgeable about the evidence base their skills in patient and family involvement by
for common nursing interventions in their field learning from colleagues with advanced skills in
of practice. handling difficult topics and difficult situations.

Bridges, J., Flatley, M. and Meyer, J. (2010) Older people’s and relatives’ experiences in acute care settings: systematic
review and synthesis of qualitative studies, International Journal of Nursing Studies, 47(1): 89–107.
Elstein, A.S. and Schwarz, A. (2002) Clinical problem solving and diagnostic decision making: selective review of the
cognitive literature, British Medical Journal, 324(7339): 729–32.
Klein, J.G. (2005) Five pitfalls in decisions about diagnosis and prescribing, British Medical Journal, 330(7494): 781–3.
www.city.ac.uk/bpop. Look at the CD on this site for guidelines on how to apply patient and relative involvement
principles to care for older people in acute settings.
References
Bond, S. and Cooper, S. (2006) Modelling emergency decisions: recognition-primed decision making. The literature
in relation to an ophthalmic critical incident, Journal of Clinical Nursing, 15(8): 1023–32.
Brannon, L.A. and Carson, K.L. (2003) The representativeness heuristic: influence on nurses’ decision making,
Applied Nursing Research, 16(3): 201–4.
Bridges, J. (2008) Listening Makes Sense. London: City University, available at: www.city.ac.uk/listeningmakessense,
accessed 2 August 2012.
Bridges, J., Flatley, M. and Meyer, J. (2010) Older people’s and relatives’ experiences in acute care settings: system-
atic review and synthesis of qualitative studies, International Journal of Nursing Studies, 47(1): 89–107.
Elstein, A.S. and Bordage, G. (1988) Psychology of clinical reasoning, in J. Dowie and A.S. Elstein (eds) Professional
Judgment: A Reader in Clinical Decision Making. Cambridge: Cambridge University Press.
Elstein, A.S. and Schwarz, A. (2002) Clinical problem solving and diagnostic decision making: selective review of the
cognitive literature, British Medical Journal, 324(7339): 729–32.
122
Gillespie, M. and Paterson, B.L. (2009) Helping novice nurses make effective clinical decisions: the situated clinical
decision-making framework, Nursing Education Perspectives, 30(3): 164–70.
Harbison, J. (2001) Clinical decision making in nursing: theoretical perspectives and their relevance to practice,
Journal of Advanced Nursing, 35(1): 126–33.
Klein, G.A. (1993) A recognition-primed decision (RPD) model of rapid decision making, in G.A. Klein, J. Orasanu,
R. Calderwood and C. Zsambok (eds) Decision Making in Action: Models and Methods. Norwood, NJ: Ablex.
Klein, J.G. (2005) Five pitfalls in decisions about diagnosis and prescribing, British Medical Journal, 330(7494): 781–3.
123
Section
Leadership, management 4
and team working
Effective leadership,
management and team
9
working skills
Yvonne Middlewick
Chapter contents
Introduction: NMC competencies The situational approach to leadership
Domain 4: Leadership, management and team Transformational leadership
working Learning to lead as a student nurse
Nursing management and leadership Personal qualities of good leaders
Management Team working
Management qualities What is a team?
Managing patient care and making Stages of team development
decisions Characteristics of successful team work
Leadership What skills do you need to work in a team?
What is leadership? Conclusion
The traits approach to leadership Further reading and resources
The functional approach to leadership References
Introduction: NMC competencies ple could equally have been used. It is suggested
that you choose a term appropriate for your field of
This chapter will help you focus on your understand-
practice and use this whenever you read ‘patient’.
ing of leadership, management and teamworking
It is important not to view the skills required
within health care settings. Every day in practice
to fulfil the competencies within Domain 4 in iso-
nurses lead and manage care of their patients and as
lation. They are closely linked to the other three
a student you are expected by the Nursing and Mid-
domains: professional values, communication and
wifery Council (NMC 2010) to show your competence
interpersonal skills, and nursing practice and
in leading and managing others in the health care
decision-making, all included in this book.
team. In this chapter there will be an exploration of
This chapter is relevant to the following NMC
the concepts of leadership and management, con-
competencies.
sidering the similarities and differences in the quali-
ties and skills required to be a good leader and man- Domain 4: Leadership, management and
ager. You will be prompted to explore your role as a team working
leader and manager wherever you are on your pre-
1 All nurses must act as change agents and pro-
registration student journey. The chapter goes on
vide leadership through quality improvement
to explore the attributes of successful and less suc-
and service development to enhance people’s
cessful teams and the potential impact these can
well-being and experiences of health care.
have on patient care.
The term ‘patient’ has been chosen for this chap- 3 All nurses must be able to identify priorities
ter. Service user, client, child, young person or peo- and manage time and resources effectively
127
Section 4 Leadership, management and team working
to ensure the quality of care is maintained or What is clear is that in the complex world of
enhanced. health care there is a need for nurses who have
4 All nurses must be self-aware and recog- leadership and management skills. As nurse edu-
nize how their own values, principles and cation has developed, the focus on these skills has
assumptions may affect their practice. They been highlighted. This is also in alignment with the
must maintain their own personal and pro- focus on high quality leadership and management
fessional development, learning from experi- in the NHS (Darzi 2008; National Leadership Council
ence, through supervision, feedback, reflec- 2012). This is to ensure the delivery of high quality
tion and evaluation. services continues to develop to reflects local need
and the financial climate. It is therefore important
5 All nurses must facilitate nursing students
that you consider how to develop or enhance these
and others to develop their competence,
skills throughout your education and beyond. This
using a range of professional and personal
will help you gain confidence to deliver first-class
development skills.
services as a registered nurse (RN).
7 All nurses must work effectively across pro-
fessional boundaries, actively involving and
Management
respecting others’ contributions to integrated
person-centred care. They must know when
and how to communicate with and refer to Activity 9.1
other professionals and agencies in order
Before reading this section take a few min-
to respect the choices of service users and
utes to reflect on management. Consider someone
others. Promoting shared decision making,
you think is a great manager:
to deliver positive outcomes and to coordi-
nate smooth, effective transition within and What qualities do they have?
between services and agencies. What do they do that makes them a particularly
good manager?
Nursing management
and leadership
Leadership and management can be defined as ‘Management’ is a broad term that can encompass
separate entities, however, when you begin to try to a number of different perspectives, making it dif-
explore these it becomes more challenging because ficult to find an agreed definition in the literature
the terms overlap and are frequently used inter- (Mullins and Christy 2010). Before focusing on a
changeably (Mullins 2007; Warriner 2009; Curtis et al. definition related to management in nursing, a
2011a). Within the nursing literature there is also starting point to enable you to begin to compare
no agreed definition of what nursing leadership and your answers in Activity 9.1 is the definition in
nursing management are (Warriner 2009; Stanley Collins English Dictionary:
and Sherratt 2010). This can make it challenging to
understand exactly what is required from nurses at 1 the members of the executive or administra-
different levels in an organization and may suggest tion of an organization or business
that leadership and management is only for those 2 managers or employers collectively
in more senior positions. It may also lead student
3 the technique, practice, or science of manag-
nurses to believe that these elements are not part
ing, controlling or dealing with [issues]
of their role until later in their education when in
fact student nurses may be well placed to influence 4 the skillful or resourceful use of materials,
the development of care from the beginning of their time, etc
journey to becoming a registered practitioner. 5 the specific treatment of a disease, disorder, etc
128
Chapter 9 Effective leadership, management and team working skills
The lack of consensus about a definition of Adair suggests that a person can be a good man-
management means that many authors focus on ager but not necessarily a good leader unless they
the responsibilities and behaviours expected in also have leadership attributes (considered in the
management to explain the meaning. Fayol (1916 next section). Mullins and Christy (2010: 425) give
cited in Sullivan and Decker 2009: 55) states that further consideration to this, stating that ‘whereas
management functions are ‘planning, organizing, leaders are not necessarily managers it could be
directing and controlling’. This view is supported argued that all managers should be leaders’. There
by Curtis et al. (2011b). Following their review of the remains a lack of agreement as to whether you
literature they found that the important functions can be a manager without being a leader and vice
of management were viewed as planning, finance, versa. Management is, however, an important
managing people and staffing. Mullins (2007: 364) aspect of nursing as nurses are expected to manage
describes management as ‘getting things done care, time and resources while maintaining high
through other people in order to achieve stated quality care. The overall aim is to have managers
organizational objectives’. He goes on to suggest who are also good leaders and to begin developing
that the manager may have a tendency to be reac- management, leadership and teamworking skills
tive in situations, focusing on solving short-term throughout the educational process. This should
problems rather than proactively considering the help with the transition from student to RN.
longer-term implications of situations.
Compare the answers you gave to the questions Managing patient care and
in Activity 9.1 to the views expressed above. Did making decisions
you have similar things on your list? You may find From very early in your practice and academic edu-
that your answers are dependent on the context in cation you will be considering the best available
which you have experienced management. Keep evidence for managing and treating conditions
hold of this list for the next section where leader- affecting patients within your field of practice. You
ship will be explored. This will allow for a compar- will also need to have knowledge of other fields of
ison of your views in relation to these terms. From practice to enable you to effectively, skillfully and
the perspective of nursing it could be argued that holistically manage your patients’ care. This should
all of the above are applicable in ensuring people be done in collaboration with patients and their
receive appropriate and timely care. However, this carers, as well as other members of the interprofes-
chapter will focus on the management qualities sional team as treatment may only be a small part
and skills required within the context of the role of of caring for your patient. To develop your skills in
a student nurse. caring it is important to gain an understanding of
how and why decisions are made. Clinical decision-
Management qualities making is explored in more depth in Chapters 7 and
Adair (2003: 62) considers managers embody the 8 of this book, however, it is important to consider
following qualities: how this links to management. Banning (2008: 188)
describes clinical decision-making as ‘a process
reliable, responsible, trustworthy, hard-working, that nurses undertake on a daily basis when they
thrifty with scarce resources, plan ahead, keep make judgements about the care that they provide
to agreed procedures or systems, prompt in to patients and management issues’. As a student
business, open minded to change, knowledge- nurse you are in an ideal position to ask questions
able in their specialties, meticulous over detail, about this often complex cognitive activity which is
cheerful, fair and courteous in their dealings linked to the management of care. Many of the staff
with staff and colleagues, keep in control of you work with will be experts in their field and may
things, loyal to the organization, achieve their appear to make care decisions intuitively (Benner
targets, good time managers. 2001). Asking questions such as ‘why did you decide
129
to . . .’ and ‘how did you come to that decision’ will

help develop your understanding. It is good prac- Case study 9.1a: Mr Jones
tice to also ask yourself these types of questions
r Jones, is an elderly man who is con-
M
as it can help you reflect on your development and
fused and has been found standing on the arms
identify any gaps in your knowledge. The aim is to
of a chair in the area of the ward where female
challenge you to develop while maintaining con-
patients are located. He is shouting very loudly.
fidence in your own abilities. You should always
He has been incontinent of urine and is causing
speak with your mentor if you are concerned about
upset to the patients nearby. The health care assis-
any aspects of your development. This is a require-
tant has been unable to persuade him to sit down
ment identified in the NMC Standards (2010) and in
and he is responding aggressively to patients try-
the Code (NMC 2008).
ing to provide assistance. He is at risk of falling.
Management of care and decision-making
are inextricably linked at all levels. The role of a
ward sister, for example, may not necessarily be
directly providing care for patients, however, they
Activity 9.2
will be expected to manage a clinical area and How would you manage the situation
make decisions that can impact on the overall described in the case study of Mr Jones?
quality of care provided. You will be supported to Write down your ideas on how best to inter-
develop management skills throughout your pre- vene. Discuss these with a colleague.
registration programme. The NMC (2010) Standards
emphasize the importance of being able to identify There are many strategies that you might con-
priorities and manage time and resources effec- sider in relation to Mr Jones. But what did you
tively while maintaining high standards of care. identify as the main goal or priority in this situ-
This may seem daunting when you start your first ation? Was it related to managing the risk to Mr
practice placement, however, your mentor and the Jones? Did you consider what might go wrong?
team will help you on this developmental journey. What skills did you draw on and how did you
As you progress you will begin to become more decide to proceed? Did you involve others?
independent, under the supervision of your mentor,
in making care decisions. Towards the end of your
education you will be supported to ‘take the lead Case study 9.1b: Mr Jones
in coordinating, delegating and supervising care he ward manager speaks quietly to Mr
T
safely, managing risk and remaining accountable Jones suggesting they have a chat together, invites
for the care given as you begin to prepare for the him to sit down and offers to make him a cup of
transition to being a registered nurse’ (NMC 2010). tea. Mr Jones accepts the offer and sits down in
These steps can happen at different times for differ- the chair. However, when the ward manager goes
ent people as team members try to ensure there is to make the tea, the health care assistants start to
gradual exposure to increased responsibilities. drag the chair backwards towards Mr Jones’ bed.
Mr Jones starts to scream.When the ward manager
Key learning
There is lack of consensus about an
! returns she asks the health care assistants what
is happening. They respond that they needed to
get Mr Jones back to his bed to change him into
agreed definition for management. clean clothes as he cannot be left in wet trousers
Management of quality patient care requires and his family are due to visit and get cross if they
good decision-making skills, time management find him wet. They also indicate that they are con-
skills, resource management and planning skills. cerned to maintain Mr Jones’ skin integrity.
130
Sometimes health care staff may have differ- Mullins 2002; Curtis et al. 2011a). Consideration
ent views about how to manage a situation, such also needs to be given to the fact that the skills of
as the one described in the case study above. The both a leader and a manager may be inextricably
NMC states that as a student nurse you should: linked.
‘take the lead in coordinating, delegating and Once you start to explore leadership it soon
supervising care safely’. There will be times when becomes apparent that it is a complex phe-
you have to make a decision when there are con- nomenon. Historical and cultural perspectives
flicting views so it is important that you are able have influenced the development of theoretical
to provide a rationale for your decisions, justi- approaches to leadership and a selection of these
fying your actions, drawing on relevant guide- different approaches is outlined below.
lines and evidence and considering the patient’s
needs.
The traits approach to leadership
This is one of the earlier theories that ‘leaders
are born and not made’. This theory focuses on
the qualities of the leader and early research sug-
Activity 9.3 gested that there were a number of innate quali-
ties that were inherited and could be measured
Think of a situation when you have
(Bass and Stogdill 1990; Mullins and Christy 2010;
encountered different ways to proceed.
Northouse 2010). Examples of such traits may be
How did you account for the different ap leaders who are confident, loyal and charming.
proaches? This approach has been included for consider-
How would you account for the management of ation as there do seem to be some people who
Mr Jones that you suggested earlier? are natural leaders. Can you think of some indi-
Is there only one best way to do anything? viduals you have encountered in nursing who
Do you think the ward manager in the case appear to be natural leaders? The research, how-
study is an effective leader? Justify and explain ever, suggests that although attempts have been
your answer and then read the following made to identify specific traits that are common
section. to leaders there is too much subjectivity about
what makes a good leader. Other potential influ-
ences such as environment, the situation and
the leader’s relationship with their followers also
Leadership play a part (Mullins and Christy 2010; Northouse
2010).
What is leadership?
A clear definition of leadership is difficult to find.
Mullins (2007: 363) suggests that leadership ‘is The functional approach to leadership
a relationship through which one person influ- The functional approach to leadership focuses
ences the behavior or actions of other people’. on the behaviours of both the leader and the fol-
This influencing relationship between the leader lowers and recognizes the impact these can have
and their followers is noted by Curtis et al. (2011a) on each other. Action-centred leadership (Adair
as a common theme of many definitions. Leader- 2003; Adair and Thomas 2004; Adair et al. 2008)
ship is often associated with skills such as ‘inno- outlines the functions of the leader in helping
vation’, ‘development’, ‘inspiration’ and the ability the group work effectively. This would involve
to challenge the status quo; management on the the leader in interpreting what is going on and
other hand can be associated with administra- then motivating others in the team to ensure they
tion, maintenance and control (Borrill et al. 2002; act in a way that achieves the group goals. An
131
example would be when a nurse in the commu- Transformational leadership

nity takes charge of a situation with which she Transformational leadership is described by Mul-
is familiar, perhaps because she knows a patient lins and Christy (2010) as ‘transforming perfor-
well, and enlists all members of the interdisci- mance’. This is done through the use of the leader’s
plinary team to achieve an appropriate admis- interpersonal skills to enable them to make links
sion following an exacerbation of a long-term to their followers’ values. Once this connection
condition. The role of the leader is to behave in a is made it generates an environment of trust,
way that enables other members of the team to enabling people to develop and work cohesively
work towards the patient’s goal objectives. Any together. Yukl (2006 cited in Mullins and Christy
member of a team can behave in a functional 2010: 391) states that to use a transformational
leadership role. approach the leader must:
The situational approach to leadership articulate a clear and appealing vision;

This approach focuses on the situation as the explain how the vision can be attained;
influencing factor with different situations requir- act confidently and be optimistic;
ing different leadership styles. Leaders respond express confidence in followers;
to the specific demands of the situation and their use dramatic and symbolic actions to empha-
followers’ characteristics and needs. Hersey et al. size key values;
(2000) describe their contingency theory, associ- lead by example.
ated with situational leadership, which assesses
the readiness of the followers. For example, at From this list it is clear that the emphasis with this
the beginning of a new task a person may require approach is the relationship between the leader
a significant amount of direction and support, and the followers. If you compare this to the
therefore the suggested leadership approach at NHS Leadership Framework (National Leadership
this time would be authoritarian or ‘telling’. As Council 2012) you may see a number of similarities.
the person becomes more proficient the leader These are a few different approaches to leader-
would change their style accordingly to be more ship and it may be useful for you to explore them or
‘permissive’. You should be able to relate this to others in more depth, particularly when you start
particular examples during your clinical place- to take on a more formal leadership role. Having
ment when working with a mentor and recog- an understanding of leadership and management
nize that as you became more experienced in a theory early in your career will help you to more
particular skill, the mentor’s style altered. When successfully develop practice. This will give you a
followers are at their most proficient the leader framework to thoroughly think about how to plan,
would use a ‘delegating’ style as minimal direc- implement and evaluate any changes as well as
tion and support is required. No doubt as you consider appropriate leadership styles.
move into your final year as a student you will
experience more situations where you will del-
!
egate work to others as you practise leading a
Key learning
team. There may always be times, such as dur-
ing a sudden emergency, when an authoritar- There are numerous leadership theo-
ian approach is needed by the leader who takes ries that can offer insights into different styles
charge. of leadership and can help with your personal
Another strategy used in the situational approach development.
is ‘participative’. This style may be used in learning Leadership can occur at any level within an
groups in university when you work in a participa- organization.
tive manner with peers.
132
So far you have been provided with some back- (NMC 2010). This is necessary when working in the
ground to what is meant by leadership from a rapidly changing environment of health to ensure
nursing perspective and your role in developing that health care delivery is evidence-based and
leadership skills as a student nurse. It is appropri- person-centred. Girvin (1998) found that nurses
ate to now look at what leadership means for you identified personal qualities, such as an abil-
as a student in practice. ity to communicate well or inspire others, when
they first described nursing leadership. This was
of interest to her as she knew of people who had
Activity 9.4 some of the personal qualities being described but
they were not necessarily good leaders. This led
Take a few minutes to consider and reflect
her to explore the available literature and consider
on the following questions:
it within her experience as a nurse. Other authors
What is your leadership role as a student nurse? have also found that nurses identify a number of
Who do you lead? Or put another way, who are different personal attributes in the people they
your followers? value as leaders (Stanley 2008; Warriner 2009;
Stanley and Sherratt 2010). These attributes will be
Once you have done this, compare your reflec-
considered after you have completed Activity 9.5.
tions to the ideas presented below.
Learning to lead as a student nurse

Key learning
Leadership focuses on the develop-
!
Curtis et al. (2011a) argue that student nurses are ment of relationships.
leaders to patients because they provide assistance to Student nurses have a leadership role that
this group and patients are reliant on the expertise develops as they become more experienced.
of the student nurse at the time they are providing
care. As you progress through your education you
may find yourself gradually leading more people by, Personal qualities of good leaders
for example, assisting the learning of other students
or support staff. You may not have considered these
important functions of leadership before because Activity 9.5
it is happening informally. Informal leadership is a Think about someone you know who you
legitimate and valuable form of leadership. Stanley think is an inspirational leader.
(2008) suggests that people do not need to have
Make a list of the personal qualities they pos-
positional power to lead and that many people influ-
sess that make them such a good leader.
ence care by demonstrating their personal values
Compare this list to the one you made when
which influence their followers. Downey et al. (2011)
considering management.
state that informal leaders are ‘hidden treasures’
What are the similarities and differences?
who are keen to share their knowledge in order to
develop clinical care. If you think about these infor-
mal situations you may be surprised at how often
you have the opportunity to provide leadership. You may find that you can clearly categorize the
As you begin to influence others you need to be differences and similarities between your chosen
aware of the importance of continually enhancing manager and leader, particularly if you have been
your leadership skills. These skills will provide a able to think of people who clearly fit into each role.
foundation for you to not only provide high quality It would, however, not be at all surprising if you have
care but to influence future service development found this task difficult, feeling that some people
133
are both leaders and managers. Adair (2003) argues

that this is because they have both leadership and Activity 9.6
management attributes. The confusion of terminol-
How might Jess go about leading the
ogy within the nursing literature may also increase
change?
the lack of clarity. It becomes apparent that what
What would she need to consider?
determines leaders are their actions and behaviours
She is trying to put patient priorities before
(Curtis et al. 2011a). Good leaders are described as
ward routine and nursing practices and may
being excellent communicators, their values and
find that she meets with resistance to change.
beliefs are clearly visible through their actions and
How might she be encouraged to move for-
they are both credible and knowledgeable role
ward with her ideas to improve patient care?
models (Girvin 1998; Warriner 2009; Stanley and
What would you do?
Sherratt 2010; Curtis et al. 2011a; Downey et al.
2011). High quality communication skills in lead-
ership behaviour enable relationships to develop
with the people who follow. Kean and Haycock- It is essential that you consider your working
Stuart (2011) suggest that leaders need to consider relationships and how you develop these with
their relationship with the people who follow them the many different people around you. This is
because leadership cannot occur in isolation. They an important part of working as a student nurse
go on to argue that the leader–follower relationship within a team and will be considered in more
is complex and that research has tended to focus depth in the next section exploring team working.
on the actions of the leader rather that the people
who follow. Peck and Dickinson (2009 cited in
Kean and Haycock-Stuart 2011: 32) state that ‘suc-
cessful leadership in organisations is the result of
the actions of many’. This means that leaders and Activity 9.7
followers need to work collaboratively to achieve Look at Domain 4 of the Standards
the task, which in the context of health care should (NMC 2010) and the National Leadership
lead to high quality, person-centred care. Other Council (2012) Leadership Framework which is
attributes of leaders include integrity, confidence, available at: http://www.nhsleadership.org.uk/
trustworthiness, approachability and openness. framework.asp.
Good leaders consider the ‘bigger picture’, have Use these to help you identify your develop-
excellent communication skills, critically analyse mental needs in relation to leadership and
situations and consider how to improve them to management and discuss them with your men-
impact on patient care (Stanley 2008; Downey et al. tor, tutor or a colleague.
2011; National Leadership Council 2012).
Case study 9.2: Jess

Jess, a student nurse, who had rotated over the full 24-hour shift in one ward, noticed that patients
were often awake until as late as 2 a.m. because of late emergency admissions. Sometimes they were dis-
turbed again during their sleep to change continence pads and were being woken at 6 a.m. when the drug
round was carried out. During the day the patients were tired; too tired sometimes to engage in their planned
therapies, and frequently aggressive. Jess wanted to try to change practice and see if the patients could be
helped to sleep better with fewer disturbances and whether the drug round could be delayed until 8 a.m.
134
Team working When you start to consider the team from the
patient’s perspective, as you did in Activity 9.8,
Teams are increasingly required to perform in
it is likely that your list of people who are involved
complex and dynamic environments. This char-
will be quite large and potentially complex. There
acteristic applies particularly to health care teams
may be numerous other professionals involved
where interprofessional working and the need to
in a person’s care and all of these form part of
work with patients and carers adds to the chal-
the team of people who are helping the person
lenge of leadership.
on their journey. It is also important to consider
What is a team? carers and other people who the patient feels is
The Royal College of Nursing (RCN 2007: 3) uses Kat- significant to them. It may be that you had per-
zenbach and Smith’s definition to summarize what a ceived some nurses as working more indepen-
team is. They define it as: ‘A small number of people dently than others, but all health professionals
with complementary skills who are committed to a are part of a large health care team. The reality is
common purpose, performance goals and approach that no professional is truly independent; some-
for which they hold themselves mutually account- one else is always needed to enable the smooth
able’. You are required to work effectively as part of transition of the patient through services, regard-
a team throughout your career (NMC 2008, 2010). less of where the services are located. It is impor-
Teams can be structured in different ways and this tant therefore that you consider the role of every-
varies from area to area. Even if you work in the same one involved so that any changes in the patient’s
field of practice you will often find that every team care can be communicated and passed on to the
can vary in the way it functions. You will have the appropriate people.
opportunity to meet and work with many different
people from many walks of life, both as a student and
an RN. The NMC requires you to always treat people
with respect including treating your colleagues fairly Activity 9.9
and without discrimination (NMC 2008). Take a few minutes to reflect on a suc-
cessful team you have been involved with (it
does not necessarily need to be within health
Activity 9.8
care), and list why you feel the team was
Identify a patient from one of your prac- successful. Then think of a less successful
tice experiences and make a spider diagram with team and list why you feel this team was not
the patient at the centre. Then add in all of the peo- successful.
ple your patient has been in contact with on their When you have read the section on team
journey through the health care system (see development and characteristics, compare the
Figure 9.1 for an example). attributes you have identified to the discussion
presented. Is the list for a successful team simi-
GP Receptionist
lar to the ideas presented below?
Keep your list relating to a less successful team
for Activity 9.10.
Patient
GP Paramedic Stages of team development

Working as part of a team can be challenging, par-
Figure 9.1 An example of a patient journey ticularly when you are joining for only a transient
period of time. Bruce Tuckman’s (1965) stages of
135
Forming Storming Norming Performing Adjourning
Figure 9.2 Bruce Tuckman’s (1965) stages of team development
group development (see Figure 9.2) can be used (2006) also found that it is important to have an
when considering the different stages experienced understanding of the roles of other profession-
by groups when new members join. Although this als as well confidence and assertiveness. Pearson
model is now over 45 years old it is a seminal et al. (2006: 135) suggest that ‘a multidisciplinary
piece of work and continues to be cited in texts approach to the delivery of healthcare results in a
discussing group development. The stages are number of improved outcomes’ for both patients
known as forming, storming, norming and per- and staff. According to Borrill et al. (2002) the effec-
forming, and in later years a final stage, adjourn- tiveness of multidisciplinary team working impacts
ing, was added for when teams have completed on effectiveness, innovation and mental health.
the task or are breaking up (Tuckman and Jensen Another attribute identified in a cohesive team
1977). According to Tuckman, groups need to is the need for everyone to be aiming for the
go through the first four stages in order to reach same goal (Adair and Thomas 2004; Atwal and
maturity. It will depend on the experiences of the Caldwell 2006). Belbin (2010: 98) describes a team
team you join as to where they are in their team as ‘a group of players who have a reciprocal part
development. If the team is in the ‘performing’ to play and who are dynamically involved with
stage then you would expect to see a cohesive each other’. This link with each other enables
group working well together. If, however, they are a group of people to become a cohesive team
in the ‘storming’ stage you may notice some ten- and highlights the importance of communica-
sions within the group. This is all a normal part tion in building team relationships (Adair and
of group development, and providing the group Thomas 2004; Atwal and Caldwell 2006; Pearson
remains respectful to one another during the et al. 2006; Kean and Haycock-Stuart 2011).
storming stage even if at times there appears to The optimum team number is an issue for
be conflict, positive developments can occur. It is debate, although between 8 and 12 people appears
a healthy stage as long as the team does not get to be the general consensus (Acas 2007; RCN 2007;
‘stuck’ within it. The inability to resolve conflict Mullins and Christy 2010). Belbin (2010) proposes
can impact on team cohesiveness, performance that a team can consist of as few as four mem-
and the quality of care it provides (Borrill et al. bers, although it is worth noting that he suggests
2002). This is when good leadership and excellent nine team roles for optimum functioning. Borrill
interpersonal skills can be used to help people et al. (2002) found that if you work in an area of the
move towards the team’s shared objectives. NHS that has more than 12 or 13 staff then sub-
groups naturally form. This is normal and if you
Characteristics of successful team work think about a standard clinical area, of say 30 staff,
Pearson et al. (2006) performed a systematic review as an ‘organization within a larger organization’,
of, among other things, the characteristics of nurs- then you will see that splitting into three separate
ing teams that contribute to a healthy working teams should enable optimum functioning. How
environment. They found that accountability, com- does this compare with the numbers of people
mitment, motivation, enthusiasm and communi- involved in the care of your patient in Activity 9.8?
cation were key components. Atwal and Caldwell The key here is that the teams are working in
136
alignment with their objectives so that they all have are excellent opportunities to gain confidence, ask
the same focus: the patient and high quality care. questions and enhance your communication skills
They may, however, achieve the objectives dif- for the clinical setting (NMC 2010, 2011).
ferently. Although there is much debate in the lit- Patients and their families sharing their stories
erature about the difference between a group and with you is one of the many privileges of being a
a team, there is some agreement on some of the nurse as well as an important aspect of being able
attributes needed for a well functioning team. to understand what patients want and need from
their health care experiences. Patients and fami-
lies are part of the team and should be treated with
Activity 9.10 dignity and respect at all times, ensuring that a
collaborative relationship is maintained. You need
In Activity 9.9 you were asked to identify
to ensure that you have this relationship to enable
some aspects of a less successful team.
you to make appropriate clinical decisions, provide
What would need to be done to make this team patient-focused care and advocate for your patient
successful? if required (NMC 2008, 2010). This is carefully out-
Make an action plan for the first three aspects, outlined in the Standards and as a student nurse you
lining how you would address these issues if this are in an ideal position to spend time building a
team were a clinical team you were working with. relationship with your patient. At first this may
What you would do in this situation once you seem uncomfortable, but you will soon become
are an RN? experienced at meeting different people. Gaining
Are the actions for you as a student different an understanding of the person behind the condi-
from those you have identified as an RN? tion is extremely important to help you build a rap-
Identify any team working developmental port with the patient and their family. You need to
needs and discuss these with your mentor, ensure that it is a collaborative relationship where
tutor or a colleague. the patient is truly a partner in their care.
What skills do you need to work in a team? Case study 9.3: Moving
Good communication skills are key to working in a and handling
team and even after years of experience you should An issue of poor practice in relation to moving
continue to develop these as they are a complex and handling was raised when a student nurse
but essential part of nursing practice. Failings in was asked to assist with an episode of care in
interprofessional communication can and do have an area caring for older people with a diagnosis
devastating effects. This has been highlighted in of dementia who required high levels of physi-
high profile cases such as Victoria Climbié (Laming cal care. This involved staff moving a patient in a
2003), the Bristol Royal Infirmary (Kennedy 2000) way which was not in alignment with the student’s
and Baby P (Laming 2009). It is therefore important learning, resulting in the patient being physically
that you consider throughout your education how lifted rather than using appropriate equipment.
you are going to develop your communication and The student nurse declined to be involved in the
team working skills.The clinical placement staff move and mentioned it to the nurse in charge of
will help identify appropriate developmental oppor- the shift. The student also sought advice from their
tunities to improve your communication in relation personal tutor who reported the situation to the
to management, leadership and team working. It link tutor for that area. The link tutor discussed this
is, however, important to recognize that opportuni- with the clinical manager who escalated the issue
ties within your university to participate in presen- to the department’s senior management team.
tations, seminar groups and lectures, all of which
137
my overall experience when student nurses have

Activity 9.11 highlighted concerns. Sometimes concerns can
be the result of confusion or a misunderstanding.
If you consider patients within your own It is therefore really important to check with col-
field of practice who are vulnerable and need high leagues and ask them to explain their decision-
levels of care then you should be able to reflect on making process so that you can develop your own
the following questions: decision-making skills in new ways. This allows
How do you think you would feel in the situa- you to learn from your experiences through reflec-
tion outlined in the moving and handling case tion and evaluation (NMC 2010). The Standards
study? also require you to learn through supervision and
How would you react if you saw something feedback. This can be done by discussing deci-
you considered to be inappropriate or poor sions with your mentor and asking for their view.
practice? Your mentor should not mind you asking for feed-
What do you think might inhibit you from back or questioning their decision-making, as
reporting this? facilitating student nurses to develop their com-
How do you think the clinical area received petence is a professional requirement (NMC 2008,
criticism in the case above? 2010).
Activity 9.12
In the case study the student was nervous about
how they would be received and initially wanted Write down three things that you will do
to be moved to another area. They were supported differently to enhance your practice as a result
by their personal tutor through the process of of reading this chapter. Discuss these with your
making a statement and meeting with the clini- mentor, tutor or a colleague.
cal manager. Both the clinical manager and the
senior management team commended the stu-
dent for highlighting the poor practice. The clini-
cal manager also said that they would be keen to
Conclusion
employ the student nurse once they were qualified This chapter has explored Domain 4 of the Stan-
as they needed staff who were willing to speak out dards for Pre-registration Nursing Education and
to ensure high quality care. considered the complexities of management,
This is an excellent example of how a student leadership and team working within the nursing
nurse can enhance patient care through both context. Having in-depth knowledge, the ability
leadership and team working. It also highlights to critically analyse situations, an understand-
the fact that a team is much wider than those who ing of how values, principles and assumptions
provide the ‘hands on’ care. In this case there is affect the giving and receiving of care and having
the involvement of the student nurse, the teach- excellent interpersonal skills will enable you to
ing staff, the clinical team, the medical staff, the develop as a practitioner. These are also impor-
senior management team and moving and han- tant attributes for a good manager, leader and
dling advisers. The team also involves the patient team worker and can assist nurses at all levels to
and their family or carers as these are the people provide high quality patient care. It is important
services are provided for and therefore should to focus on leadership, management and team
always be at the centre of any care provision and working early in nurse education as they are an
decisions (DH 2006; National Leadership Council integral part of the nurse’s role, not an optional
2012). Although this is just one example, it reflects extra.
138
In summary: and consider their contribution to this from the

beginning of their education.
Leadership, management and team working Leadership, management and team working
skills are complex and inextricably linked in are an essential part of the role of nurses at all
the provision of high quality health care. levels within organizations.
Student nurses are required to learn about
leadership, management and team working

Curtis, E.A., De Vries, J. and Sheerin, F.K. (2011) Developing leadership in nursing: exploring core factors, British
Journal of Nursing, 20(5): 306–9.
Mullins, L.J. (2007) Management and Organisational Behaviour, 8th edn. Harlow: Financial Times/Prentice Hall.
National Leadership Council (2012) Leadership Framework, available at: www.nhsleadership.org.uk/framework.asp.
Stanley, D. (2008) Congruent leadership: values in action, Journal of Nursing Management, 16(5): 519–24.
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764.
140
Enhancing and developing
leadership, management
10
and team working skills in
the community setting
Heather Bain and Mark Rawlinson
Chapter contents
Introduction Management of nursing care in the community:
NMC domain 4: Leadership, management and caseloads
teamworking The management of long-term conditions in the
Anticipating your learning needs community
The importance of leadership Case management
Nursing in the community Conclusion
Context of care Further reading and resources
Political context and influences on community References
nursing
Care at or close to home
Patient-centred care in the home
Introduction thoughtful reflection that a deeper understanding

This chapter will explore the application of leader- of leadership and management can be developed
ship and management skills when applied to com- (Bach and Ellis 2011).
munity nursing. The content is primarily aimed at The initial focus of the chapter will be on the
student nurses approaching ‘sign off’, however, importance of understanding the context of care,
the principles and application of knowledge are as well as highlighting the opportunities available
relevant to all students at any stage in their gradu- to meet the Nursing and Midwifery Council (NMC)
ate programme, as well as in preceptorship and (2010) competencies presented in the list below.
beyond. NMC Domain 4: Leadership, management
As an adult learner you will have experienced and teamworking
in life a range of learning opportunities that
have shaped your perception and understand- 3 All nurses must be able to identify priorities
ing of what it is to lead and manage as well as and manage time and resources effectively
what makes someone effective in this role; this to ensure the quality of care is maintained or
may be from personal experience, observation or enhanced.
from what you might have read. As well as acquir- 4 All nurses must be self-aware and recog-
ing new knowledge, it is through acknowledg- nise how their own values, principles and
ing these life experiences and the application of assumptions may affect their practice. They
141
must maintain their own personal and pro- is to pre-plan or investigate what the placement
fessional development, learning from experi- actually is, where it might be, and try and think
ence, through supervision, feedback, reflec- about the scope of care and range of clinical chal-
tion and evaluation. lenges which you may encounter. A community
6 All nurses must work independently as well placement will offer vast opportunities to meet the
as in teams. They must be able to take the required competencies of the NMC (2010) and each
lead in coordinating, delegating and super- placement will be different. So how can you go
vising care safely, managing risk and remain- about getting to know your placement in advance?
ing accountable for the care given.
Ring the placement provider prior to your start
7 All nurses must work effectively across pro-
date, introduce yourself and arrange an intro-
fessional and agency boundaries, actively
ductory visit to meet your mentor.
involving and respecting others’ contribu-
Visit the placement provider’s website or the
tions to integrated person-centred care. They
Department of Health’s (DH) website (countries
must know when and how to communicate
specific). These portals will give you an indica-
with and refer to other professionals and
tion of who works where and what they do.
agencies in order to respect the choice of ser-
They may indicate what the clientele is and the
vice users and others, promoting shared deci-
population the placement serves.
sion making to deliver positive outcomes and
Identify relevant community focused journals
to co-ordinate smooth, effective transition
and texts.
within and between services and agencies.
This chapter will also provide an opportunity to Figure 10.1 opposite is an illustration of how
explore some key aspects of the management of you might conceptualize a community placement
care in the community, including care manage- from a user’s perspective. The inner sphere repre-
ment, case management and caseload manage- sents the focus of your enquiry, for example, the
ment. Aspects of team working will be integrated patient and their family. Orbiting this might be a
throughout the chapter. But first we will take a sphere populated by information about where
brief look at how as a student nurse you can start they live. The next sphere might be their known
to develop your leadership and management health needs or personal targets to promote health
capability by taking responsibility for your own and well-being; the next could be which health/
personal and professional development, through social care professionals (and non-professionals)
managing your learning in your community place- are involved with them. Each orbiting sphere could
ment. have co-spheres, until you start to build up a matrix
(or concept map) for that individual and their rela-
tionship to the community in which they live.
As can be seen from Figure 10.1 and your
Anticipating your learning needs undertaking of Activity 10.1 it is possible to start
Building your leadership and management capac- to get an idea of the complexity of care delivery in
ity does not begin when you start a placement. the community. Activity 10.1 could be repeated
As an undergraduate student nurse you are not many times, for example putting the team you
an empty vessel waiting to be filled. Taking per- are working with at the centre and then creating
sonal responsibility for your own learning is an a matrix that looks at the caseload management
important part of qualifying as a graduate nurse required for each day, each week, etc. Presenting
and is an expected part of your professional role. your conceptualizations to your mentor is an ideal
One way of getting the most out of any placement opportunity for reflection and discussion.
142
Chapter 10 Enhancing and developing leadership
Location
Rural/inner-city
House/flat
Private/rented
Local
housing
dept.
Client/patient/
service user
Age/sex/
Relationships
Brother/wife
Reason for
Involvement
contact
Health and/or
Client identified
social care/
Health or social
voluntary/
need:
statutory
stop smoking
District nurse
Health care
support worker
Parkinson’s
Society
Figure 10.1 User-centred matrix
clinician’s (nurse’s) training. Consequently a

Activity 10.1 Clinical Leadership Competency Framework has
been published (NHS Institute for Innovation and
Now attempt to replicate Figure 10.1
Improvement 2011). It is expected that all indi-
but put yourself in the centre sphere. Then put
viduals operating in a clinical role will be able
the NMC domain requirements for leadership
to demonstrate competence in the five identified
in the separate orbiting spheres. Now build a
domains:
matrix which utilizes the opportunities which
you think might be available in your community demonstrating personal qualities;
placement. working with others;
managing services;
improving services;
setting direction.
The importance of leadership
According to the NHS Institute for Innovation Furthermore, each of the domains has four
and Improvement (2011) the development of elements to it and each element has four com-
leadership capability is an integral part of any petences to be attained. As a student nurse you
143
are not required to demonstrate competence in you with a more detailed understanding of what
the domains but they do serve as a useful frame- leading and managing care in the community
work to understand what being involved in might involve, but we start with a brief explora-
shared or distributed leadership involves once tion of what a ‘community’ might be: after all,
you are qualified. These domains complement this is what makes a community placement so
the NMC domains and will be threaded through- different.
out the various activities and content in this
chapter.
An attribute of strong professional leadership
Nursing in the community
is to be able to look at yourself and your current Developing an understanding of community,
capacity to lead and manage. This is a dynamic together with identifying health needs, is a pre-
process and as you progress in your career the requisite in order to plan effective health care for
level of responsibility and scope of accountability individuals, families and/or communities. The
also normally increases. As a student nurse on a different settings for health care are more than
community placement there are normally many just geographical or organizational variations
opportunities for you to develop your leadership and often require a different approach and phi-
capacity. This will range from being involved losophy to nursing care. The terms ‘community’
in delivering one-to-one individualized care, to and ‘community nursing’ are ill defined in the lit-
planning and managing a small caseload as well erature, according to Chilton (2012). The differing
as working alongside the team leader to under- perspectives on what a community is make it dif-
stand the management of the team’s workload, ficult to define, and it is therefore unsurprising that
for instance. What is, however, just as impor- it is equally as difficult to define what community
tant to understand is the context in which you nursing might be, what or who a community nurse
will be learning. The following sections provide could be, and what that role entails.
Case study 10.1: John and Margaret

John and Margaret Sutherland are both 85 years old and living in a three-bedroomed detached
country house in an affluent area. John is a retired teacher and Margaret has been a mother and housewife
all of their married life. Financially they are struggling to maintain the house within their income and over
the last few years they have used up their savings to put in central heating and replace their windows. With
the current global economic situation their bills have escalated in the last year. However, they are reluctant
to move as the house holds many happy memories.
Up until recently they have both kept good health but lately have been beginning to fail. John has devel-
oped maturity onset diabetes and Margaret’s mobility has declined due to her rheumatoid arthritis and
she is becoming increasingly confused. Last week she fell, causing a pre-tibial laceration. Jackie, their
eldest daughter, a 60-year-old widow, has decided to retire and to relocate to be near her parents. Jackie
is physically fit but overweight. Up until recently she has had a very stressful job and enjoys two or three
large glasses of wine every evening to relax. Melissa, who has just turned 16, is the granddaughter of
Jackie and has chosen to go and stay with her granny at her great grandparents’ house for a week in the
school holiday. Melissa has the potential to go to university and she is keen to study medicine. While she
is at her great grandparents, she is being sick in the morning. She finally discloses to her granny that she
is pregnant but is terrified to inform her mother.
144
It is important to understand the fundamental

Activity 10.2 ethical principle at the heart of nursing: that every-
one is an individual and as such should be cared
Try to define what you think a commu- with due regard to this truth (NMC 2008). Accord-
nity might be. Consider what it might consist ing to the World Health Organization (WHO 1974),
of, how it could be organized, what values and a community is: ‘a social group determined by
rules it may ascribe to, as well as where it might geographical boundaries and/or common values
be and who could be considered to belong to and interests. Its members know and interact with
any given community. each other. It functions within a particular social
Now consider Case Study 10.1, and for each structure and exhibits and creates certain norms,
individual (including the great granddaughter) values and social institutions’. While this may be
develop a concept map (as in Activity 10.1). true of what a community could be, it could also be
Try to identify which professionals or others argued that this is not that representative of many
could be involved with the family. What is of the communities which nurses often find them-
important here is to start to think about why and selves working in and with. For a district nursing
in what capacity they may be involved and to team who are mainly involved with the house-
remember that professionals often have mul- bound community (patients, carers and family) it
tiple roles that occur simultaneously. The com- would be unusual for all members (of that com-
munity nurse, for example, might be involved munity) to know each other or interact with each
in the clinical care of Margaret regarding other, let alone have a recognized social structure.
her rheumatoid arthritis and her leg lacera- The communities the district nursing team nor-
tion. That nurse would also be responsible for mally serve will at one level be geographically ori-
undertaking a risk assessment regarding pre- entated and comprise of a population of between
vention of falls, as part of promoting health and 10,000 and 30,000 people. Working at this level
well-being. requires the nurse to have strategic leadership
and management skills and expertise based upon
an understanding of epidemiology as well as local
knowledge of social structures and networks if
Context of care the intention is to understand/address need and
Communities are defined from many perspec- actively promote health and well-being.
tives. If you accept that society in part is made up What emerges out of this brief discussion about
of various ‘communities’ and that some may be the nature of communities is that a definitive defi-
more visible than others, because they have cer- nition is elusive if not illusive, a point well made
tain characteristics or identifiable features (e.g. a elsewhere by Chilton (2012).
demographic profile), then understanding the con- Despite this, for a student nurse or anyone new
cept of a community becomes more accessible. At to community nursing, it is helpful to have a frame-
a very simplistic level, in health care, communi- work which allows a baseline of understanding to
ties are often defined by a certain demographic be developed. This ideally should address not just
characteristic (e.g. by age, sex or disease). We the context of care in the community but the pro-
would suggest that as a student nurse, however, cess of care delivery. Laverack (2009) presents a
it is important to try not to limit your understand- framework that implies that communities can be
ing of your patients and patient communities to understood through critical analysis of their key
these constrained definitions. Rather, it is pivotal characteristics, these being:
to your understanding that you acknowledge the
characteristics of differing cultures, expectations spatial dimensions – this refers to a place or
and needs. locality;
145
interests, issues or identities that heteroge- but appreciate policy is made as a consequence
neous groups of people share; of decisions involving a wide range of people and
social interactions that are often powerful in organizations at local, national and international
nature and often tie people into relationships level. Within the UK, each of the four countries has
or strong bonds with each other; its own health and social care policy, mainly due
shared needs or concerns that can be addressed to the differing political stances since devolution
by collective and collaborative actions (Chilton (Bain and Adams 2011). While there is increas-
2012). ing divergence in terms of how health and social
services are developed across the UK, all services
However, the challenges facing nurses working have a shared approach that is ‘shifting the bal-
in and with communities extend beyond the seman- ance of care’. Keeping people out of hospital is a
tics of definitions, and extend to such influences priority (DH 2006; Scottish Government 2007),
as health inequalities, economic and employment along with addressing health inequalities (Farrell
opportunities, poverty and deprivation – in other et al. 2008; Scottish Government 2009a; Depart-
words, the social determinants of health (Wilkinson ment of Health 2010; Welsh Assembly Government
and Marmot 2003). Addressing this type of need 2010). Then there are the challenges of an ageing
at a community level is primarily the responsibil- population and workforce, with a greater num-
ity of specialist community public health nurses, ber of people with multiple long-term conditions
such as health visitors, school nurses, sexual requiring complex health needs to be addressed
health nurses and occupational health nurses, in community settings (Welsh Assembly Govern-
although local authorities have been charged with ment 2007; Scottish Government 2009b; Balanda
the responsibility to lead on public health in society et al. 2010; King’s Fund 2010). Recent reports have
(DH 2010). suggested that the integration of health and social
For district nursing teams the same issues have care has the potential to address some of these
to be recognized and addressed but often at an issues by improving services, resulting in bet-
individual or group level (Rawlinson et al. 2012). ter patient outcomes and better use of resources
Consequently, public health is also a central tenet (Humphries and Curry 2011; Scottish Government
of the practice of community nursing for other dis- 2012). Integration is well established in Northern
ciplines or, as Cowley (2007) so aptly puts it, public Ireland, but is currently in its infancy in other areas
health is everybody’s business. The central focus of the UK, with some pilot sites now beginning to
of this chapter is not public health per se, but it will emerge. Unfortunately, like any period of signifi-
be threaded throughout the various sections. cant change, there is the potential for a period of
It should by now be possible to start to appre- unrest. However, the consequence for community
ciate the complexity submerged within the con- nurses of evolving policies has been the oppor-
cept of community nursing. We now consider the tunity to influence local policy and increase their
political context of community nursing, prior to leadership and management capabilities in order
looking in more depth at the delivery of care in the to develop services to meet the policy agenda
community. Community nursing is far more than within the challenging context of the community
just focusing on clinical care. (Dickson et al. 2011).
As a nurse you will have the opportunity on
your community placement to explore how policy
Political context and influences impacts on professional practice and understand
on community nursing the significance it has on quality improvement
Policy is an integral component of community and service development to enhance people’s
nursing and practitioners need to not only recog- well-being and experience of health care and its
nize the content of relevant health and social policy subsequent evaluation. Clearly nurses do engage
146
with policy at different levels to improve national in the community. All provide vision and suggest
and local services, and the National Occupational strategies by which this might be achieved, and
Standards for public health, mapped onto the local policy is often developed to address national
Knowledge and Skills Framework, clearly outline policy. Both national and local policy not only
how this can be achieved (Skills for Health 2009). informs your practice in the community, but your
As a first-year student nurse it would be accept- practice helps to influence policy. Your contribution
able to have a broad awareness of policies that to issues such as quality, service design and the
directly relate to yourself and to feed back any service user experience are all policy issues that
positive or negative comments relating to these are essential to nursing in the community (NHS
policies to your mentor. However, as a nurse at Education for Scotland 2012).
the point of registration you would be expected
to have knowledge of the major government poli-
cies relevant to health and inequalities, and to
understand the implications for your practice. In
addition you should be able to contribute to the
Key learning
A knowledge of policies and strategies
!
development and implementation of specific poli-
to address health and well-being is essential
cies, or identify the impact of policies and strate-
within community nursing and an essential part
gies on the population. Being actively involved in
of leadership.
this would allow your mentor to assess your lead-
ership potential.
Care at or close to home
Having a community experience grounded in the
reality of care delivery in or close to someone’s
Activity 10.3 home environment provides a unique opportunity
Before commencing this activity, read it to see how care can be individualized and person-
carefully and give some thought to how you might centred. Care-giving in the home environment
approach it – we would suggest you undertake is very different to hospital- or clinic-based care,
this activity over a period of time. because the home environment does not have the
same structures, focus and equipment of a hos-
Access a local or national policy/strategy pital-based setting. For example, there is no pro-
aimed at addressing health care needs in the fessional routine in a person’s home, there are no
community. You may find it useful to look again hierarchical structures, such as those you find in a
at Case Study 10.1 and consider policies relat- hospital, and most notably there is no continued
ing to issues such as inequality, dementia, long- presence of a health care professional. While all
term conditions, nutrition, alcohol and teenage care is oriented around the patient’s need what-
sexual health that may apply to this scenario. ever setting it is delivered in, factors such as how
Consider the wider context of the selected they live, where they live and with whom they
policy/strategy and the local impact, then anal- live all have an impact on care-giving in the com-
yse it considering the implications for the role munity context. That is not to say that a home is
of nurses working in the community. absent of resources and routines and not subject
to policies and guidelines – it is – but they are in
the background and the person(s) and their family
From examining both local and national policy network are usually more obviously the focus of
you will recognize that there are many policies the foreground.
available aimed at improving health and well- As previously alluded to, delivering care in
being, and supporting people to live independently a wide variety of settings with variable facilities
147
poses unique challenges (QNI 2010). In addition to and choice (Wilson and Miller 2012), can be chal-
having to comprehend and adjust to the environ- lenging, especially if patient/carer expectations
ment in which the care is required, appreciating are at odds with those of the nurse. Nurses need
that often patients and families are much more to take the position that optimal care is being
involved in the negotiation of care and its subse- patient-centred, based on the premise that all
quent management can be a challenge to existing people want to be able (are able) to take decisions
ways of organizing, planning and monitoring care and responsibility for themselves (mental capacity
delivery. withstanding), as opposed to the position that the
Underpinning effective community nursing is nurse knows best.
the relationship that is established at the point
of care delivery (Wilson and Miller 2012). Work- Management of nursing care in the
ing with frail and vulnerable people across the community: caseloads
life span will often require the community nurse
(student) to demonstrate a range of effective and In Activity 10.2 you will have identified the vari-
appropriate communication, management and ations in the approach to work organization, pri-
leadership skills, because care in the home is oritization and delegation of nurses working in
nearly always associated with and dependent on the community. However, all nurses in the com-
a team or collective of practitioners. Empower- munity will commonly refer to their ‘caseload’.
ing others is an ascribed aim of nursing care, and Haycock-Stuart et al. (2008) describe the commu-
for this to be possible there needs to be clarity nity nurse’s caseload as a ‘ward without walls’.
around responsibilities and management plans Bain and Baguley (2012) define a caseload as the
for empowering the patient and their family. This designated population in a practice or geographi-
clarity needs to exist in order to promote health cal area for which the community nurse is respon-
and well-being more broadly and not just revolve sible. Caseload management is an organizational
around the immediate task that is to be under- technique that involves individuals’ and families’
taken (Baker and Rawlinson 2012). health care needs being met by the right person at
Consequently for the nurse (as illustrated in the right time.
Case Study 10.1) this often involves undertaking
a comprehensive assessment (sometimes jointly
with other services) in order to coordinate a wide Activity 10.4
range of services and referrals to ensure a patient
As a student, what experience have you
can manage at home (QNI 2010).
had of caseload management? Have you identi-
Patient-centred care in the home fied any differences between how a district nurse,
A term often used in community nursing is that health visitor or school nurse manages their case-
of being a ‘guest’ in someone’s home (McGarry load? Do the processes you have observed man-
2003). This approach to care clearly suggests age the demand for the service? What skills are
that the patient is at the centre of the relation- required to manage a caseload?
ship with the health care professional, indicating
that the power lies with the consumer and not
the provider. This is a concept that is ideologically By doing Activity 10.4, combined with your
aligned with current government rhetoric, and can practice learning experience to date, you will have
be put another way: ‘No decision about me, with- recognized that caseload management is a com-
out me’ (DH 2010). However, maintaining this type plex process that involves a different set of skills
of therapeutic relationship, where it is a fluent yet from working in the acute sector and focusing
ill-defined concept, based on the idea of autonomy on the care of individuals. There is little quality
148
research in the literature on caseload manage- different from setting priorities for a case-
ment but there is literature offering professional load. Ervin (2008) describes priority-setting
opinion (Kolehmainen et al. 2010). Ervin (2008) in the community on three levels. Firstly, it
identified three skills of caseload management: is a philisophy of care determined by the
organization holding the caseload. Sec-
organization; ondly, it is the scheduling of visits on a daily,
prioritization; weekly or monthly basis. And finally, it is
coordination. the rescheduling of visits and also allowing
capacity for new referrals to be admitted
However, considering the changing workforce
onto the caseload.
in the UK, with an increasing number of support
workers and assistant practitioners in the commu- 3 Coordination is the third skill required for
nity, delegation also needs to be considered as an caseload management, and involves effec-
essential skill (Bain and Baguley 2012). tive communication between team members
You now need to consider these skills in the and among the multidisciplinary team (Ervin
context of community nursing and adopt an 2008). Coordination is a skill you will have
incremental approach to developing your com- developed throughout your undergraduate
petence in caseload management. As a student nursing course, and in the community you
nurse you may have the opportunity to develop will be able to develop it further. Actively
some of the following skills by starting with a engaging in team meetings and case confer-
small caseload. ences will afford you this opportunity, as will
participating in more recent concepts such
1 Organizational skills provide the framework as ‘virtual wards’. A virtual ward is where
for caseload management. The approach the ‘ward’ mirrors a hospital ward but the
taken depends on whether it is a corporate patient remains in their own home, with the
caseload as opposed to a single caseload relevant services and professionals network-
being held and managed by an individual ing ‘electronically’ to manage the care (Ross
practitioner (Bain and Baguley 2012); or a et al. 2011).
GP-attached caseload where care is provided 4 Finally, delegation is important to consider.
to all registered patients to a GP surgery; or Delegation can be defined as the process
a geographical caseload where care is pro- of directing another person to perform
vided to a whole population (Gould 2012); tasks or activities. It involves a two-part
or an integration of different approaches. responsibility. The one to whom authority
Understanding the approach taken to man- is delegated becomes responsible to under-
age caseloads will help you to consider the take the task, but the delegator remains
structures utilized within the everyday plan- responsible for getting the job done (Barr
ning of work. For example, clearly defined and Dowding 2008). The NMC Code (2008)
referral criteria will aid the management of states that:
the demand for the service and help achieve you must establish that anyone you dele-
effective, efficient and equitable caseload gate to is able to carry out your instruc-
management, and having a filing system tions;
(whether electronic or paper-based) will help you must confirm that the outcome of any
to manage the workload. delegated task meets required standards.
2 The second identified skill for caseload
management is priority-setting. However, It is acknowledged that delegation is a com-
setting priorities at an individual level is plex process, and even more so in the community
149
Assessment of
task
Key learning
Caseload management is an important
!
skill to develop for nurses working the
Evaluation Match task to community.
and feedback competencies
as appropriate of staff Organization, priority-setting, coordination
and delegation are key skills of caseload man-
agement.
Supervise and
monitor task Assign tasks
When reading this section on caseload man-
completion agement you will have realized that the individu-
als within the caseloads are often referred to as
Tasks are ‘cases’ and all require different approaches to
completed by
staff address their health care needs. In the literature
this can be confusing as the term ‘caseload man-
Figure 10.2 Cycle of delegation agement’ is often confused with the terms ‘care
management’ and ‘case management’, which
are used interchangeably (Ervin 2008; DH 2010).
The NHS has used these terms for many years
when, often, people are lone workers and working in the areas of mental health and social care
in environments that are unpredictable. It is there- but now ‘case management’ is a term mainly
fore essential that within teams there is an aware- used to address the management of long-term
ness of everyone’s knowledge, skills and capabili- conditions.
ties, there is familiarity with the evidence for risk
management, and leaders need to be fully aware The management of long-term
of the accountability, responsibility and authority conditions in the community
issues that are interrelated. Gopee and Galloway
(2009) suggest a six-stage linear process for effec- The management of long-term conditions is a key
tive delegation, and developing this into a cyclin- priority in all four countries of the UK. The Health
drical process as illustrated in Figure 10.2 could and Social Care Model (DH 2005) illustrates the
be seen to develop teamwork. level of dependency of patients on health and
social care professionals (see Figure 10.3).
You can see that there are three approaches to
care according to need.
Activity 10.5 Level 1, self-care: which encourages people

Reflect on a day’s activities from your to take an active role in managing their own
community placement and the cycle of delega- health with support from health professionals.
tion in Figure 10.2. Was it clear what was dele- Some 70–80 per cent of people with long-term
gated from the team leader? How did they make conditions are within this category.
delegation decisions? Were the delegated deci- Level 2, care management: which is aimed
sions reasonable? You may wish to discuss this at people with one long-term condition to
activity with your mentor. allow them to manage their condition with the
support from a multidisciplinary team.
150
to reduce hospital utilization (avoid admission

or promote earlier discharge);
to improve care outcomes for patients;
Level 3
Case to enhance the patient experience.
Management
Considering the aims of case management it
Level 2
is evident that it has the potential to be a signifi-
Care Management
cant element of the community nurse’s role, and
in particular the district nurse. Please note that in
Level 1 some areas of the UK terms such as ‘community
Self Care matron’ or ‘case manager’ are used to define the
role of community nurses undertaking work with
this particular client group and this can cause con-
Figure 10.3 Health and social care model (DH 2005)
fusion. However, for the purpose of this chapter it
is more important that you understand what case
management is.
Level 3, case management: aimed at people
Hutt et al. (2004) identified six core elements of
with two or more long-term conditions who
case management:
have complex needs.
case-finding or screening;
These approaches are not confined to one pro-
assessment;
fessional group and components will be integrated
care planning;
into your role as a nurse working in the community.
coordination and referral;
The various health needs of the population allows
monitoring;
for a diversity of approaches and interventions (Hutt
review.
et al. 2004). As a novice in the community you are
more likely to be involved with self-care and care More recently Ross et al. (2011) identified the
management but as you advance in your career same elements but redefined care coordination to
case management will be an increasingly impor- include: medication management; self-care sup-
tant concept. At this stage it is important that you port; advocacy and negotiation; psychological
have a broad understanding of the key principles support; and monitoring and review, followed by a
of case management. final element – case closure for time-limited inter-
ventions (see Figure 10.4).
Case management
This approach mirrors the nursing process
Case management is a generic term with no single
which you will be familiar with, however, Hutt
definition which has led to confusion and uncer-
et al. (2004) differentiate case management from
tainty about what it involves. For example, in some
similar approaches by the following features:
contexts it refers to an intensive and time-limited
intervention aimed at preventing an event such intensity of involvement;
as a hospital admission. Others see it as ongo- breadth of services planned;
ing individualized care aimed at keeping people duration of involvement.
well (Ross et al. 2011). Case management recog-
nizes that the intensity of needs in people with There are many different models of case manage-
long-term conditions varies and that care should ment used in the UK (Lewis 2008) such as Evercare,
be targeted accordingly. Ross et al. (2011), in their Kaizer and Pfzizer and the more recent virtual ward
review of the literature, suggest that the key aims (Ross et al. 2011). The evidence of their effec-
for case management remain unchanged and are: tiveness is mixed due partly to the complexity of
151
Case finding
Assessment Care planning Care

Clinical coordination
Past medical history
Current health status Medication
Referrals to services
Medication review management
Activities of living
Cognitive functioning
Emotional well being Coordination of Self-care support
Mental health services
Specific assessment tools
Advocacy and
Social negotiation
Home occupants
Monitor referrals
Dependants
Housing Psychological support
Financial
Carers
Employment and
Monitor progress Monitoring and review
education
Local amenities
Case closure (in time limited interventions)
Figure 10.4 Components of case management
the factors involved, and not all case manage- development and its delivery. The enabling factors
ment models measure outcomes. However, it is that Ross et al. (2011) identified are:
acknowledged that case management is a valid
approach for managing people with complex assigned accountability;
needs and long-term conditions in the community. clarity around roles;
Factors identified in the more successful examples clinical and non-clinical skills:
range from the competencies of the individual interpersonal skills
case manager to the overall programme design problem-solving skills
and the context in which these operate (Ross negotiation and brokerage skills
et al. 2011). prescribing qualification
There are different levels of responsibility for access to adequate training;
nurses within case management. However, it is building relationships:
clear that it requires practitioners to be working between case managers and their patients
towards an advanced level in an autonomous role between case managers and GPs
and that effective leadership is required for both its between case managers and hospital staff;
152
programme design: embrace the case management approach to meet

targeting and eligibility the changing demography of the population. Case
caseload size study 10.2 provides one example of a case man-
single point of access/assessment agement approach.
continuity of care
effective use of data and communication
processes;
factors in the wider system: Activity 10.6
shared vision and objectives In the light of Ian’s case study, consider a
collaboration between health and social care client from your community placement who would
aligned financial flow and incentives have benefited from the principles of case man-
stakeholder engagement agement.
resources and services available in the
community. What would be the advantages of this approach
to the service, the primary health care team
It is identified that case management requires and the client?
to be an approach that is supported by relevant What key skills are required to undertake an
policy and infrastructure that is well organized assessment of the client?
and delivered within an integrated care system What resources are required to manage their
(Ham 2009). This will then result in improving care, including input from nurses and other
patient experiences and outcomes (Powell-Davies members of the multidisciplinary team?
et al. 2008). Community nurses therefore need to
Case study 10.2: Ian

Ian is a 78-year-old man who has recently moved into a sheltered housing complex in a town after
having given up his farm following several hospital admissions. He is a widow with two grown up children
living 100 miles away and has a past medical history of chronic obstructive pulmonary disease (COPD),
Parkinson’s, type 1 diabetes and rheumatoid arthritis. He has had four hospital admissions in the previous
six months for unstable blood sugars and exacerbations of his COPD. On his last hospital admission a care
package was commenced with a daily visit from a formal carer to assist with personal hygiene and super-
vise medication. It also resulted in a referral to the district nurse to act as case manager.
The case management approach involved:
development of anticipatory care plan – shared with Ian’s GP and the out of hours service outlining his
full range of needs;
weekly visits from the district nurse;
carers increased to twice daily to assist with evening meals and supervise medication;
patient education programme about lifestyle advice in relation to diabetes, COPD, rheumatoid arthritis
and Parkinson’s;
installation of a telehealth monitoring system to record a range of vital signs on a daily basis, to be
transmitted to a monitoring centre;
fortnightly meetings via the virtual ward to discuss and plan care with the multidisciplinary team;
six-monthly medication review by the district nurse who is a non-medical prescriber;
one exacerbation of COPD managed at home due to early intervention;
one hospital admission where an early discharge was facilitated due to the support mechanisms in place.
153
Conclusion ment and case management have been explored.

It is hoped that having read this chapter you will
This chapter has offered an insight into some of
have developed an understanding of management
the management and leadership skills required
and leadership issues in the context of community
in the context of community nursing and builds on
nursing, and recognized that the development of
the previous key points of Chapter 9. The impor-
effective leadership and management skills and
tance of team work and collaborative working to
expertise is considered to be a continuous and
meet health care needs is threaded throughout the
evolving process (RCN 2012).
chapter, and the concepts of caseload manage-

Chilton, S., Bain, H., Clarridge, A. and Melling, K. (eds) (2012) The Textbook of Community Nursing. London: Hodder
Arnold.
NHS Education for Scotland (2012) Modernising Nursing in the Community, available at: www.mnic.nes.scot.nhs.uk.
Ross, S., Curry, N. and Goodwin, N. (2001) Case Management: What is it and how it can be best implemented? available
at: www.kingsfund.org.uk/publications/case_management.html.
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155
Leadership, management
and team working in an
11
acute care setting
Debbie Goode and Pauline Black
Chapter contents
Introduction Learning to lead and manage
Domain 4: Leadership, management and team Skills of leadership and management in
working an acute setting
Skills of leadership, management and team Team working
working required from an acute care Components of building a safe and effective team
perspective Poor teamwork and the potential impact on
Required personal attributes patient care and safety
Required professional attributes The importance of patient safety
The person-centred nursing framework Leading resolution in conflict situations
Leadership and management skills and their Conclusion
impact in acute care settings Further reading and resources
Leadership in acute care settings References
Introduction This chapter will focus on an exploration of the

skills of leadership, management and team work-
In the previous two chapters you were introduced
ing required from an acute care perspective. It will
to the concepts of leadership, management and
explore the components required to build a safe and
team working. You were encouraged to identify the
effective team and identify, using case studies, exam-
importance of leadership from the start of your stu-
ples of poor teamwork and their potential negative
dent journey. Key questions were posed and you
impact on patient care and safety. In particular the
were encouraged to reflect upon leadership at dif-
chapter will facilitate and support you in understand-
ferent stages of your learning and development as
ing and interpreting evidence and the application of
a professional nurse. It is important to remember
developing graduate attributes by using examples
the attributes and attitudes required to make a good
drawn from the different fields of nursing practice.
leader and the impact they have on patient care,
team working and your career development. These Domain 4: Leadership, management
qualities also require adaptation, depending on and team working, generic standard for
which practice learning setting you are working in. competence
In Chapter 10 you focused on leadership skills The Nursing and Midwifery Council (NMC) for all
and styles required by nurses in a community set- nurses (2010: 20) states that:
ting. Leading a caseload of patients or a team of
staff, along with case management and its com- All nurses must be professionally accountable
plexities were discussed using examples from and use clinical governance processes to main-
community and public health perspectives. tain and improve nursing practice and standards
157
of healthcare. They must be able to respond and team working. Each one of us has differing
autonomously and confidently to planned and personal beliefs and values and it is these that
uncertain situations, managing themselves make us unique.
and others effectively. They must create and max- Caring is a crucial and pivotal requirement
imise opportunities to improve services. They for all nurses as professionals (McCormack and
must also demonstrate the potential to develop McCance 2010). Nursing is a unique profession
further management and leadership skills during where the care of others, often in a time of stress,
their period of preceptorship and beyond. vulnerability or panic, is evident. It is therefore
crucial to understand that the way we view our-
It is also important to be cognizant of the need selves influences the way we interact with others.
to demonstrate your leadership abilities both in Often, if we are encouraged and praised we will
a team setting and as an individual practitioner. feel positive and strive to do our best, and as a
Many of the skills and principles already discussed personal attribute it is important that we can dem-
in this book, such as professional values (Chapter onstrate this to others also. When you think about
2) and decision-making skills (Chapters 7 and 8) your personal beliefs and values around nurs-
are implicit in the way in which leadership is dem- ing it will hopefully reflect and help to enhance a
onstrated and actioned in clinical practice. person-centred approach to care.
Skills of leadership, management Required professional attributes

and team working required from The NMC (2011) has published Guidance on Profes-
an acute care perspective sional Conduct for Nursing and Midwifery Students.
Several of these guidelines relate specifically to
In order to discuss the skills that a nurse requires
working as part of a team. This guidance should
to lead, manage and be an effective team member
help you begin to formulate how you develop as a
it is useful to revise or revisit your own personal
nurse as well as a member of the health care team,
and professional attitudes and attributes.
no matter what area, speciality or branch you
practise within. The guidelines relate to the com-
Required personal attributes petencies that you must achieve prior to registra-
In order to achieve competency you must become tion. However, as part of your ongoing journey it
self-aware and recognize how your own values, is important that your use of this guidance moves
principles and assumptions may affect your practice, from a position of knowledge to a demonstration
especially in relation to leadership, management of practice, as this is a fundamental requirement of
professionalism.
As a student who is required to develop and
Activity 11.1 demonstrate leadership and management skills, it
is essential that you have the correct policy knowl-
Take some time to reflect on the reason
edge to support your practice. In each field of nurs-
why you wanted to be a nurse.
ing practice there will be strategic differences.
Has it changed since your application to the Through your course to date you will have been
course? introduced to many theories, statements, proce-
Is the course what you expected, either in a dures and evidence to support your practice. In
good way or in a negative way? becoming a team member the skill is to integrate
What impact has nursing had on your life as a the best of all of these aspects into your own per-
student and what path do you think nursing will sonal style, which helps to shape you as a profes-
take you down in your future life? sional. This will not happen immediately but will
grow with your confidence and ability.
158
Chapter 11 Leadership, management and team working
When working as part of a team it is pivotal that The second element in the model is the care
you become familiar with the roles and responsi- environment. This component of the framework
bilities of other people involved in providing health focuses on the context in which the care is pro-
and social care. Importantly you will recognize the vided. This includes appropriate skill mix, shared
need to: decision-making, effective staff relationships, sup-
portive organizational systems, power-sharing,
work cooperatively within teams and respect the potential for innovation and risk-taking, and
the skills, expertise and contributions from all the physical environment. For many of you, each
people involved with your education; care environment may be new and you should
treat all colleagues, team members and those begin to recognize how the dynamics of the envi-
with whom you work and learn fairly and with- ronment may influence the care you provide. The
out discrimination; environment or culture can play a large part in
inform your mentor or tutor immediately if you how you achieve your competencies as there can
believe that you, a colleague or anyone else be differences in interprofessional behaviour, lead-
may be putting someone at risk of harm. ership styles, team dynamics and mentor support
(Pollard 2009). As a final-year student especially,
you will begin to develop your own management
The person-centred nursing skills in each care environment. You should have
framework studied academic modules or units on leadership
Now that you have thought about your own personal and management that will enable you to reflect
and professional attitudes and attributes you can upon the type of leader, manager or team member
begin to place them within the context of leadership, that you wish to become. Often, though, the care
management and team working. This will assist you environment will influence your style. This can
in developing a strategy to achieve competency. happen as a result of positive and negative influ-
The person-centred nursing framework devised by ences. You may witness attributes in other nurses
McCormack and McCance (2006) is one way to help that you want to emulate, such as the way Nurse
you plan your learning and development as a nurse. Green always speaks in an informative manner to
It is comprised of four key constructs. patients and families. However, in an acute setting
The first element is described as the prequisites you may also witness team dynamics and personal
(the attributes of the nurse). These would align management styles that you definitely do not wish
themselves to the four domains of professional to copy. This may be the way Nurse Brown likes to
values, communication and interpersonal skills, be in control and does not delegate any aspects of
nursing practice and decision-making, and lead- management to others for fear they would not be
ership, management and team working. These completed to the correct standard.
are important as they relate to the generic and The third element of the framework is care pro-
field-specific competencies and progression points cesses. This component of the model focuses on
that you have to achieve to qualify as a registered the actual development of person-centred care
nurse (RN). So, for you to achieve competency, through a range of activities. If your focus in
you must demonstrate that you are professionally care delivery takes account of working with the
competent, that you have the interpersonal skills patient’s beliefs and values, engagement, shared
necessary to be an RN in your field of practice, that decision-making, having sympathetic presence
you are committed to the job of being a nurse, as and providing holistic care, then you are develop-
well as showing clarity in your beliefs and values ing person-centred care processes. To ensure your
and being self-aware. These qualities will enable progression at each stage of the programme you
you to develop the skills required to be part of a are expected to deliver care with a high degree
safe and effective team in any field of nursing. of effective communication skills that require a
159
therapeutic engagement with the person (please on patient care, team working and career develop-
refer to Chapter 6). Communication in leadership, ment. You should now recognize that leadership
management and team work is essential. For you and management are not the same, but are often
to achieve these competencies you should begin to discussed as one skill within nursing and health
consider the patient or client as a partner in care. care. In this section you will focus on the effects
The final element of the framework is the of these attributes and attitudes on the delivery of
person-centred outcome. If you have begun to acute care.
achieve the first three elements the results should Clarke and Ketchell (2011: 2) provide a helpful a
be satisfaction with care, involvement with care, definition of acute care:
feeling of well-being and the creation of a thera-
peutic culture. If you have achieved this you will The care provided to patients experiencing seri-
be able to reflect on your development as a ques- ous acute illness, which is often accompanied
tioning and compassionate practitioner. You will by a rapid and progressive deterioration in their
also have a structure on which you can develop condition, and which requires urgent assess-
your leadership, management and team working ment to determine the level of care required.
skills in the acute setting. Expectations follow from This will normally require frequent monitoring
experience and the exposure that you have had to and reassessment of need. Acute illness can
leadership, management and team working. In complicate existing chronic illness.
the previous chapters you will have reviewed the
qualities that make a good leader. The NMC (2010: 39) states that: ‘All nurses must
work independently as well as in teams. They
must be able to take the lead in coordinating,
delegating and supervising care safely, managing
Key learning
An awareness of how personal attitudes
! risk and remaining accountable for the care given’.
For the student nurse it is vital that you focus on
influence your practice is essential to guide developing:
your skill development in leadership, manage-
dependability;
ment and team working.
accountability;
Professional guidance provides you with
responsibility;
frameworks within which to work.
collaboration;
Understanding the influence of your atti-
responding/presencing;
tudes and attributes and the environment
delegation/supervision.
and processes of care is integral to achieving
person-centred outcomes for those in your
care. Leadership in acute care settings
Leadership skills are essential to encourage and
develop teams in any setting but in the acute care
setting the clinical situation can change very rap-
Leadership and management idly. Admissions and transfers can happen at any
skills and their impact in acute time of the day or night and clinical conditions
care settings can be unpredictable and deteriorate without prior
In Chapter 9 you were introduced to the concepts, indication. The nature of patient illness in this set-
skills and differences of leadership, manage- ting can really test, stretch and challenge the per-
ment and team working. Key questions you have sonal and professional attributes you possess, as
addressed related to the required attributes and identified earlier, as well as your leadership skills
attitudes of leadership and the impact they have and style.
160
these skills then the evidence suggests that prob-

Activity 11.2 lems may occur. Padilla et al. (2007: 179) describe
the five features of destructive leadership:
Think of examples from your practice
learning where you have observed events sud- it is seldom wholly destructive: there are both
denly changing around you, and reflect on the good and bad results in most leadership situa-
response of the health care team. tions;
it involves dominance, coercion, and manipu-
Who led?
lation rather than influence, persuasion, and
Was it the person you expected?
commitment;
What was the outcome?
it is focused more on the leader's needs than
Would you act differently if you were in the situ-
the needs of the team;
ation tomorrow?
it produces results that compromise the qual-
ity of the working experience for the team and
detract from the team’s main purpose;
Effective leadership is a key characteristic of an it will continue to thrive where there are sus-
effective team (WHO 2011). Effective team lead- ceptible followers and conducive environ-
ers facilitate and coordinate the activities of other ments.
team members and use their skills to be:
These features are also explained in the ‘toxic
confident and willing to lead; triangle’, where the destructive leader is placed in
aware of their strengths and weaknesses and a situation with susceptible followers and an envi-
when they require additional help and guid- ronment which is conducive to further development
ance; of their poor leadership behaviour (Padilla et al.
vigilant as to what is happening around them; 2007: 180) (see Figure 11.1 on the next page).
competent to make clinical judgements in As a student you may experience some of
order to set priorities and make decisions; these elements while on placement or during your
able to delegate activities to the team in a course within the university. You may feel that you
manner that encourages strengths and over- may be a ‘conformer’ due to lack of experience
comes weakness of each individual member; and in that respect become a susceptible follower.
logical and fair when negotiating resolutions However, the NMC (2006) states that all practice
to conflict;
able to use available resources effectively;
able to create a culture that welcomes ques-
tioning practitioners and encourages feed- Activity 11.3
back;
Have you had any experiences of bad
able to communicate openly in a way that
leadership? If so:
ensures all team members know exactly what
is expected of them at any given point in time. Think about the situation you were in at the time.
How did your personal attributes help you deal
Leadership in acute care is essential because with it?
of the nature of the environment and the require- Did the environment have any impact on what
ments of the patients. So when leaders can dem- was happening?
onstrate and apply the skills outlined above, the What effect did this have on you?
impact on the workplace can be positive and effec- What have you learned from it?
tive. If the nurse as a leader does not demonstrate
161
Destructive leadership
Charisma
Personal power
Narcissism
Negative life themes
Ideology of hate
Conformers Colluders Instability

Unmet needs Ambition Perceived threat
Susceptible Low maturity Bad values Cultural values Conducive
followers Low evaluation Similar world Lack of checks environment
of self view and balances and
ineffective institutions
Figure 11.1 The toxic triangle: elements in three domains related to destructive leadership
learning environments must be audited to ensure

that they are conducive to learning for you; so
this element should not occur. If it does there are
Key learning
Effective leaders are facilitators who
!
‘checks and balances’ in place within your univer-
place the needs of the people in their team
sity and the practice learning setting to ensure that
and in their care before their own status.
action is taken to alleviate such problems. As you
Effective leaders need a team who are will-
develop a set of skills to assist you in the acute
ing to commit to a shared purpose and goal.
care setting you will soon discover people who
Destructive leaders have a need to force the
can help you. These people may be your lecturer,
team and those in their care to conform to the
practice teacher, mentor or other staff member.
roles that have been set for them in order for
You do not have to take this journey alone. If you
the leader to feel successful.
are experiencing issues around leadership and/
Destructive leaders often have team members
or management during your practice learning you
who either submit to their authority without
need to address it before it becomes detrimental to
question or who try to imitate them – thus
your development. reinforcing their negative behaviour patterns.
Learning to lead and manage discovered in Chapter 9, leaders do not always

Think about some activities that you have carried have a management role and managers are some-
out with friends, colleagues, team-mates, groups, times not great leaders. As a student you should
clients, professionals and other people. As you plan to observe and interact in as many team,
162
leadership and managerial situations as possible.

Your mentor will discuss this with you when you Activity 11.4
are developing your learning contracts and action
plans for a particular period of practice learning Martin Bromiley founded the Clinical
placement, relating to your stage of training. Human Factors Group (CHFG) after the death of
his wife in 2005. The website can be found here:
www.chfg.org/about/background-to-chfg.
Skills of leadership and management in
an acute setting Watch a reconstruction of what happened
In acute care nursing managers have to develop during that routine operation and have a look
many varied and skills. They have a physical envi- at ‘Just a routine operation training video’ at www.
ronment to organize and maintain as well as a institute.nhs.uk/safer_care/general/human_
personal dimension to facilitate on many levels. factors.html. This highlights the issues of lead-
Nurse managers must be the link to the organi- ership, management and team working in
zational hierarchy as well as the ward leader in acute care very clearly.
relation to staff, patients and families.
The government has encouraged support for
ward managers as they have to develop skills to
be able to cope with issues such as: Team working
Lafasto and Larson (2001) believe that effec-
conflict; tive team members bring ‘added value’ to the
apathy; group. These members contribute in a unique
stress; manner by, for example, building confidence and
pressure and shortage of funds, staff and trust or by having a positive attitude to the work
resources; involved. Some of the issues of working in a team
personality clashes; within the acute care area are exemplified in a
bullying and harassment; survey of operating theatre surgical teams (Flin
delegation; et al. 2006). Consultants, trainee surgeons and
cultural relationships/traditions; theatre nurses reported generally positive atti-
complaints; tudes to behaviours that were associated with
risk management. effective teamwork and safety. Some responses
to the questionnaire demonstrated that there
Plus many more. What other issues do you think a was a sense of personal invulnerability to stress
manager will have to consider? and fatigue. Human factors of stress, poor com-
As a student who has to learn to manage a munication and tiredness within teamwork are
group of patients in the acute care setting, you areas where teams can fail and patient safety can
will also be aware of many of these elements be compromised. The Patient Safety First cam-
within your practice learning. You may wonder paign launched in response to the Department of
how you will be able to do this, but if you think Health’s review of patient safety in England (DH
about your transition from primary school to 2006) is an example of how a focus on safety can
secondary education and the transition you have improve outcomes for people requiring care. Fur-
now made to university, you will realize that you ther details can be found at www.patientsafety-
have already managed many of the above situ- first.nhs.uk.
ations. The World Health Organization (WHO 2011)
When there is no clear leader in an acute setting presents the qualities shown in Figure 11.2 as
the results can be disastrous (see Activity 11.4). timeless characteristics of teams that work well.
163
Energy and
clarity of purpose
Ability to blend
Clear goals
talents of others
Integrity and Strong leadership

honesty
Facilitates Initiative
communication
Competent/hard
Raises issues
working/reliable
Disarming
frankness
Figure 11.2 Qualities of an effective team member
Each of us has attributes that we can bring to a developed a method of managing this in a profes-
team, for added value. In health care settings such sional manner. For example, if you canot answer
as acute care the ward manager of the clinical a relative’s question you would respond by saying,
area may not have any say in the people allocated ‘I do not know the answer to that question, but I
to the team, but the care delivery in the area will will find out for you.’ Fear of questions can then be
ultimately be their responsibility. One of the most removed from an encounter because you have a
important skills that you can learn to develop is to method for managing the situation. You also may
be able to manage yourself. You will have found have been able to manage your time in the prac-
that you have been able to develop different man- tice learning environment by developing learning
agement skills during your course to date. When contracts and making action plans in relation to
the course began you may have been hesitant specific skills you wanted more experience in. So
in talking to patients and relatives but have now by developing the skill of self-management you
164
will already have become a person who can fit into given you the confidence to work within an inter-
a team. professional team as well as voice your opinion
on patient care. Suter et al. (2009) present a case
Components of building a safe for competent collaboration: knowing how your
and effective team professional culture will impact upon patient
Lafasto and Larson (2001) realized that each team care as well as the ability to find your place within
has a goal to reach; something that they are trying the clinical team, recognizing each participant’s
to do rather than be. In order for the effective team strengths. This can only happen in an environ-
to achieve that goal there needs to be an element ment or culture that fosters mutual respect and
of collaboration (working together with the multi- collaborative practice and therefore there is
disciplinary team) and coordination (who is doing inevitably a strong correlation between the cul-
what, when and how?). ture in which you work clinically and your ability
to demonstrate clear leadership and manage-
ment skills. In nursing there is a vital clinical ele-
ment in teamwork: you have to know what you
Activity 11.5 are doing when collaborating towards a com-
mon objective.
As a student, what experiences have
In any area of nursing, teamwork is seen as a
you had in teams in the clinical area?
vital component to achieving the common objec-
Do they all work in the same way?
tive, which is quality patient or client care. Each
Have you felt included in the team?
one of us has different experiences and we bring
What are the reasons why you did/did not feel
different problem-solving skills to each situation.
included?
Neumann et al. (2010) presented a special report
on the importance of interdisciplinary team work-
ing within the speciality of physical and rehabili-
Pollard (2009) believed that the student expe- tation medicine. They believe that teams work
rience of practice learning within interprofes- best because they not only have a combination
sional settings varies considerably. There were of skills, but also work towards agreed aims
several contributing factors to the success of using an agreed strategy. What one person lacks,
interprofessional learning as described by Pol- another has in abundance: this is the strength of
lard, including the influence of doctors and dif- teams (see Figure 11.3). We can then support
fering professional cultures; mentors’ support for and develop one another to ensure that our work-
student engagement in interprofessional working knowledge is at its most efficient. So a student
ing; and individual students’ confidence levels. going into his or her management placement will
The clinical areas when Pollard was writing were be supported by the rest of the clinical team to
largely managed by nurses and some senior achieve competency at the final progression point.
nurses were proactive in involving students in The sign-off mentor will facilitate clinical expe-
the work of the interprofessional team. However, rience along with the medical and other allied
Pollard found that many students lacked system- health professionals.
atic support for interprofessional engagement. The problem with teams is exactly the same
You may have had experience of working and as their strength: they are made up of individuals
learning with other professionals as interprofes- who have different experiences and bring different
sional learning and activities are a common aspect problem-solving skills to a given situation. Each
of your nursing education as well as an expected team member may believe their way is best and
outcome of your development. This may have this can lead to conflict.
165
Openness (exchange
of ideas)
Personal style
Supportiveness Teamwork (comfortable
(willing to help
listens well) factors motivator
creative)
Action orientation
(rises to challenge
energetic)
Figure 11.3 Factors that distinguish effective team members
Case study 11.1a: Nurse Blue

Student Nurse Blue is a Year 3 adult nurse in placement in the accident & emergency (A&E) depart-
ment of a local hospital. It is week 6 of a 10-week experience. She has not had learning opportunities in
this hospital area before. She has worked with her mentor on days and nights on a regular basis and has
a good relationship with him. He is experienced in A&E nursing as he has worked in this area for over 10
years. He has mentored many students in A&E in the past.
On duty today is Consultant Able who is renowned for her high level of knowledge and expectations.
She would say that ‘she does not suffer fools gladly’ and demands a high standard of care to be delivered.
The next senior doctor on duty is Doctor New. He has only just begun his rotation into this clinical area and
appears hesitant in his decision-making, often relying on nursing staff for guidance. The nurse in charge is
dynamic A&E Sister Confident who has 15 years’ emergency care experience. Her decision-making skills
are rapid and responsive. The other senior nurse is Sister Duty; she is due to retire in three months’ time. She
has been allocated a heavy administrative role because the ward manager is on sick leave after surgery.
Also on the unit is Staff Nurse Element, who usually works nights but has been rotated onto days in order to
undertake training. There is one agency nurse who has little A&E experience and can only care for trolley waits.
She has been allocated this duty for the entire shift. The ward assistant is a mature student nurse who worked
in A&E for 18 years prior to realizing her dream of getting a place at university to study nursing. She is in Year
2 of the same course as Student Nurse Blue. The ward assistant is working part time to help fund her place on
the course. She has a daughter the same age as Student Nurse Blue. The ward clerk covers the whole of the
emergency department, but is more familiar with the minor injury area, as this is where her desk is located.
166
The WHO’s multiprofessional Patient Safety Cur-

Activity 11.6 riculum Guide (2011: 22) states:
What are the skills, strengths and weak- Patient safety skills and behaviours should begin
nesses of the members of the team outlined in as soon as a student enters a hospital, clinic or
case study 11.2? health service . . . Most health-care students have
What questions would you ask about this team high aspirations when they enter into their chosen
to help you work in this area? Think about their field, but the reality of health-care systems some-
experience, skills and personal attributes but times deflates their optimism. We want students
also consider the physical environment. to be able to maintain their optimism and believe
that they can make a difference, both to the indi-
Poor teamwork and the potential impact vidual lives of patients and the health-care system.
on patient care and safety
Problems with teams can contribute negatively to
The importance of patient safety
the climate of communication within a team. Man- Patient safety within the acute care area has many
ser (2009) published a review of the literature on elements. We previously outlined the person-
teamwork and patient safety in dynamic domains centred framework in caring for our patients. Pro-
such as operating rooms, intensive care, emergency fessional competency is one area that needs to be
medicine and trauma and resuscitation teams. highlighted. As a student you should be working
Flawed teamwork was shown as an important con- in a safe learning environment, one which places
tributing factor in the analysis of incident reports patient safety high on the agenda. Planning how
or adverse events, usually in relation to commu- you are going to achieve your learning outcomes
nication issues. The issue of communication with in the practice learning area will assist you to
different terms of reference (different clinical back- develop management and team-building skills. A
grounds) also caused breakdown in teamwork. safe environment for you as a student is an area
Case study 11.2

It is 8.40 a.m. on a Friday morning and the A&E department is quite calm. There are a few patients
awaiting transfer to wards and some waiting for minor interventions following triage.
Two patients arrive in the department at the same time, one via ambulance and the other by private car.
The patient in the ambulance is Tom, a 56-year-old man complaining of chest pain. The second patient is Jane, a
9-year-old girl with learning disabilities who has had vomiting and diahorrea all night and has a pyrexia of 38.5°C.
Student Nurse Blue has been allocated Jane to admit to the department while her mentor admits Tom.
Suddenly, Tom has a cardiac arrest and everyone in the immediate care area runs to his cubicle. Stu-
dent Nurse Blue has never seen an arrest and is keen to participate in resuscitation, having developed a
learning contract for this in her portfolio. Consultant Able is off the floor at an audit meeting and Doctor
New is the most senior doctor in the unit. Sister Duty is covering tea breaks and is at Tom’s bedside. Stu-
dent Nurse Blue is called into the arrest situation by her mentor.
Doctor New asks her to begin chest compressions, which she does effectively. In the meantime, Doctor
New is trying to assess heart rhythm but does not instruct Student Nurse Blue to stop compressions while
he does this. She continues as instructed but when Sister Duty observes this she shouts loudly at both
Doctor New and Nurse Blue. Nurse Blue becomes very distressed at what she feels is a mistake in this
acute episode and runs out of the cubicle. As she passes Jane she notices that her condition has deterio-
rated and her mum has fallen asleep with her head on the trolley.
167
provide a systematic depth of information-sharing

Activity 11.7 that will lead to timely action being taken. SBAR is
an acronym for situation, background, assessment
Consider Student Nurse Blue’s predica- and recommendation, and is used as a technique for
ment in case study 11.2 communicating critical information. It is intended
What actions would you take if you were in this to ensure that the correct information and level of
situation? concern is communicated in an exchange between
What happened in the few minutes that have health professionals (Haig et al. 2006). Thinking
just been described? about the care provided in a systematic way can also
Think about patient safety, communication and influence practice safety. One way to achieve this
the learning environment. is using the ‘five Ws’ approach (who, what, where,
when, why). Keep on asking questions until you
understand what is happening (see Figure 11.4).
that you may not have thought of before, but a
safe nurse will ensure patient safety is maintained
throughout an acute care episode. Box 11.1 Using the SBAR tool
Several suggestions are made on how to make The Situation, background, assessment and
your practice environment safer in the NHS docu- recommendation (SBAR) tool is systematic, logical
ment Implementing Human Factors in Healthcare and helpful and is often used by professional lead-
(see http://bit.ly/YizsjA). It is recommended that ers in analysing a situation. Have a look at this link:
safe and relevant communication can be achieved http://bit.ly/10ilyGl.
through the use of a structured framework to
Think about
possible
distractions and
interruptions
Know your stress
Environment
Be self-aware Lighting
Prepare for Clutter/storage
emergency
Safe care
Safe workplace
Ask the 5Ws Physical
Safe nurse demands
Keep asking until
you get to the Demands >
root cause capability?
Device or
Teamwork
product design
Briefing/debriefing
How does it
SBAR/Plan B
work?
Figure 11.4 How to build a safe environment
168
Case study 11.3

Student Nurse Blue remembers what her mentor told her during her induction to the department.
If there is an emergency she should push the emergency button and all staff will come to the area where
the call has originated from. She hesitates for a moment, thinking that she will be shouted at again, but then
looks at Jane and thinks to herself:
Jane is deteriorating
There are not enough staff on the department to deal with Tom’s arrest and Jane’s condition
I do not have the knowledge, experience and skills to deal with this on my own
I need help
So she pushes the emergency call bell.
Within seconds other staff arrive at her bedside. Sister Duty asks, ‘What has happened?’ Student Nurse
Blue remembers a technique for team members to accurately share information and ensure that the
focus is on the information being communicated. She reports using the SBAR tool (situation, background,
assessment, recommendation).
Situation
What is going on with these patients?
There are two patients who need urgent attention. Tom has arrested in Cubicle 2. Doctor New and Sis-
ter Duty are in the cubicle performing CPR. They have the crash trolley. Nurse Blue has found her patient,
Jane, unresponsive.
Background
What is the clinical background or context?
Tom, a 56-year-old man complaining of chest pain, was admitted 10 minutes ago. No family are here
yet. Jane, a 9-year-old girl with learning disabilities, has had vomiting and diahorrea all night and has a
pyrexia of 38.5°C.
Assessment
What is the problem?
Tom may have had a myocardial infarction. Jane has shallow, rapid breathing and is a very poor colour.
Her mother is beside the trolley. Nurse Blue is concerned about the deterioration in her condition.
Recommendation
What should be done to correct the problem?
Having outlined the situation Student Nurse Blue asks Sister Duty’s advice on how to proceed.
How did Student Nurse Blue deal with this situation?
She left Tom’s cubicle distressed and annoyed, but then her observation skills overtook her own sense of
injustice. She used her skills of recall from previous learning to apply the SBAR tool to provide a structured
handover to Sister Duty.
She realized that as a team member she did not have the skills to act in Jane’s best interests and knew
when and how to call for help. There were several factors that impacted on her experience of teamwork.
Look back at Figure 11.4 and identify them.
After the situation in A&E has been resolved and both patients have been stabilized Student Nurse Blue
is angry at the way Sister Duty spoke to her in the arrest situation and feels that there is now a bad relation-
ship between herself and Sister Duty. She wants to resolve the issue and speak to Sister Duty.
169
Leading resolution in conflict tions that you are uncomfortable with will assist
situations you in developing a personal and professional port-
folio of coping strategies that will stay with you for
As nurses in a professional environment we have
your whole life.
to respect the other person’s viewpoint, even if we
do not agree with them. It is sometimes very dif-
ficult to work alongside a person who completely Case study 11.4
disagrees with your view or assessment of a situ- Student Nurse Blue is able to speak to
ation. When this happens it is often necessary to Sister Duty with her mentor and explain that she
speak to the other person to resolve an area of felt angry and humiliated that she was shouted at
conflict. Arnold and Boggs (2007) highlight several during the arrest, even though she was conduct-
methods that could assist you in cases such as ing herself in a professional manner and doing
this. These have been integrated into a diagram- as instructed by Doctor New. Sister Duty is able
matic plan of action, shown in Figure 11.5. to understand this and apologizes for shouting.
A key demonstration of professional behaviour She explains that she felt under a lot of pressure
expected of all professionals, particularly lead- at the time and should not have reacted in that
ers, is the ability to apply these strategies as part manner. Student Nurse Blue is able to reflect
of your day-to-day practice. Pivotal to this is your on her A&E experience as one which clearly
ability to communicate appropriately. It is evident improved her communication and team working
that the qualities of leadership in a professional are skills. She was able to demonstrate competency
multifaceted and require a range of knowledge, in these areas for her mentor.
approaches and skills. Learning to manage situa-
Evaluate
Ask for a change
One issue at a time

Focus on the present
Organize the time
Allow for discussion and listening
Manage your anxiety
Use breathing and relaxation techniques
Organize your information
Consult with someone who is objective. Rehearse
Prepare for the encounter
Be clear of the purpose of the discussion and have main points ready
Figure 11.5 Developing a strategy to address conflict
170
Conclusion Effective leadership is a key characteris-

tic of an effective team. Lafasto and Larson
This chapter has focused on the skills of leadership,
(2001) believed that effective team members
management and team working from an acute
brought ‘added value’ to the group. These
care perspective. The components needed in order
members contributed in a unique manner by,
to build a safe and effective team were highlighted
for example, building confidence and trust
through a case study. Examples of poor teamwork
or by having a positive attitude to the work
and their potential impact on patient care and safety
involved.
were presented in relation to clinical evidence.
Patient safety can be improved by good team-
work, especially communication.
In summary:
Reflection on your experiences will assist
you in developing a plan to achieve compe-
To become an effective practitioner you must
tency.
be aware of your own personal and profes-
sional attitudes and attributes.

http://bit.ly/10dWhvN. The NHS Institute has developed a leadership framework to provide guidance, available
at this link.
http://www.institute.nhs.uk/. The NHS has developed leadership and management programmes and a suite of
resources that can be accessed at this link.
You will also find the following links helpful:
http://www.nmc-uk.org/Students/
http://bit.ly/10PIAHb
http://www.patientsafetyfirst.nhs.uk/
http://nhsleadershipframework.rightmanagement.co.uk/website/default.aspx
http://www.nmc-uk.org/Students/
http://teamstepps.ahrq.gov/abouttoolsmaterials.htm
http://www.patientsafetyfirst.nhs.uk/ashx/Asset.ashx?path=/Intervention-support/Human%20Factors%20
How-to%20Guide%20v1.2.pdf
References
Arnold, E. and Boggs, K.U. (2007) Interpersonal Relationships: Professional Communication Skills for Nurses, 5th edn.
Philadelphia, PA: W.B. Saunders.
Clarke, D. and Ketchell, A. (eds) (2011) Nursing the Acutely Ill Adult: Priorities in Assessment and Management. Basing-
stoke: Palgrave Macmillan.
DH (Department of Health) (2006) Safety First: A Report for Patients, Clinicians and Healthcare Managers. London: DH.
Flin, R., Yule, S., McKenzie, L., Paterson-Brown, S. and Maran, N. (2006) Attitudes to teamwork and safety in the
operating theatre, Surgeon, 4(3): 145–51.
Haig, K.M., Sutton, S. and Whittington, J. (2006) SBAR: a shared mental model for improving communication between
clinicians, The Journal on Quality and Patient Safety, 32(3): 167–75.
Lafasto, F. and Larson, C. (2001) When Teams Work Best. Thousand Oaks, CA: Sage.
Manser, T. (2009) Teamwork and patient safety in dynamic domains of healthcare: a review of the literature, Acta
Anaesthesiol Scand, 53: 143–51.
McCormack, B. and McCance, T.V. (2006) Development of a framework for person-centred nursing, Journal of
Advanced Nursing, 56(5): 472–9.
McCormack, B. and McCance T.V. (2010) Person-centred Nursing: Theory and Practice. Chichester: Wiley/Blackwell.
Neumann, V., Gutenbrunner, C., Fialka-Moser, V., Christodoulou, N., Varela, E., Giustini, A. and Delarque, A. (2010)
Interdisciplinary team working in physical and rehabilitation medicine, Journal of Rehabilitation Medicine, 42: 4–8.
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NMC (Nursing and Midwifery Council) (2006) Standards to Support Learning and Assessment in Practice. London: NMC.
NMC (Nursing and Midwifery Council) (2011) Guidance on Professional Conduct for Nursing and Midwifery
Students. London: NMC.
Padilla, A., Hogan, R. and Kaiser, R.B. (2007) The toxic triangle: destructive leaders, susceptible followers, and con-
ducive environments, The Leadership Quarterly, 18: 176–94.
Pollard, K. (2009) Student engagement in interprofessional working in practice placement settings, Journal of Clinical
Nursing, 18: 2846–56.
Suter, E., Arndt, J., Arthur, N., Parboosingh, J., Taylor, E. and Deutschlander, S. (2009) Understanding and effective
communication as core competencies for collaborative practice, Journal of Interprofessional Care, 23(1): 41–51.
WHO (World Health Organization) (2011) Patient Safety Curriculum Guide, multi-professional edition. Geneva: WHO,
available at: http://tinyurl.com/c6lbcsm.
172
Section
Achieving competencies: 5
simulation, working with
mentors and learning
when working abroad
Simulation: crafting
your care
12
Eloise Monger and Kate Goodhand
Chapter contents
Introduction Does reality matter?
Simulation: enhancing professional skills Limiting self-reliance
and competence Receiving feedback
What is simulation? What does this mean for you as a student nurse?
Adult and child field Making the most of feedback
Mental health and learning disability fields Conclusion
Simulation and learning theory Further reading and resources
Preparing for simulation References
What do students think?
Introduction to learn in practice placement’ and ‘making the

most of feedback’, the objective is to provide prac-
This chapter provides an insight into the use of
tical advice which students can use to capitalize
simulation as a means to learn the craft of caring.
on their simulated practice experiences in the real
The complexities of learning a craft are acknowl-
world.
edged and a set of practical activities are suggested
This chapter is relevant to all of the NMC com-
to help get the most out of your experiences. The
petencies in each of the four domains: profes-
chapter will demonstrate how students in all fields
sional values; communication and interpersonal
of practice can utilize simulated practice activities
skills; nursing practice and decision-making; and
as part of their learning to achieve the Nursing and
leadership, management and team working.
Midwifery Council (NMC) competencies. We will
outline how simulation is built on learning theory
and discuss the ways in which you can use simu-
Simulation: enhancing professional
lated practice to link what you learn in lectures
skills and competence
with what you do in your practice placements. The Learning, rehearsing and perfecting the skills
chapter will provide an insight into the underpin- required to qualify as a nurse is a complex and chal-
ning thinking that you will need to engage with to lenging task. Most importantly, these skills extend
get the most out of simulated practice and high- well beyond the ability to perform physical tasks.
light how experiences in simulation contribute to In order to be prepared for the exciting and ever-
the development of graduate attributes. The case changing world of health care, you will embark
studies from the University of Southampton and on a journey of personal, professional and aca-
Robert Gordon University draw on research evi- demic discovery. A variety of strategies and tech-
dence to illustrate the sophisticated nature of this niques are used throughout your course to assist
method of learning. By focusing on ‘learning how in the process of developing these professional and
175
Section 5 Achieving competencies
graduate attributes. The most obvious professional to pursue this career path and the experiences you
development strategy is the requirement for nurse will encounter throughout your career will con-
education in the UK to incorporate learning not tinue to shape your learning. The combination of
only in the university, but also in real health care theory and practice during a nursing course builds
environments. This helps students contextualize on past experiences and provides the framework
the knowledge required and recognize the practical for the personal and emotional development which
competencies associated with that knowledge. The is necessary to support professional caring. Over
ability to apply the theoretical knowledge gained the past decade, simulation and simulated practice
from academic study to clinical situations, and to have emerged as educational techniques to help
do this well, is one of those essential attributes. students develop these relationships in learning.
Another is the ability to reflect on, and develop,
one’s professional skill set from experiences in What is simulation?
practice. This means not just being able to under- The NMC describe simulation as any simulated
take the physical task, but to demonstrate compas- teaching and learning activity that is applied to
sion, respect and sound decision-making while you teach and assess skill acquisition through an inter-
are doing it. Being able to put theory into practice active experience (NMC 2007; Ricketts 2011). Gaba
is not as easy as it sounds, nor is the development (2004: 126) describes it as a technique that may be
of the range of learning skills that are required in used ‘to replace or amplify real experiences with
such different environments. Learning will occur in guided experiences that evoke or replicate substan-
both theory and practice; however, for that learn- tial aspects of the real world in a fully interactive
ing to have added value, there needs to be a con- manner’. The majority of simulated activity in health
duit between the two so that the ‘understanding’ care involves combinations of simulated ward envi-
does not get separated from the ‘doing’. ronments, mannequins/equipment and/or simu-
Figure 12.1 depicts these learning relation- lated patients (which generally means actors)
ships. Everyone begins their nurse education with (O’Hagan et al. 1986) and the students’ interactions
a range of experiences of health care: personal epi- with a set scenario (Kneebone et al. 2006; Scherer
sodes of ill health, and those of family and friends, et al. 2007). These scenarios can be generic – i.e.
being a carer, doing voluntary work, unpaid work relate to all fields of practice – or field specific – i.e.
experience or work as a health care assistant. adult, child, mental health or learning disability. It is
These life experiences, both good and bad, will likely that students in the different fields will have
have been an important influence in your decision exposure to a different balance of environment/
equipment/actors depending on the aims of the
sessions. Mental health and learning disability stu-
dents may participate in more scenarios with actors,
Students’ pre- whereas adult and child field students are likely to
existing knowledge,
skills and attitudes have comparatively more exposure to sophisticated
computer controlled mannequins, which can repli-
Academic Practice cate physiological signs and symptoms.
study in experience in
Learning An example of a generic scenario would be an
theory time clinical
placements initial patient/client assessment, which would
include demonstration of communication skills,
NMC domains of
competence appropriate use of standard precautions (hand
Graduate attributes washing and infection prevention), history-taking
and recording of observations, reporting of rel-
Figure 12.1 Learning relationships evant facts to senior colleagues and documenta-
tion, all using actors as patients.
176
Chapter 12 Simulation: crafting your care
Adult and child field

Adult and child field student simulations often Activity 12.1
involve interaction with sophisticated computer
controlled patient mannequins which are designed
How would you feel about enaging in
to demonstrate physiological changes. These man-
a simulated practice experience: about being
nequins can simulate breathing, blinking, speak-
watched, maybe even filmed, and about dis-
ing, bleeding and fitting, and they have pulses,
cussing your performance afterwards?
heart sounds, lung sounds, reactive pupils, etc.
Next consider the public’s expectations of the
They can be programmed to deteriorate or improve,
care they receive. Ask a few friends and rela-
depending on the student’s actions. As an example
tives who are not health care professionals what
students may be asked to care for a post-operative
they think about nurses practising skills in simu-
patient who starts to bleed internally and develops
lation before they do them with real people.
the signs of hypovolaemia.
What are the differences in views or attitudes
that this exercise highlights?
Has thinking about the perceptions of others in
Mental health and learning
disability fields terms of the work nurses do altered your initial
The scenarios in the mental health and learning thoughts?
disability fields more commonly use real people as
simulated patients in order to focus on therapeutic
techniques, risk assessments, case presentation, Lastly we should consider what simulation is
etc. These activities involve a subtlety of com- not:
munication which cannot be achieved with man-
nequins, and simulated patients generally require simulation is not a replacement for practice;
specific training to be able to accurately represent unless you are specifically told to prepare for
the behaviours required in the scenario. an exam, simulations are not tests: you will
not be judged against your peers and you will
‘A simulation creates a scenario that mimics a real not be told off for getting anything wrong.
life situation. For this reason, simulations provide
a way for students to gain experiences in problem Simulation and learning theory
solving and decision making without the realities To learn a practical task requires performance of
and demands of an actual clinical situation.’ that task. The ancient Chinese proverb, ‘I hear I
(Gaberson and Oermann 1999: 135). forget, I see I remember, I do I understand’, is a
simple way of thinking about the value of simu-
This quotation highlights two important issues:
lation, a method of learning reportedly practised
Simulation mimics reality but is not real. Equiv- since 800 bc (Wildman and Reeves 1997). Health
alence to real practice is therefore dependent care professionals in general, and student nurses
on the student’s perception of how real the in particular, are recognized as a distinct group of
scenario is, and this may vary with the activity learners, striving to acquire the knowledge, skills
undertaken. and attributes needed for professional practice. It is
Simulation is safe, for both patients and stu- recognized that the outcome of this type of learning
dents. It is common practice for high-risk is competence. The way in which learning, in order
industries to use simulation when training to achieve competence requires different compo-
staff – for example, pilots. In fact, many peo- nents was first recognized by Aristotle who made a
ple would not be prepared to put their trust in distinction between technical and practical knowl-
a pilot who had not done simulator training, edge. Ryle (1949) describes this distinction more
such is the value placed upon it. accessibly as ‘knowing that and knowing how’.
177
Eraut (1994) categorized these forms of knowl-

edge further, as the building blocks of what he
describes as experiential learning:
Key learning
Experiential learning in simulation
!
knowledge of people; allows you to identify and develop strate-
situational knowledge; gies of learning that you can use in clinical
knowledge of practice; placement.
conceptual knowledge;
process knowledge or know-how;
control knowledge – knowledge of the self,
strengths and weaknesses, how to receive
Preparing for simulation
feedback, how to utilize knowledge from other Building on Activity 12.1, spending some time
sources and limit self-reliance. thinking about your expectations of a simulated
practice experience is an excellent first step to
Boud et al. (1993) assert that the essence of prepare for such an experience. Developing your
how people learn from experience is by a cycle of understanding of the use of simulation will also
activity, reflecting on that activity, relating it first help. Learning in both simulation and practice
to what is known from past experiences, then to is very definitely active. You therefore need to
what it may be used for in the future, and finally approach these experiences with an open mind,
validating it against the experience of others. Sim- do any pre-reading or e-learning activities set by
ulation works in that way: it provides the opportu- your tutors and familiarize yourself with the NMC
nity to perform an activity and then to debrief and competencies.
reflect upon the experience in a structured way to The purpose of this chapter is more than pro-
identify the points of learning for individual stu- viding an overview of simulation in nurse edu-
dents. Experiential learning theory also recognizes cation. The intention is to translate some of the
that individual students will learn different things research evidence and experience from two of the
from exposure to the same event, because of the leading centres for simulation in the UK into prac-
personal nature of their learning journey. tical advice that students can use. This provides
As Frye (2000: 541) has suggested: ‘There really an example of research evidence and will enable
can be no goal where taking the journey itself is you to develop your skills in using evidence from
the best thing to be done’. This means that you two case studies to inform and enhance prac-
should expect that your experience in a simula- tice, as discussed in Chapter 1. We have therefore
tion scenario will be completely personal to you. chosen two elements, situated within the domain
What you learn will be framed by your previous of Eraut’s ‘control knowledge’, which have very
life experiences. Your learning may be about the practical relevance for students. We now use two
tasks in the scenario, but may equally provide case studies to demonstrate simulation at work.
clearer insight into how you learn, what you think The first (12.1 opposite) is from the University of
about certain issues, how you feel about certain Southampton and focuses on how students can
situations, or how you handle your emotions. Your use simulation to develop understanding of their
expectations of what will happen in a simulation strengths and weaknesses, utilize knowledge
may turn out to be very different from the reality, from other sources to limit self-reliance and learn
and what you learn may be different from what how to get the most out of practice.
your colleagues learn, but this is perfectly normal. The second case study (12.2, p. 182) is from
Whether in simulation or in clinical practice, you Robert Gordon University and focuses on how to
need to learn to take the journey and capitalize on receive feedback, and how this enables students
whatever events occur along the way. to gain knowledge of themselves.
178
Case study 12.1: Learning how to learn in practice: lessons from the
University of Southampton
Up until 2007, any simulated practice activity undertaken as part of a nursing programme was not consid-
ered as practice and therefore had to be accounted for in theory time. In 2006, with the growing accep-
tance that more universities were choosing to use simulated activities, the NMC commissioned work to
assess the value of simulation in supporting student learning as part of their clinical hours. The results from
the 13 participating universities were amalgamated to produce the NMCs final report which concluded
that simulation enhanced students’ practice learning and that up to 300 ‘clinical practice’ hours could be
used in simulated practice (NMC and Council of Deans for Health 2007). The University of Southampton
was one of the participants and the research evidence provided data from 348 students’ experiences of
simulation in Year 2 of the programme. Year 2 nursing students (277 adult field, 53 child field and 18 mental
health and learning disability), undertook field-specific simulated practice activities in groups of three to
four students at a time.
This evaluation data was corroborated by the field notes of the researchers and reports of the
mentors – practitioners who had not facilitated simulated practice before – who confirmed that the major-
ity of students engaged in the scenario as if it were real. 90 per cent of students felt that the learning was
valuable and relevant. It is interesting to note though that only 50 per cent felt that it helped them learn
how to work in a team. This finding fits with experiential learning theory and demonstrates that this kind
of learning is personal; the students state that they have learned but not all of them are considering other
people working with them. This demonstrates normal student development, where in Year 1 you are com-
pletely focused on yourself and the learning of practical skills. In Year 2, you will begin to feel more confi-
dent with your role and recognize your place in the wider team, and by Year 3 the majority of students will
have gained professional self-confidence. The research data shows that about 50 per cent of the Year 2
students were aware of the teamwork element which reflects this period of transition from selfish learner
to self-confident professional learner.
What do students think? ‘You don’t stand around on the ward –

The following student comments demonstrate the other patients would make it more real.’
three main issues which were identified as impor- ‘Not just one patient – [do] this job and
tant after the simulation. another, other distractions would make it
more real.’
1 The comparison of the students’ expecta-
3 Linking theory and practice.
tions of the experience and the actuality.
‘Gets you really thinking, it puts things
‘OK once you got used to it.’
together.’
‘More real than I thought.’
‘Here it’s like placement, but I understand
‘I am on a medical ward – it’s very like
the processes.’
the patients on my ward.’
‘Theory – could think about it a bit, but
‘But it’s like this every day in practice.’
didn’t think I was practising. When I saw
2 The physical reality of the simulated environ- others doing it I thought “God, that’s how
ment. its done, sounds more professional”.’
‘It’s dead quiet – would be easier if it were ‘The first couple of weeks on a placement
noisy.’ you are determined to keep theory in the
179
forefront, but after a couple of weeks arts of observation and building relationships
you forget the theory and do it properly. while performing tasks. Counterintuitively, the
Doing this once a week while in practice use of mannequins can highlight the types of
would keep it fresh in your mind. In prac- cues which are used in the observation of, and in
tice – you do the same as everyone else relationship-building with, real patients because
which is not always the best practice.’ they are missing. Students often suddenly recog-
nize that with a real patient they would be look-
These quotes provide a clear insight into how ing at the patient’s body language or their colour
experiences in simulation get students to think and that it would be easier with a real person.
about their practice. The learning is about recognizing how we rely
What the quotations above illustrate is that on these cues and how we can develop our skills
simulation is not about learning an individ- of observation. In a similar way, the removal of
ual task, like giving an injection. Although the some cues makes the assessment more focused
simulations involved undertaking a number of on appropriate questioning, distillation of rel-
tasks, the students do not describe those tasks evant facts and using frameworks for assess-
when considering their learning. They do, how- ment. The removal of the subtle intuitive sense
ever, appear to be thinking broadly about their you get from a real patient focuses the mind on
performance, what they did well and what they the objective physiological evidence presented.
needed to improve, and how. This is, of course, When the evidence is presented in this way, it is
partly because of the way the facilitators led the possible to begin to understand how to use theo-
debrief, but it is a good example of how simula- retical knowledge to build the bigger picture of
tion allows you to recognize your strengths and what is happening with the patient. This is what
weaknesses. If you can do this, you are able to the students were saying when they talked about
identify where you need to practise more, and ‘putting it all together’. It is not until this objec-
if you cannot do it, your learning will be seren- tive bigger picture can be seen that it is possible
dipitous and potentially much slower than if you to communicate patients’ problems profession-
actively worked at it. ally, or to hone decision-making skills. If you are
interested in the reading more about the ways we
Does reality matter? have been researching some of the challenges
posed by simulation, Gobbi et al. (2012) provides
a useful summary.
Activity 12.2 The cumulative findings of these research stud-
At some point you will have been involved ies have informed the ‘stacking’ approach to simu-
in a simulation, although you may not have thought lation at Southampton (see Figure 12.2).
about it that way: a mock exam, a rehearsal for ‘Skills stacking’ means that simulation sce-
a play or interview practice, for example. Think narios are embedded in the curriculum to provide
back to those activities. What did you think at the sequential opportunities for learning. Skills are
time? Was your expectation of the event different built up like a pyramid, adding a new layer each
to the actuality? Did it help you when the real event time. During the first few weeks of the course, the
occurred? Was it important for the practice to be concept of professional values is introduced and
‘real’? linked to skills (see Chapter 2). This is then con-
solidated by the first simulation experience which
focuses on practising communication with the
Simulation provides the opportunity to prac- patient to demonstrate compassion in a profes-
tise a skill, in context, without the fear of mak- sional way and professional information-sharing
ing mistakes. It allows students to develop the with colleagues.
180
decision-making. The scenarios will focus on

NMC Standards Domain building evidence-based action plans to manage
4: leadership, the identified problems in appropriate ways. The
management and team
working simulation is timetabled to occur prior to the final
AND
Essential skills clusters: practice experience so that students can reflect on
organization of care their learning needs, identify areas for develop-
NMC Standards Domain 3: nursing ment and use the last placement to complete their
practice and decision-making
AND skills set.
Essential skills clusters: infection
prevention and control; nutrition
and fluid management; medication Limiting self-reliance
management
The ability to develop professional relationships
NMC Standards Domain 2: communication is fundamental, and one of the most important
and interpersonal skills
AND initial lessons to learn in simulation is how to
Essential skills clusters: care, compassion
and communication
get the best out of your mentor in practice –
when to ask, how to ask, and how to act (you
NMC Standards Domain 1: professional values can explore working with your mentor in more
detail in Chapter 13). In simulated practice, the
Skills build up over time environment is similar to the ‘real world’ which
makes it easier to recognize different strategies
Figure 12.2 Skills stacking to communicate most effectively with health care
professionals. Your facilitators may ‘act’ or role-
play both good and bad practice in order to help
you develop sound strategies of communication.
In Year 2, students have had time in clini- This will be followed by a debrief which is struc-
cal practice, and we expect them to bring those tured to help you learn from the discussion and
experiences to simulation. The field-specific feedback. Recognition of the pitfalls of commu-
scenarios develop decision-making skills while nication between professionals in a busy envi-
students demonstrate their professional values ronment forms the development of this theme
and hone their communication and practice in Year 2 and 3 scenarios. Developing strategies
learning skills. The scenario design and debrief to ‘park’ certain pieces of information until later
process highlight how essential skills (infec- is extremely important as you begin to take a
tion prevention, nutrition, fluid and medication more senior role in clinical environments. As an
management) and holistic care (psychological, example: taking a phone call, receiving informa-
social and spiritual well-being) are becoming tion, and then being side-tracked by a pressing
embedded in the way students are working in clinical problem. The loss of these seemingly
practice. This provides direction to students to trivial pieces of information is a huge problem
recognize personal progress which is essential for any health care environment, and the conse-
for the transition from dependent to indepen- quences can be extremely serious, even if they
dent learner. seem harmless at the time. Seeing other stu-
In Year 3, the scenarios challenge and extend dents’ strategies and hearing facilitators’, tried
students’ developing decision-making skills. By and tested techniques can help you find ways of
this stage the students’ range of practice expe- dealing with these kinds of issues more quickly
rience will have firmly embedded professional and efficiently. For further discussion on commu-
values and communication skills, and allowed nication see Chapters 4, 5 and 6.
them to develop confidence in the identification Simulation experiences also provide oppor-
of patient problems and the associated initial tunities to try out different strategies that you
181
may not have felt comfortable with attempting in Receiving feedback

practice. It can be a bit like trying on a different
set of clothes; if you are normally shy and happy
to take orders, try giving some orders and see Case study 12.2: Lessons from
how it feels, and likewise the other way around. Robert Gordon University
In order to get the most out of simulation, stu- At Robert Gordon University School of Nursing
dents must be self-aware and open to construc- and Midwifery, there is an established ‘volunteer
tive criticism. For some personality types this patient programme’ facilitated by staff from the
comes naturally; others will find it more diffi- clinical skills centre. The volunteers are mem-
cult. The recognition of the personal challenges bers of the public who simulate real patients by
posed by this type of activity is fundamental to playing specific roles in the ward and in com-
professional development. When we consider munity settings; sometimes this involves com-
our development to adulthood, some of the most plex scenarios, other times it means simply
important lessons learned will have been by allowing students to practise non-invasive clini-
making mistakes: getting burned by something cal skills such as manual blood pressure. The
hot, trusting a ‘friend’ who lets you down, or fail- volunteers receive an induction after they have
ing a test because you didn’t prepare. In simula- been accepted onto the programme and about
tion, we see students making mistakes, but we two-thirds of them have also received training in
also see things being done well, and both will be how to give feedback to students.
referred to in the debrief. Highlighting events in Involved third-year student nurses participate
this way is a really powerful way to learn, but it is in a ward simulation and then receive verbal
not unusual to see students feeling embarrassed face-to-face feedback from volunteer patients
or even upset. When someone cares about what (Webster et al. 2012). Yin’s (2009) six case
they are doing, or feels that attention is focused study steps were followed and focus groups
on them, that is to be expected. To manage this were used to collect data from the volunteers,
very human emotional response, we talk through from which four distinct topics were defined
the practical lessons that the whole group can which will be of interest to you. The volunteer
take away for the future. Where an error has patients recognized that unless they played their
been made we also point out that we know that role of patient authentically, the learning expe-
because of the power of the learning, they will rience of the student may be compromised.
never make that mistake again, which is a really They also recognized the importance of con-
positive message to take away. The other stu- structive critical feedback from staff to enable
dents in the group also gain a real insight into them to feel supported to carry out their role in
the personal impact of making an error, which is order to meet the needs of academic staff and
equally valuable. Getting it right in real life is the students.
part that matters. In the clinical simulations, volunteer patients
were requested to provide feedback on commu-
nication and interpersonal skills. The volunteers
!
suggested they would prefer to do this in a one-
Key learning to-one, face-to-face situation so that it could be
Simulation is a learning opportunity; no done in an honest and open way without causing
one can get hurt. embarrassment to the student.
Learning by doing, both by doing well and by A very strong sense of empathy for the student
making mistakes, is very powerful. situation was evident and the volunteers real-
ized how nervous the student nurses became.
182
For this reason the volunteer patients did not

What does this mean for
you as a student nurse?
like giving negative feedback and were keen to
Simulation affords you as a student with the
encourage and support the student nurses. This
opportunity to receive specific feedback on how
support mirrored what occurred in clinical envi-
you performed as a nurse and delivered care. Vol-
ronments when the volunteers had been service
unteer patients take their role very seriously and
users. The volunteer patients said that motivation
request feedback on their own performance from
to become a volunteer patient came from hav-
staff and students. It is important, therefore, that
ing been a patient and experiencing health care
any dialogue between you and the volunteer is
provision first hand. The need to ‘give back’ was
based on mutual respect and that you value their
strong and they felt that their ability to play the
contribution. Without them, simulation scenarios
role of patients was enhanced as they had first-
would often not be as real.
hand experiences to draw on. They felt knowing
Volunteers want to encourage you in your
what to expect gave them authority to give feed-
chosen profession and prefer to give face-to-face
back to students.
feedback in a one-to-one situation so that the
feedback can be individual, honest and construc-
tive. This will enable you to start to see yourself
as others see you. Remember, volunteer patients
Feedback is critical in facilitating learning and a
have a great deal of empathy with you and want
very powerful tool (Hattie and Timperley 2007;
to help you, so any comments are well intended.
Norcini 2010). The NMC values the role of feed-
If something is raised that worries you or is not
back in the learning process as students make the
explained fully, then please raise this with your
transition to being a registered nurse (RN). Under
simulation facilitator. Finally, remember that as
Domain 4 (leadership, management and team
past, current and future service users, volunteers
working), the importance of real patients giv-
are well placed to provide you with valuable
ing student nurses feedback is highlighted under
feedback.
Competency 4:
All nurses must be self-aware and recognise how Making the most of feedback
their own values, principles and assumptions It is important that you make the most of any feed-
may affect their practice. They must maintain back received and continue your development
their own personal and professional develop- while on clinical placements. As student nurses
ment, learning from experience, through super- and developing professionals, it is critical that we
vision, feedback, reflection and evaluation. learn to listen to feedback, reflect on it and move
(NMC 2010) forward. The person giving the feedback should be
aware that in order for it to be effective, it should
The benefit to you as a learner of getting feed- be facilitative – a two-way interaction between the
back from others, including patients, is that you student and the educator, more like a dialogue or
can start to see yourself as others see you, which conversation. It should focus on the task rather
is crucial because patients are receiving their than the individual, be specific and be linked to
care from you. As simulations that occur in the personal goals or the learning outcomes for the
clinical skills centre should be as authentic as simulation activity (Archer 2010). It is important
possible, it makes sense to include the volun- that as the receiver of feedback, you are open to
teers in giving feedback to students. For further suggestions and prepared to think about the com-
discussion of receiving feedback in practice, see ments made to you. Then you can engage in a
Chapter 14. period of reflection where you can consider the
183
feedback in detail. Reflection is the process through to pull out the learning points for you. One method
which you look at yourself and your practice that can be used to structure the debriefing activity
objectively. It is not about being overly critical of is to use the ABCD of effective feedback (Student
yourself or being superficial or dishonest. Sitiver Participation in Quality Scotland 2011) and this may
suggests that through reflection we can develop a be employed by the facilitators or used as a tool to
deeper self-awareness (2008: 163). Being self- get students to provide feedback to each other:
aware is defined by Bulman and Schutz (2008: 30)
as being ‘conscious of one’s character, including Accurate: try and give specific comments
beliefs, values, qualities, strengths and limitations’. rather than generalizations; as evidence you
The process of using reflection to develop self- might cite examples or numbers.
awareness is a continual one, and the method by Balanced: positives as well as negatives.
which you continue to develop, even when you are Constructive. Try to offer solutions for nega-
a qualified nurse. Using a reflective model can help tive points.
you by providing a structure for your thoughts. Depersonalized: rather than mention names
There are many models available in the literature of individuals, describe the experience and the
for you to have a look at. A really simple one is impact it had on you.
Borton’s (1970) framework (cited in Jasper 2006:
73). He suggests that in order to reflect, you should This structure provides a framework for effective
ask yourself three very simple questions: feedback.
What?
So what?
Now what? Activity 12.4
Using the ABCD model, construct
some feedback you could give to a colleague/
fellow student you have worked with recently
Activity 12.3
about something you thought they did well.
Think about a recent event on placement How easy/difficult was it to do this?
or in your workplace that you felt you dealt with
well and ask yourself:
The debrief as a ‘reflection on action’ (Schön
What? Describe the event as it happened.
1983) is likely to encourage you to work through
So what? What was the significance of this
what you did, identify the important issues,
event to you?
explore what you know, or what find out would
Now what? What does this mean for the future?
help you learn from the experience. Your facilitator
will point out some of the links to the theory which
you should examine further. Practising this process
As pointed out right at the beginning of this will enable you to develop the skills to be able to
chapter, learning how to craft your care is not easy. do this for yourself when reflecting on practice in
It is a process that you need to engage with and the future. When you are on practice placement,
understand, and the final part of simulation, the the time to reflect on an episode with your mentor
debrief, is where this starts to happen. In general, will be limited because of the pressures of working
simulated activities are relatively short – 30–45 min- in the real world. The ability to develop the skills to
utes is about average. However, the debrief is gen- identify significant episodes and to reflect on them,
erally as long, if not longer than the activity itself. both with your mentor when you have the chance,
This is where you will be guided by your lecturers and on your own when you don’t, will help you get
184
the most out of your placement experiences. One to provide students with opportunities to develop
of the benefits of simulation is that the time to do strategies to link theory with practice, making the
this is built in, but in order to get the most out of most of learning from experience, and is based on
the experience you will need to reflect further on established theoretical underpinnings. By describ-
your own, and explore the theoretical links which ing two case studies where research has positively
were pointed out to you. Listening to feedback and influenced the incorporation of simulated practice
then reflecting on what others think can help you into nursing programmes, it is hoped that we have
gain knowledge about yourself and enable you to been able to provide practical examples of how
learn from your actions and even mistakes. This you can capitalize on these opportunities in your
will build your ‘control knowledge’ as we described journey to professional registration. Even if you do
earlier in the chapter (Eraut 1994). The whole pro- not have the opportunity to engage in simulated
cess of engaging in a simulation activity, receiving activities during your course, it is hoped that we
feedback and then reflecting on it will enable you to have provided some useful tips which will help
make the most of any simulation experience, mak- you learn the craft of caring.
ing your student journey a valuable one and ulti-
mately assisting you in the transition to becoming a
qualified practitioner.
In summary:
!
Experiential learning in simulation allows you
Key learning to identify and develop strategies of learning
The debrief after the session and the that you can use in clinical placements.
personal reflection you undertake afterwards is Simulation is a learning opportunity; no one
where the learning happens. can get hurt.
Learning by doing, both by doing well and by
making mistakes, is very powerful.
Conclusion The debrief after the session and the personal
In conclusion, simulation is used in nurse educa- reflection you undertake later are where the
tion for a number of reasons. It is used as a tool learning happens.

Gobbi, M.O., Monger, E.J., Weal, M.J., McDonald, J., Michaelides, D. and DeRoure, D. (2012) The challenges of devel-
oping and evaluating complex care scenarios using simulation in nursing education, Journal of Research in Nurs-
ing, 17(4): 329–45.
Jasper, M. (2006) Professional Development, Reflection and Decision Making. Oxford: Blackwell.
Watkinson, G., Spencer, A., Monger, E., Weaver, M. and Gobbi, M. (2006) Case study 17a: using technology to teach
clinical skills, in C.A. Weaver, C. White Delaney, P. Weber and R.L. Carr (eds) Nursing and Informatics for the 21st
Century. Chicago: HIMMS.
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186
Working with mentors:
how to get the most from
13
working with your mentors
in practice
Sheila Reading, Alison Trenerry and Cathy Sullivan
Chapter contents
Introduction Working with your mentor and other members
The importance of learning in practice of the multidisciplinary team
Allocation of practice learning experiences Engaging with others to support your learning
Sharing personal information with the in practice
practice area Learning from your patient care experiences
Competence in practice Being reflective about your practice
Mentors: gatekeepers to the profession Skills and competencies
Mentors, associate mentors and buddies When things don’t go as planned
Mentor preparation Failure to achieve in practice
Mentor and student expectations Challenges while working in practice
Preparing for going into practice placements Mentors are people too
Your first day in a new placement Conclusion
Learning to give quality care Acknowledgements
Developing a learning contract Further reading and resources
Making progress in practice settings References
Introduction lar opportunities which are available to meet your

learning needs. It is important that you reflect on
This chapter aims to prompt you to think about,
how to optimize your working relationship with
and prepare for, your practice experiences. Good
your mentors.
preparation is essential for success. If you can
get the preparation right it will help to make your
practice experience rewarding and provide you
The importance of learning
with valuable learning opportunities. Practice
in practice
is where you will achieve much of your learning As a student nurse you will learn much about
and is often the most rewarding part of your pro- health care and your specific professional field
gramme. While part of good preparation requires by working within the reality of practice set-
you to consider the need to take responsibility for tings. Neary (2000) indicates that in nursing you
your own learning, remember your mentors will learn by doing, and Midgley (2006) highlights
facilitate it for you and help you to identify particu- that placements are where you can link theory
187
and practice, the ‘knowing what’ with the ‘know- Allocation of practice learning
ing how’ of nursing. You will not only gain and experiences
enhance clinical knowledge and skills – practice The practice learning circuit is usually extensive
experiences will enable you to learn ‘how to be’ a and may be geographically spread across a large
qualified health care professional (Egan and Jaye area. Your university will work in partnership with
2009). a number of trusts and many independent and
Learning within the practice setting is a fun- voluntary sector providers to provide you with the
damental process by which you will get to know required experiences to qualify as a safe practitio-
what it is to be a competent practitioner in your ner. Be aware that you may be expected to travel
chosen field and by which you will eventually to a placement or move into accommodation near
become a registered nurse (RN) and graduate. your placement if it is situated a long way from
Clinical practice gives you a unique opportunity your university or the transport links are poor.
to explore all aspects of a patient’s care path-
way. Understanding the wishes of an individual Sharing personal information with the
in relation to their specific physical, mental and practice area
other health needs is the basis to being able to Your university works in partnership with their
deliver seamless and safe patient care. As the practice learning providers and as such it is
Department of Health (DH) White Paper on Equity required to share some of your personal informa-
and Excellence: Liberating the NHS (2010) empha- tion with them as you will be providing care within
sizes, the focus of all nursing care must be on their organization. This usually includes:
promoting the quality of a person’s care and
experiences. your name and student number – this will be
During your programme, you will spend 50 used for allocating you a mentor, roistering
per cent of your time in different practice environ- you shifts, etc.;
ments, including community settings, voluntary verification of good health and good character
organizations, clients’ homes, acute care areas, as required by the professional bodies;
nurseries, primary health care, public health care, verification of statutory and mandatory skills
highly complex care settings and many others. that have been undertaken before commenc-
You will have supernumerary status while working practice.
ing in practice. This means that while you are
undertaking practice experiences as part of your
programme of study you are in addition to the
established numbers of nurses working in any
Key learning
To become a competent practitioner
!
given location. You will be allocated a negotiated
50 per cent of your programme time is under-
workload that is within your scope of practice and
taken in practice where you will have super-
that meets your learning needs. Your allocated
numerary status and be supported by a
practice placements will be exciting, rewarding
mentor.
and dynamic but on occasions may prove chal-
lenging, uncomfortable and potentially stressful
as you learn how to work with others and care for
clients. That is the nature of contemporary health
Competence in practice
care practice. However, each placement has the Practice experience offers the opportunity to learn
potential to offer you a rich learning experience more about nursing care and working with others;
and, importantly, you will always have a mentor, however, it takes time to become competent. An
and other staff, available to support and facilitate experienced nurse is able to undertake many com-
your learning. plex skills but may not easily be able to explain
188
Chapter 13 Working with mentors
UNCONSCIOUS INCOMPETENT
At this stage you are not aware of your own inabilities and may do something wrong without knowing it
Your mentor can help you to recognize areas which you need to learn more about and offer opportunites
to observe and practise in order to develop your competence
CONSCIOUS INCOMPETENT
At this stage you are aware of your deficits and not sure how to do the task. You may give it a go and make
mistakes. Although we all learn from our mistakes it does not always help our confidence or self esteem
The mentor can support you in refining your skills and perhaps demonstrate, or model how to do things
and observe you while giving guidance
CONSCIOUS COMPETENCE
Now you are becoming competent. But you are a little hesitant and slow and have to concentrate hard on
what you are doing. You may need to break the task down into stages or steps
Your mentor encourages practice and can provide feedback to support your further improvement
UNCONSCIOUS COMPETENCE
You are now able to practise without having to think much about it and you feel confident
Your mentor will encourage you and hopefully you will receive praise and recognition for your achievement.
It is importnat to ensure poor habits do not emerge at this point
Figure 13.1 Conscious competence model diagram adapted from Howell 1982
how this is done as it has become almost auto-

matic, like riding a bike or driving a car.
Howell (1982) has described a four-stage model
to explain the processes involved in learning new
Key learning
Practice experiences are rich learning
!
skills, known as the conscious competence model environments where you will become con-
(see Figure 13.1 above). You may find this help- sciously competent.
ful when discussing your development, learning
goals and achievements with your mentor.
It is important to recognize that you will be per-
forming at different stages of the model depending
Mentors: gatekeepers to the
on what it is you are learning to achieve compe-
profession
tence in. For example, you may be unconsciously
competent in some aspects of communicating Mentorship is pivotal to students’ clinical expe-
with patients but unconsciously incompetent when riences and is instrumental in preparing them
starting to lead a team in practice. There are always for their role as confident and competent prac-
areas of practice in which you will be strong and titioners.
others where you are only beginning to learn. (Myall et al. 2008)
189
The Nursing and Midwifery Council (NMC) Stan- work with. This is a strategy for ensuring you have
dards for Pre-registration Nursing Education (2010) support from another member of staff, for exam-
consists of two distinct elements: ple when your mentor is busy or off duty.
standards for education;

Mentor preparation
standards for competence.
One day you too will be a mentor. Mentorship
The standards for education support excellence programmes are arranged between placement
in student learning and assessment in practice providers (NHS, private and voluntary sectors)
placements, and define the principles and profes- and universities. All registered mentors will have
sional scope of standards required of your pro- undertaken a programme of study and assessment
gramme providers to ensure good mentorship for to achieve the mentor standards (NMC 2008a). A
students. RNs are professionally required by The mentor must have been registered for a minimum
Code: Standards of Conduct, Performance and Eth- period of one year prior to undertaking the men-
ics for Nurses and Midwives to ‘facilitate students tor programme and being successfully assessed as
and others to develop their competence’ (NMC able to facilitate student learning, supervise and
2008b). Ultimately, it is the mentors you work assess in practice. To become a sign-off mentor
with in practice who make the day-to-day judge- requires the mentor to be experienced and regis-
ments on whether you are achieving the required tered on the same part, or sub-part, of the register
standard for competence in practice. At the end as the one you are aiming to register on.
of your programme the sign-off mentor will testify
as to whether you have achieved the competen-
cies required to register as a nurse in your chosen
field. Remember, the NMC register exists to protect Activity 13.1
the public and maintain and promote professional
What do you know about the prepa-
standards. The role of the sign-off mentor there-
ration and mandatory updates required by
fore has considerable responsibility.
the NMC to be a mentor? Have a look at
There are many people other than mentors
this website to help you find out more: http://
who support learning in practice. Link teachers,
bit.ly/rvhGvW.
practice educators, the providers of clinical place-
ments, the university and others, such as commis- Having looked at the website can you answer the
sioners of nurse education and the NMC, all col- following questions?
laborate to ensure mentors are supported in their
How much time are you required to spend with
role and that the optimum learning environment is
your mentor?
provided for students.
What shifts do the Standards require that you
work?
Mentors, associate What is the minimum length of time required
mentors and buddies for you to spend in your final practice experi-
There are many staff that can support your learning
ence?
in clinical practice to achieve the required compe-
tencies. You should always ask your mentor about
working with other people who can offer specific
learning opportunities as it is important to have To support the work of mentors, all placements
exposure to different perspectives and sources are audited to ensure they are suitable learning
of expertise in clinical practice. You may find you environments for students, and annually mentors
have a named ‘associate mentor’ or ‘buddy’ to must demonstrate evidence of mandatory updating
190
‘to maintain and develop their competence and and, as well as providing you with feedback, will
performance’ (NMC 2008a). help you to identify further learning goals and
possible strategies for successful achievement in
practice.
Key learning
Mentors are gatekeepers to the pro-
!
fession and are required to undertake a pro- Activity 13.3
gramme of preparation for the role and there-
Think of people you have worked
after annual updates.
alongside who have helped you learn new
skills, increased your knowledge and insight,
changed your attitudes to something or have
Mentor and student expectations given you confidence in what you were doing.
Make a list of these people and identify what
they did that most helped your learning. This
Activity 13.2 will help you when you talk to your mentor to
What do you think mentors expect you outline specific approaches that encourage
to do as a student to enhance your learning? your learning in practice.
List 5 to 10 things and then review them with
your peers.
What do you expect from your mentors to sup-
Preparing for going into practice
port and enhance your learning? List 5 to 10
placements
things and again review them with your peers.
Compare and contrast the answers on your Starting a new clinical experience can cause a
lists. number of emotional responses. Students nor-
mally experience some excitement, tinged with a
little anxiety, about starting a new practice place-
Talking to some second-year students revealed ment but get some comfort in knowing their men-
that they expect mentors to be: tor is able to provide guidance and support (Gray
and Smith 2000). Research confirms that all stu-
enthusiastic; dents feel like novices in very unfamiliar settings
generous with praise; when they start a new placement (Spouse 2001).
able to give feedback constructively and in pri- Here are some examples of second-year stu-
vate rather than shout or yell at them in front dents’ views on starting new placements:
of others;
polite: to call them by name, and not just ‘stu- ‘You really do not have any confidence when
dent’; you first start your placement.’
willing to say thank you. ‘You worry about working with your mentor.’
‘It is not always easy to integrate into a team in
According to the literature a good mentor from a relatively short time.’
the student perspective is someone who is sup-
portive, and acts as a good role model, teacher, Sometimes disappointment or annoyance can
guide and assessor; someone who has a genu- be experienced when you are allocated a place-
ine concern and the student’s interests at heart ment that is not to your liking or is not where you
(Andrews and Chilton 2000; Gray and Smith 2000; see yourself working when qualified. There are a
Neary 2000). Mentors will monitor your progress number of ways to manage these emotions.
191
the nursing care that is offered in the prac-

Activity 13.4 tice setting and undertaking some ‘revision’
is helpful. For example, checking on the law
How do you feel before starting a new regarding lone working and other social, eth-
practice experience? It will help if you write down ical and legal frameworks relevant to work-
your feelings and thoughts about going into a new ing in mental health care settings, learning
clinical area and take this document with you on disabilities care, child health, family situ-
your first day to discuss with your mentor. Try ations or community care is always worth
to include some positive feelings and emotions doing. This will enable you to start forming
in your list. This will give you and your mentor a a ‘picture’ of the care you will be involved in
basis to start from when planning your placement giving and is key in enabling you to ‘hit the
to ensure that you are able to overcome any fears ground running’. Looking at the organiza-
or anxieties, while at the same time building on tion’s website will also give you some insight
areas that you feel more confident with. Doing this into how the whole service is run.
each time you go to a new placement can help
4 Find out about your practice area and
you manage the situation more positively and
the type of client group you are likely to
confidently.
meet. Is there any reading you could under-
take before you commence your placement
Before starting a new practice experience you that would help you understand the client
will find it helpful to do the following. group you will be caring for? Reading about cli-
ent experiences will enhance the knowledge,
1 Make sure you know where you’re going. skills, values and attitudes needed for safe and
This may seem obvious, but knowing the effective nursing practice. Doing this will help
placement name and location clearly means you feel more confident and empowered to
this is one less thing to be concerned about. build initial rapport with clients by demonstrat-
You will not be looking for the placement ing a sincere interest in their condition and an
location at 7 a.m. on the morning you are due understanding of their potential needs.
to commence and therefore can confidently 5 Ensure that you adhere to professional
walk onto the ward or department. Find out expectations. Wear your uniform as required
about the best travel options and costs, and by the organizational policy (e.g. hairs off the
leave adequate time to get there. Car park- collar, nothing below the elbow, reduce jew-
ing, meal availability, and any accommoda- ellery, etc.). This is essential, not only in giv-
tion requirements should be planned for in ing a professional impression but in ensuring
advance to reduce last-minute anxieties. patient safety and reducing infection risks.
2 Contact the ward or department by 6 Make sure you are punctual and ready to
phone. This enables you to speak to a member start work at the beginning of your shift.
of staff, get your off duty and maybe arrange a You should try as much as possible to mirror
visit before you officially start. It demonstrates the off duty of your mentor or buddy mentor.
that you are organized and keen to attend the Be prepared to undertake all shifts (including
placement while also enabling you to ask if weekends and nights). Remember you will be
there is any ‘pre-placement’ work that would doing unsocial hours when you qualify.
benefit you when you start. 7 Overall, the main message is to be pro-
3 Investigate the clinical area you will be active and positive. That means talking
working in and the experience you are initiative for your learning. You may feel
likely to gain. Having an understanding of that the experience is not for you, but there
192
is learning to be had in all experiences. into the roles and responsibilities within the
Remember, do not always wait to be told immediate and less immediate team – all of
what to do e.g. if phone rings answer it. which contribute to individual patient path-
ways and the seamless transition between
The Royal College of Nursing (RCN) has published an services.
excellent resource for students starting placements
2 Develop your relationship with your mentor
entitled Helping Students Get the Best From Their
and buddy. This is central to your learning
Practice Placements (2006). Access a copy of this
and progress in clinical practice. Having a
online and read it prior to starting your placement.
positive attitude is important and demon-
strating that you are keen to learn is always
beneficial. Understanding that every activity
Key learning
It is important to consider a range of
! you are involved in is a learning opportunity
is important, and this does not end when you
have registered.
practical matters about a new practice experi-
ence in advance to ensure you plan and are 3 Be prepared – ensure that you have your
well prepared for it. assessment of practice document with you
and that you have completed all the neces-
sary paperwork required.
Your first day in a new placement 4 Complete any induction paperwork that you
The first day in placement is when you start to find have been given. An orientation to the place-
your feet. You will of course be nervous – this will ment is very important in gaining an over-
be expected by the new team you will be working view of your practice base.
with and who will be supporting you in your learn- 5 Ask questions and follow them up if you feel
ing and gaining of new experiences. that you have not got a full answer or that
Mentors and other staff are used to new stu- you don’t understand it. Mentors will show
dents arriving. You will, however, need to work you how to do something if you don’t know
to integrate yourself into the new environment as or understand, but don’t forget they have
quickly as possible so that you are able to spend other work to do as well.
time developing your clinical skills and knowledge.
6 Be honest about any lack of capability you
Undertaking the activities suggested above should
have in terms of either your knowledge or
give you a firm foundation but you are also going
previous clinical experience. An open dis-
to need to make an effort at becoming a member of
cussion will enable you and your mentor
the team. The following are useful ways forward.
to gain an insight into areas that you need
to develop and which can be offered in that
1 Introduce yourself to as many members of
placement area. Remember, it does not all
the team as possible. Do not restrict this
need to be clinical: it may be that you are
to the nursing staff, as many other staff
working in the community and need to under-
will be involved in the care of the patient/
stand how the acute service and community
clients. The quicker you become familiar with
services work together, or how clinical spe-
the roles staff have in the care of patients,
cialists work across the health care sector to
the quicker you will be able to expand your
provide mental health care provision.
learning, through observing staff at work and
undertaking visits with them (e.g. with occu- 7 Become familiar with your preferred learning
pational therapists on home visits). These style and discuss it with your mentor – this
interactions will enable you to gain insight will help you plan learning opportunities.
193
8 If you have any learning needs or a disability that you should concentrate on is your role and
that you require an adjustment for, you will your responsibility in the delivery of quality nurs-
need to discuss this with your mentor. ing care. As you go through the placement and
observe and take part in delivering quality care,
write down your experiences and record what you
!
have learned. Use your portfolio for this. Check
Key learning
your learning about quality care with your mentor
It is important to acknowledge and to get their perspective and to invite feedback. By
deal with any emotional feeling about the the end of your programme you will have devel-
practice placement that may impact on your oped insight into quality nursing care and be able
learning and share this with your mentor. Be to articulate this, regardless of where you are
proactive, ask questions and start getting to working.
know your mentor and others as soon as
possible. Developing a learning contract
It is important to develop the ability to identify
your learning outcomes or goals and learn how
Learning to give quality care to write an action plan or learning contract (see
After undertaking the above, it is time to focus on Table 13.1). This process will allow you to be
learning as much as possible within the time you more active in your learning and to identify a wide
have. Caring for patients and clients in whatever range of resources that are available to support
environment you find yourself means you are in a your learning. Developing a learning contract is
privileged position. You will be involved in the life a creative activity and can be used to positively
of others, sometimes for only a short time, others promote your relationship with mentors. It will
for longer. Key to this is the establishment of pro- also encourage you to evaluate your achieve-
ductive relationships with patients and their fami- ments and reflect on your progress in achieving
lies. Over the course of your programme, one area your goals.
Table 13.1 An example of a learning contract
Learning Evaluation and

need: what am Resource or Date for review
I planning to Goal/aim learning activity achievement How well completed?
learn? Why? How? When? Any further learning?
To understand To gain Work alongside
the processes experience of mentor and
involved and successfully become familiar
demonstrate preparing and with discharge
competence in supporting four planning and
the successful patients being liaison with
discharge of discharged from relatives, carers and
patients from hospital care to other health care
hospital care community care professionals
Mentor signature Student signature
Date:
194
being engaged defines belonging. What it takes

Activity 13.5 for a community of practice to cohere enough
to function can be very subtle and delicate.
Think about your present or next prac-
tice placement. Review your learning needs
Working with your mentor and other
and make a list of learning activities you might members of the multidisciplinary team
need to undertake. You need to consider your responsibilities for your
Once you have a list you can talk to your men- own learning during placement. The RCN (2007:
tor and agree on an action plan or learning 16) states that: ‘It is important to understand that
contract. This should include the activities you students have a central role in maximising their
will need to undertake to achieve your goals. learning experience during placement, taking
Hint : a good reference for this is Elcock (2006). responsibility in directing their own education
through interaction with relevant staff and the cre-
ation of learning experiences’.
Making progress in practice As you will have read at the beginning of this
settings chapter, mentors undertake the support of stu-
dents following the successful completion of their
In his theoretical exploration of how people learn,
mentorship programme. Your relationship with
Wenger (1999: 74) indicates that it is a student’s
your mentor is central to your achievements while
participation in the activity of the placement with
in clinical practice and therefore this relationship
others that provides the basis of the learning expe-
needs to be built on a firm footing. Mentors help
rience:
you in planning your learning. It is very impor-
Practice does not reside in books . . . it resides tant that you make yourself aware of the variety
in a community of people . . . it exists because of learning opportunities available in a practice
people are engaged in actions whose mean- placement as you may find that your practice
ings they negotiate with one another . . . Being experience is not in one place and may follow a
included in what matters is a requirement for patient journey or pathway.
being engaged in a community’s practice, just as For your part, as a student nurse with an assess-
ment of practice document to complete, you must
be fully aware of the NMC requirements and have
considered how these can be met, particularly after
Activity 13.6 the completion of your first placement. You should
The quote from Wenger offers several become increasingly aware of the areas that you
points to consider when working with a mentor. need to be working on, whether it be undertak-
Think about the following. ing a specific clinical skill (e.g. undertaking sim-
ple dressings before moving on to more complex
How do you negotiate with your mentor?
ones), or improving your confidence when advo-
How do you demonstrate being willing to
cating for a patient on a ward round.
engage in nursing care?
It is important to understand that each practice
What helps you to feel ‘included’ in the practice
experience is not a hundred-yard dash where you
activities of any particular placement?
achieve everything, have it signed off and then for-
Developing your insight and self-awareness of get it as you move to your next experience and the
these things can improve your self-confidence as next race. Each experience is part of a relay race with
a student nurse and help you to learn and achieve the feedback from one mentor being the ‘baton’ for
new skills and competence in practice. future learning and development. The NMC requires
an ongoing record of achievement that demonstrates
195
continual and stepped progress across your entire your mentor aware so that you get appropriate sup-
programme with all feedback documented. port. It is important always to be honest with your
Being proactive is important throughout your mentor. Often you will be able to complete many of
practice experience. The more self-motivated you the activities asked of you in practice. However, in
are, the more learning you will achieve, whether it order to become more experienced or skilled at car-
be managing a patient’s care, supporting other stu- rying out certain procedures you will need the sup-
dents or team working. Taking up all opportunities port of your mentor. Frequently mentors will work
to learn about the patient’s condition, the organi- with you to instruct you in how to engage in more
zation in which you are working and the political complex and subtle activities that may seem to you
landscape of the NHS will all contribute to your to be performed automatically. By working together
development as a nurse who is able to manage the you can learn more about these subtle aspects of
complexities of clinical care within the context of practice. This could include how to talk to different
the ever-changing health care environment. Being patients, how to assess their condition and how to
adaptable is fundamental to maintaining high identify their actual and potential problems.
quality care within the reality of resource restric- As Spouse (2001: 519) states, if students are left
tions and political change. to roam about talking to patients or carrying out
mundane activities which keep them busy and out
Engaging with others to support your of the way, then they will miss out on: ‘learning the
learning in practice artistry and the science of caring for . . . patients
Although practice placements are where you that mentor(s) could teach . . . The key element
learn and develop your competence, each place- is the collaborative nature of the interaction
ment environment is part of a particular social between practitioner and student’. Spouse goes on
world (Goffman 1961) and as such you will need to emphasize the importance of dialogue between
to understand the specific, and often hidden, sub- mentors and students. You may want to use cer-
tle or unspoken cultural practice of each of your tain learning experiences to debrief with your
placements. Your mentor will be crucial in sup- mentor and help you plan for future opportunities.
porting you in doing this. Consider another quote You can link this to any previous learning while in
from Wenger (1999: 75): the university setting or identify any further learn-
ing you might want to follow up independently or
Mutual engagement involves not only our own possibly linked to a written assignment.
competence, but also the competence of others.
It draws on what we do and what we know, as Learning from your patient care
well as our ability to connect meaningfully to experiences
what we don’t do and what we don’t know – that When working in clinical practice, consider the
is, to the contributions and knowledge of others. patient holistically: not just the condition or diag-
nosis they may have, but all the information you
Wenger is highlighting the importance of observ- have about them as a person. Make links to the
ing and learning from others. It is always interest- initial assessment, the ongoing care and all men-
ing to ask questions of others about what they are tal, spiritual, emotional and physical needs. To
doing and why, and how they do what they do. You support your development and understanding of
will need to be sufficiently self-aware to recognize all aspects of caring for a patient or client, you
your own strengths and also which areas you need should do the following.
to develop further. It is important to be honest with
others about what you really do know, recognizing Make the initial assessment of the patient/
your capabilities, potential and limitations. If you client. Make sure that you record everything
have a learning need you will of course need to make that is important to the care of the patient’s
196
condition but also other factors, such as spiri- managing situations. Remember, all patients are
tual beliefs, family and carers, any specific different even if a situation is the same. Reflec-
patient requests about their stay. You should tive practice will help you understand and man-
consider the patient’s interests/hobbies and age your emotions and those of others. Using a
how they may be able to maintain these while reflective model (for an example see Chapter 7)
away from their normal surroundings (e.g. will help identify your learning needs, motivate
books to read, listening to music, links to the you to achieve goals and deal with challenges and
chaplaincy department). setbacks, maintain your physical and emotional
Care for the patient/client during their well-being, enable you to feel confident in your
episode of care. This may be just for a clinic decisions and actions, and help you to have clarity
appointment or longer if the patient is in an of thinking when adapting to new situations.
acute setting or in their own home.
Skills and competencies
After the episode of care, you should reflect on
You will have practice documentation developed
what you have learned and ask yourself the fol-
by your university which you should share with
lowing questions.
your mentor throughout the practice experience.
This comprises a set of learning outcomes that you
Did you fully understand the patient’s pre-
are required to achieve, based on competencies
senting condition? Did you know how this
and skills set by the NMC. The competencies have
impacted on the signs and symptoms that the
four domains which are:
patient described and could you relate this to
all the aspects of clinical care that the patient
professional and ethical practice;
received?
care delivery;
Where you had gaps in theoretical or practical
care management;
knowledge or skills, what did you do?
personal and professional development (NMC
Did you fully understand the impact on the
2010).
patient’s life and family? What is your role in
minimizing stress and anxiety for patients in
To support these domains the NMC (2010) has
the setting?
also identified essential skills clusters (ESCs) to
Did you communicate with the patient in an
ensure you will develop the skills required for entry
appropriate way?
to the register. These are generic skills statements
What health advice/promotion did you give?
that are applicable to all fields of nursing and all
Was the patient safe under your care at all times?
fields of practice. However, the ESCs do not include
Did you feel confident in the activities you
all the skills and behaviours required of an RN and
undertook in caring for the patient?
your university will include additional skills appli-
Did you challenge any aspects of care delivery?
cable to your field of nursing.
There are five ESCs:
These questions and the care that you deliver will
contribute to your wider understanding of care
care, compassion and communication;
delivery plus your ability to be an advocate for
organizational aspects of care;
patients and clients.
infection prevention and control;
nutrition and fluid management;
Being reflective about your practice medicines management.
Undertaking reflection on your clinical practice
and linking it with theory will enable you to con- You and your mentor will need to sign each as
sider, creatively, different ways and methods of you achieve them. Your mentor will then sign your
197
paperwork at the end of the placement to show be the same because of the individuals involved,
that you have passed the placement. It is therefore and your reflection can support you to manage
important that achieving these learning outcomes these differences. It is also worth noting that you
forms the basis of regular discussions of your should always reflect on what went particularly
learning needs and that records of achievement well. You may want to consider keeping a reflec-
are completed regularly to help you successfully tive diary (ensuring data protection is adhered to),
pass your placement. or engaging in reflection with your mentor as ways
of learning from the challenges of clinical practice.
When things don’t go as planned
Not everything that happens in clinical practice
will go as planned. This is the nature of supporting Activity 13.7
and caring for patients and their relatives who are
Find out about your local policies and
in unfamiliar and stressful situations, and work-
procedures for asking for support for your
ing in teams (both immediate nursing teams and
learning during your practice experience (see
interprofessional teams). It is good practice at the
also Figure 13.2).
beginning of a placement for the student and men-
Identify everyone you can ask for support
tor to clarify and discuss each other’s expectations
when you are working in practice.
to ensure these are realistic. This will help to avoid
any uncertainties or misunderstandings (Wilkes
2006). You will probably already be familiar with
establishing ground rules. Understanding that the Failure to achieve in practice
clinical area is going to challenge you on many Most students will be able to demonstrate com-
levels is essential. Developing skills of reflection petence in practice appropriate to their stage on
is crucial in enabling you to understand situations the programme, but occasionally you may fail to
that you may find yourself in. You should reflect achieve a competence at the first attempt, or fail a
on the way that you and others responded and placement and have to repeat it. Duffy and Hardicre
consider how the situation could have been man- (2007) explored the reasons why students fail to
aged differently, and from this will come learning. achieve in practice and identified the following:
While situations may be similar, they will never
poor interpersonal and communication skills;
poor professional behaviour;
lack of insight into own performance;
University
Academic staff Placement not responding to feedback from mentors;
Student services provider personal issues, poor health, tiredness and
Clinical link tutors Practice educator lack of motivation or commitment;
Policy and procedures Ward manager
inconsistency in performance.
Mentors will be responsible for giving you feed-

Mentor back on your progress and will provide details of
Other health care
successes as well as highlighting areas for further
staff
(Associate mentor
development. The NMC considers it important that
Student
or buddy) you have ‘an ongoing record of achievement and
that mentors have an audit trail to support their
Figure 13.2 Sources of support for students while decisions’ (NMC 2008b: 33).
in practice Most students are aware of their weaknesses
and it can be helpful to have a discussion with
198
your mentor about this – perhaps documenting it

and making a plan for action during a placement.
Do not forget the role your personal tutor can play,
or the clinical link tutor. They are there to sup-
Activity 13.8
If you felt uncomfortable about some-
!
port your learning in practice. Feedback is of little thing your mentor was doing or saying such as
value if it is not responded to or if no action results calling you ‘student’ rather than by your name
from it. Remember, feedback from mentors, asso- or criticizing you in front of others, what would
ciate mentors and other members of the practice you do about it?
team will help you to identify your strengths and Consider this comment: ‘My mentor had agreed
achievements as well as flagging up areas for fur- earlier that day I could do the drug round with
ther development and improvement. her but when I went to ask her about it she told
me we were short of staff and I needed to help
a patient eat his lunch. I had already helped this
!
patient during the last week to eat his meals and
Key learning was concerned as I needed to be signed off as
There are times when you may find it competent in drug administration. But I could
difficult to achieve competencies in practice, see no point in saying this to her again.’ What
but all feedback is helpful and needs to be would you do in this situation?
responded to.
Be prepared to question aspects of practice.

Challenges while working in practice As a student you are in the environment to learn
In the 1980s Melia (1987) explored how nurses and can ask for explanations or evidence under-
were socialized into the profession, and described pinning practice. With developing confidence
how students in placement spoke about ‘get- and knowledge you may become more able to
ting the work done’ and ‘fitting in’. As a learner speak up. Sometimes it is just about saying ‘No’
it is likely that you will want to fit in and feel like assertively. You may want to prepare yourself
you belong. We all need to belong and feel very in advance and plan a time to meet with your
uncomfortable if we are excluded from a group. mentor to discuss the situation. Be clear about
Naturally when you start in a placement you what you want to say. You may want to refer to
will quickly want to respond to the norms of the some evidence such as guidelines or policy and
location in order to feel that you belong. In a research to help you state your view. An impor-
research study carried out in Australia and the tant part of your learning is about empowering
UK, Levett-Jones and Lathlean (2009) reported on others, so make sure you can demonstrate that
how student nurses tend to conform and comply you are empowered to stand by your principles
with situations in the practice setting. Sometimes and values.
it is easier to accept the values of the placement
rather than challenge them:
Mentors are people too
students related how they complied with unac- McKenzie (1991) found that when mentors
ceptable nursing practices because they were effectively support students they found it easier
reticent to endanger their precarious sense of to adapt and settle in to learn within a practice
belonging. This was particularly true of stu- placement. Of course mentors are people too; they
dents who felt less secure of their place in the have their own work pressures and professional
nursing team and personal concerns which can impact on how
(Levett-Jones and Lathlean 2009: 348). they respond to and support your learning (Cowan
199
2000). Here are two comments about mentors and other health care staff. You will bring your own
from students: values and cultural assumptions to your develop-
ment as a nurse. However, as discussed in Chapter
‘I had a mentor who looked bored. Later I 2, it is critical that you have an awareness of these
discovered she was actually preoccupied values and cultural assumptions and be open to
with some personal difficulties. Now I always learning from and respecting the different values
remember that mentors are people too. More and cultural diversity of others, be they patients,
than that, they have been students too!’ your mentor or other staff. At the heart of effec-
‘I have learned that my attitude impacts on the tive nursing is an ethos which respects the integrity
mentor and on our relationship. Despite some- and dignity of the other, whoever they may be.
times hearing others say that X is a poor men- In this and all that you may learn, the role of the
tor I try to keep an open mind.’ mentor is fundamental to your learning in prac-
tice placements. While it cannot be guaranteed
There will always be people you do not get on that you will not have any negative experiences,
with. One of these might be your mentor. How- the research evidence indicates that most students
ever, remember you cannot always work with are effectively supported by mentors in practice
‘friends’ and you must always behave profession- (Myall et al. 2008). Getting the most from work-
ally. This is an important aspect of personal and ing with your mentor will be helped by you being
professional learning, both for your future career self-aware, self-motivated and self-confident. This
and for life. Consider what personal attributes you chapter has highlighted some of the ways you can
possess that would help you to build on past expe- achieve this during the varying placements you
riences and deal with more challenging individu- will encounter in your programme.
als, rather than feeling frustrated, upset or possibly
even about to give up. If you need help, do discuss
the matter with another member of staff on the Acknowledgements
ward, or with your academic tutor or link lecturer. We would like to acknowledge and thank Claire
Millard, Liz Pearson and Chloe MacArthur, student
nurses in the Faculty of Health Sciences at the
Conclusion University of Southampton and Kathryn. Read-
You do not carry out practice experiences in a vac- ing for sharing their experiences of working with
uum. You will be engaging with a range of people, mentors and how they developed good working
from patients and their relatives to your mentor relationships with them.

Arkell, S. (2007) How nursing students can make the most of placements, Nursing Times, 103(20): 26–8.
RCN (Royal College of Nursing) (2006) Helping Students Get the Best From Their Practice Placements: A Royal College of
Nursing Toolkit, available at: www.rcn.org.uk/publications/pdf/helpingstudents.pdf.
References
Andrews, M. and Chilton, F. (2000) Student and mentor perceptions of mentoring effectiveness, Nurse Education
Today, 20: 555–62.
Cowan, L. (2000) Lessons of experience: working with students in community midwifery practice, in J. Spouse and L.
Redfern (eds) Successful Supervision in Health Care Practice: Promoting Professional Development. Oxford: Blackwell
Science.
DH (Department of Health) (2010) Equity and Excellence: Liberating the NHS. London: DH.
Duffy, K. and Hardicre, J. (2007) Supporting failing students in practice, 1: assessment, Nursing Times, 103(47): 28–9.
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Egan, T. and Jaye, C. (2009) Communities of clinical practice: the social organisation of clinical learning, Health: An
Interdisciplinary Journal for the Social Study of Health, Illness and Medicine, 13(1): 107–25.
Elcock, K. (2006) Wake up and learn, Nursing Standard, 20(49): 61.
Goffman, E. (1961) Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. Oxford: Anchor Books.
Gray, M.A. and Smith, L.N. (2000) The qualities of an effective mentor from the student nurse’s perspective: findings
from a longitudinal qualitative study, Journal of Advanced Nursing, 32(6): 1542–9.
Howell, W.S. (1982) The Empathic Communicator. Belmont, CA: Wadsworth Publishing Company.
Levett-Jones, T. and Lathlean, J. (2009) ‘Don’t rock the boat’: nursing students’ experiences of conformity and com-
pliance, Nurse Education Today, 29(3): 342–9.
McKenzie, K.M. (1991) A study of the perceptions of support among student nurses with a mentor and student nurses
without a mentor in the clinical area. Unpublished MEd thesis, University of Aberdeen.
Melia, K. (1987) Learning and Working: The Occupational Socialization of Nursing. London: Tavistock.
Midgley, K. (2006) Pre-registration student nurses’ perception of the hospital learning environment during clinical
placements, Nurse Education Today, 26(4): 338–45.
Myall, M., Levett-Jones, T. and Lathlean, J. (2008) Mentorship in contemporary practice: the experiences of nursing
students and practice mentors, Journal of Clinical Nursing, 17(14): 1834–42.
Neary, M. (2000) Responsive assessment: assessing student nurses’ clinical competence, Nurse Education Today,
21: 3.
NMC (Nursing and Midwifery Council) (2008a) Standards to Support Learning and Assessment in Practice: NMC Stan-
dards for Mentors, Practice Teachers and Teachers. London: NMC.
NMC (Nursing and Midwifery Council) (2008b) The Code: Standards of Conduct, Performance and Ethics for Nurses and
RCN (Royal College of Nursing) (2006) Helping Students Get the Best From Their Practice Placements: A Royal College of
Nursing Toolkit, available at: www.rcn.org.uk/publications/pdf/helpingstudents.pdf.
RCN (Royal College of Nursing) (2007) Guidance for Mentors of Nursing Students and Midwives: An RCN Toolkit. Lon-
don: RCN.
Spouse, J. (2001) Bridging theory and practice in the supervisory relationship: a sociocultural perspective, Journal of
Advanced Nursing, 33(4): 512–22.
Wenger, E. (1999) Communities of Practice: Learning, Meaning, and Identity. Cambridge: Cambridge University Press.
Wilkes, Z. (2006) The student-mentor relationship: a review of the literature, Nursing Standard, 20(37): 42–7.
201
Learning abroad: the
student experience of
14
nursing in a European or
international context
Avril Milne, Jean Cowie and Brian Webster
Chapter contents
Introduction Learning abroad in the USA
Gaining a theoretical understanding Challenges of undertaking nursing practice
Global citizenship in the USA
The benefits of learning abroad: exploring Preparation for a learning abroad experience
the evidence Understanding cultural contexts
Learning abroad in Europe The future
Erasmus+ Conclusion
Making it work: our experience Further reading and resources
References
Introduction also provides you with some reflective analysis

This chapter will provide you with an overview of our student nurses’ experiences of learning
of some of the benefits and challenges of work- abroad as well as useful tips for you, mentors and
ing abroad. It will draw on the experience, exper- other academics in nursing departments across
tise and knowledge of staff and students from the UK.
one school of nursing and midwifery in the UK, The role of health care organizations in nurturing
the Robert Gordon University, Aberdeen, where a the development of a culturally sensitive workforce
number of highly successful Erasmus and inter- is essential to meet the expectations of increasingly
national student exchanges have been offered diverse staff and patient populations (Papadopoulos
and embedded as a successful pre-registration et al. 2004). In recognition of these changing health
student learning experience for some time. It care dynamics, the Nursing and Midwifery Council
will offer you a theoretical understanding of the (NMC) Standards for Pre-registration Nursing Edu-
benefits and learning opportunities that such cation (2010) have been aligned to the European
exchanges can bring from a global perspective Directive 2005/36/EC to promote mutual recog-
and stretch your understanding of cultural com- nition of qualifications (European Commission
petence and the application of clinical practice in 2005). This provides you, the student nurse, with
a range of varied health care delivery systems, as an increased scope to undertake diverse learning
well as provide you with practical advice and con- opportunities outside the UK for a period of up to
siderations from years of experience. The chapter six months. Student nurses expanding their
203
international profile via learning abroad experi- professional practice in a culturally diverse health
ences will be able to evidence key graduate attri- care environment, nationally and internationally, is
butes and qualities to prospective employers, crucial (European Commission 2009a; WHO 2009).
thereby increasing the possibility of employment The new NMC Standards provide you as a student
success (European Commission 2010; British with an opportunity to obtain a comparative expe-
Council 2012). rience of health and nursing in a different country
and to build your personal and professional con-
fidence and ability to provide culturally sensitive
Gaining a theoretical care (Lee 2004). Clinical learning abroad, whether
understanding it is observational or direct participation in health
The literature indicates that learning abroad care, facilitates an opportunity to equip you with a
enables you as a student nurse to go beyond the versatile professional knowledge base and a pre-
level of cultural knowledge gained through theo- paredness for culturally competent nursing practice
retical learning and develop a greater awareness following graduation (Kokko 2011).
of how your own cultural values impact on your
professional practice (Greatrex-White 2008). In
fact, Greatrex-White highlights the potential for
Activity 14.1
you as a student to experience an obvious cogni-
tive change as a result of a learning abroad expe- Try to identify why you think you might
rience and an increased awareness of different benefit from a learning experience in another
cultures. Learning abroad can provide you with country.
a unique intercultural experience and exposure
What challenges would this pose for you?
to foreign nursing cultures that can enrich your
What personal attributes could be enhanced
professional skills repertoire (Lee et al. 2007). We
by this experience?
believe that the need for providers of nurse edu-
cation, in collaboration with their practice learn-
ing partners, to develop valuable learning abroad
opportunities for student nurses is an essential Global citizenship
component of pre-registration nurse education The notion of global citizenship or global com-
today. The increasing multicultural nature of petency has gained popularity in education in
societies across the globe requires the registered recent years (Oxfam 2006; Diamond et al. 2011a,
nurse (RN) of tomorrow to be personally and pro- 2011b; Hounsell 2011). Oxfam has been a key
fessionally confident in their ability to respectfully player in promoting global citizenship in pri-
care for diverse patient populations and effec- mary and secondary education; however, the
tively lead a multicultural nursing and health care principles and concepts are equally applicable in
workforce (Lee 2004). higher education. According to Oxfam (2006) a
Global demographics have changed signifi- global citizen:
cantly over recent years, with societies becoming
increasingly multicultural and ethnically diverse. is aware of the wider world and has a sense of
Across the globe, there is a demand for nurses their own role as a world citizen;
to be able to deliver a quality health care service respects and values diversity;
to people of differing cultures and to be effective has an understanding of how the world
members of a multicultural health care work- works economically, politically, socially, cultur-
force (Lee et al. 2007). Within the context of your ally, technologically and environmentally;
learning the responsibility for you to be prepared for is outraged by social injustice;
204
Chapter 14 Learning abroad
participates in, and contributes to, the commu- the above global competencies and are essen-
nity at a range of levels from local to global; tial, enabling qualities.
is willing to act to make the world a more
sustainable place;
takes responsibility for their actions.
Activity 14.2
Clearly, Oxfam’s ethos of global citizenship has
In what way can global citizenship
an integral place within higher education, and
impact on you and your clinical practice?
this is supported by Hounsell (2011) who identi-
What impact will global citizenship have on
fied global citizenship as one of the key graduate
nursing in 10 years’ time?
attributes for the twenty-first century. The Council
for Industry in Higher Education (CIHE) (Diamond Take time to think these questions through and
et al. 2011a, 2011b) refers to the concept of ‘global reflect on your answers.
graduates’ and highlights their critical competen-
cies as follows.
Although the CIHE discusses the global gradu-
A global mindset: to have an awareness of ate and global competencies in relation to indus-
different cultures and values, and how one’s try and business, we believe that the concepts are
own culture and values differ. equally applicable to the nursing profession. The
Global knowledge: knowledge of the global employee may also be the global patient
economics, history and culture of different or indeed the global colleague of the future. An
countries. understanding and respect of cultural diversity,
Cultural agility: the ability to understand the inequity and social injustice, economics and poli-
perspectives of individuals from different cul- tics is, therefore, essential for the graduate nurse
tures and backgrounds and to empathize with of the twenty-first century.
these views and respond to them; the ability to With regard to the course and curriculum
cope with and adapt to living in different envi- requirement for the NMC, the principles under-
ronments. pinning the philosophy of the global graduate and
Advanced communication skills: the ability global citizen marry well with the four generic
to communicate effectively with others from standards for competence set out in the new
around the world. Standards for Pre-registration Nursing Education
Management of complex interpersonal (NMC 2010). For example, fundamental concepts
relationships: the ability to manage rela- such as respect, dignity, compassion, culture, socio-
tionships with diverse teams and clients economics, politics, social justice, inequity, part-
from across the globe and deal with inherent nership, team working, leadership, accountability
challenges. and autonomy are just some of the shared values
Team working and collaboration: the abil- (Oxfam 2006; NMC 2010; Diamond et al. 2011a,
ity to work collaboratively and empathetically 2011b; Hounsell 2011).
with diverse teams from across the globe.
Learning agility: the ability to rapidly assimi-
late knowledge and develop understanding
The benefits of learning abroad:
in order to rapidly respond and adapt to new
exploring the evidence
challenges, circumstances and cultures. According to Fielden et al. (2007), learning
Adaptability, flexibility, resilience, drive and abroad has many benefits for you as a student.
self-awareness: these attributes underpin In addition to the opportunity to learn and
205
develop language and linguistic skills, the learning experience, with some being rejuvenated
ing abroad experience helps you to broaden your and invigorated for an active career in nursing
academic experience and to clarify your under- within the UK or overseas, while others have
standing within your field of study. It can also developed a better appreciation of the benefits
strengthen your commitment to your current and shortcomings of the health care system in
studies and perhaps inspire you for further stud- the UK.
ies or for work overseas. We have personally Table 14.1 highlights the benefits of learning
witnessed this in our student nurses who have abroad based on the evaluations of our students
returned from a European or international learn- who participated in learning opportunities there.
Table 14.1 The benefits of learning abroad: student evaluations

Personal An independence that will benefit you for years to come
advantages to A self-belief and confidence beyond anything you can imagine
learning abroad A greater awareness of who you are and what you believe in
Social Lifelong friendships with many people from across the world
advantages to Opportunity for future travel to visit new friends
learning abroad An appreciation of different cultural beliefs, traditions and lifestyles
Increased social skills
Professional Professional confidence and assertiveness
advantages to Ability to communicate with people from different cultures
learning abroad Ability to provide nursing care to culturally diverse populations
Ability to draw on a comparative knowledge of other health care organizations
and nursing practices
Ability to establish a network of professional colleagues to share best practice
An understanding of different styles of health care delivery (e.g. NHS services free
at point of delivery, whereas there are insurance and cost implications in other
countries)
A fuller appreciation of the value of the role of the NMC in protecting the
public and safeguarding patients (e.g. practitioner accountability in the safe
administration of medicines)
Innovative alternative approaches to infection control that could be adopted in the
UK (e.g. the routine autoclaving of hospital beds between patient use)
Impact on An appreciation of how patients may feel when they don’t understand nursing
patient care jargon
Improved communication skills with patients and colleagues
Ability to recognize and value wider issues impacting on patient admission, health
care delivery and discharge options
Increased understanding of need to practise person-centred nursing care
Impact on Raises the international profile of your CV

future nursing An advantage to gaining employment as an RN as employers increasingly value
career the outcomes of a learning abroad experience to their organization
Recognized internationally as a key graduate attribute
Adds value to your application for studies at masters and doctoral level
206
Fielden et al. (2007) also highlight that the expe- about global health and nursing to individuals, pri-
rience of living, working and studying in another vate and voluntary organizations and the public.
country facilitates personal growth and develop- Each of the key organizations can be easily
ment that can enable you to confidently adapt to a accessed via the internet and provide a rich
new environment and country and in the process resource for students and RNs and facilitate a
become more culturally perceptive and tolerant. greater international awareness about profession-
The need for you to be able to integrate socially specific topics.
with local students and residents, as well as visiting
international students from elsewhere, necessitates
Learning abroad in Europe
the development of enhanced communication and
social skills to maximize the learning abroad expe- The Bologna Declaration, commonly referred to
rience. The personal and professional maturity and as the ‘Bologna Agreement’, is a key document in
independence alluded to here has been frequently the European higher education arena (CRE 2000).
cited by returning student nurses as a key outcome Essentially the Declaration aims to converge or
of the learning abroad experience. draw higher education institutions together so
Learning abroad, therefore, promotes the devel- that there is greater understanding of the edu-
opment of graduate nurses who are confident as cation systems and frameworks used in differ-
well as independent and autonomous beings who ent countries. Within the Declaration it is clear
can face the many challenges that a career in nurs- that the intention is not to impose standards or
ing may present. Indeed, several nursing students uniformity among higher education institutions
who have participated in the learning abroad pro- in Europe, but rather to promote a system of
gramme at the Robert Gordon University have opted compatibility whereby academic qualifications
to work overseas on completion of their nurse edu- obtained in one European country are recog-
cation. Others have reported a keen interest in the nized, accepted and transferred accordingly to
learning abroad programme from prospective a higher education institution in another Euro-
employers and believe that the formal recognition pean country. The Declaration, therefore, has
of the academic credit gained from the experience established a European Higher Education Area
has strengthened their CVs and been a key factor in (EHEA) that is able to provide world-class higher
their employment success (European Commission education that is attractive to you as a student
2010; British Council 2012). This supports the notion as well as qualified staff, and is also competi-
offered by the CIHE (Diamond et al. 2011a, 2011b) tive within the global economy. The overarch-
that the experience of working abroad and being ing qualification framework developed by the
immersed in a different culture and lifestyle is EHEA consists of three cycles: bachelor, mas-
invaluable and can propel graduates into being con- ters and doctorate. All countries of the EHEA are
sidered for rewarding and challenging roles. committed to developing national qualification
From our experience, we believe that the stu- frameworks that are compatible with the EHEA
dent nurse of today will witness a growth in the framework (Gobbi 2005; European Commission
amount of opportunities available to the nursing 2009b, 2011a) and the promotion of the EHEA is
profession to become increasingly internationally expected to strengthen student and staff mobility
aware from a professional perspective. For exam- and employability within Europe and across the
ple, the World Health Organization (WHO), the globe (European Commission 2009a).
International Council of Nurses (ICN), the British
Council, the European Commission and the Vol- Erasmus+
untary Services Organization (VSO) are all key The Erasmus Lifelong Learning Programme (ELLP
promoters of the internationalization agenda and to be renamed erasmus+ as of January 2014) is
provide valuable advice, guidance and resources funded by the European Commission and is directed
207
at higher education institutions with the aim of pro- orative staff activities. The School has established
moting student and staff mobility within Europe. a strong presence in Europe with eight European
The European Commission, via the British Council, partners in five different countries (Belgium, Finland,
provides grants for you as students as well as staff the Netherlands, Norway and Spain) and has suc-
activities within the ELLP (British Council 2012). cessfully been engaging in pre-registration accred-
Armed with the knowledge about ELLP activities ited student nurse exchanges for over 10 years. The
and resources, the School of Nursing and Midwifery number of student nurses and staff participating
at the Robert Gordon University targeted new and annually in an exchange programme has grown
existing European partners to create a centre of exponentially from three student nurses and two
excellence for student nurse exchanges and collab- staff to 32 student nurses and eight staff per year.
Case study 14.1: Reflections of a third-year student nurse (ELLP)

The opportunity to participate in the ELLP has been an absolutely amazing experience. I was
very excited about the exchange opportunity and also had some anxieties prior to departure. How-
ever my worries were needless as I found I was very well supported by staff at the university, on clinical
placements and also by fellow students. Not only was I making friends with Finns but I was meeting stu-
dents from other countries and other university courses who were also participating in the ELLP.
Although I was concerned about the language barrier I found that most students and many of the staff
both in the hospital and university had a good command of English. In situations where the language
barrier was an issue I had to resort to non-verbal means of communication. Although this could be
hilarious at times it also made me realize the many challenges faced by minority groups and immigrants
at home who have limited understanding of English.
During my time in Finland I had the opportunity to visit several places of cultural interest. I also had
the opportunity to try skiing, go to the Arctic Circle and to visit a Snow Hotel with the other students. I
was also invited into Finnish homes by my new friends and colleagues and able to experience Finnish
life at first hand. Finnish people like to have a sauna and most have a sauna in their home. Where I stayed
the sauna was available for girls two evenings per week or it could be booked for use privately. Myself
and the two other girls from my university booked the sauna for us to use on our own. It was really nice.
On my practice placements I worked alongside an English-speaking mentor who ensured that I got
to see lots of procedures and to go to theatre to see operations. It was interesting to see the similarities
and differences in nursing practices. For example, the focus of nursing in Scotland is on caring and main-
taining dignity, whereas in Finland more emphasis is placed on technical skills. I think my experience in
Finland has given me a better understanding of health care systems and provision and also of the valu-
able role of the NMC. I’ve almost finished my course now and went for an interview for a nursing job.
The interviewers were very interested in my ELLP experience and I’m sure it was this that gave me the
advantage over the other candidates to secure the position as a staff nurse.
Taking part in the ELLP and living in Finland for three months has been an absolutely fantastic expe-
rience. I learned a lot about myself and my ability to cope in a new and strange environment and also
to deal with any unforeseen challenges. I think I have grown as a person as a result of the exchange
experience. I feel I have greater self-awareness and developed valuable transferable skills such as
improved communication skills, the ability to adapt quickly to change and to use my initiative. I feel I
have more confidence – certainly people have commented that I am more confident. The ELLP experi-
ence has been amazing and I feel very privileged to have had the opportunity to go to Finland. I would
advise anyone thinking about taking part in the ELLP to just go for it – you’ll have the experience of a
lifetime.
208
We recommend that student nurses develop a

Activity 14.3 study plan for outstanding coursework and assess-
ments to reduce the workload during the learning
In what way do you think a learning abroad experience. Although each practice place-
abroad experience will influence your future ment partner has a well stocked library of nursing
career in nursing? texts and journals in English, student nurses are
How would you best prepare for a valuable encouraged to creatively plan access to the library
learning abroad experience? materials they require from the UK in advance of
the exchange.
Making it work: our experience

The School’s European Exchange Module sup-
ports the ‘Study Mobility’ element of the ELLP, Activity 14.4
which the Robert Gordon University actively chose Try to imagine you have been accepted
to invest in rather than the ‘Training Mobility’ ele- for an Erasmus exchange in one of our
ment (British Council 2012), in order to maintain European partner countries. Try to identify what
the quality assurance role it has for all its prac- you might need to explore about nursing and
tice learning partners. Student nurses exchange health care in that country before you leave.
13 weeks of their programmed practice learn-
ing during the third year of their course with an
equivalent practice learning experience at one of
the European partners. On successful completion
Learning abroad in the USA
of the practice learning experience, our student The opportunity for you as a student nurse to
nurses receive 20 European Credit and Accumula- cross international boundaries to learn about
tion Transfer System (ECTS) credits from the Euro- nursing and health care in different countries is of
pean partner providing the exchange opportunity. growing global interest. The WHO has developed
In keeping with the ethos of the Bologna Decla- global standards for the initial education of nurses
ration the ECTS credits are transferable between and midwives (WHO 2009) and the EHEA has
institutions (European Commission 2011b) and announced a significant advance in cooperation
this is acknowledged as such in the student gradu- between European and international partners to
ation transcript. The School provides a reciprocal mutually recognize qualifications and support stu-
arrangement for student nurses from the Euro- dent and staff exchanges (Bologna Process 2007).
pean partner institutions to undertake an equiva- Within the context of the USA there is a wealth
lent practice learning experience and obtain the of literature available in relation to the value of
same ECTS credits, which in turn enriches not only transcultural nursing care and global nursing edu-
the students learning but that of our NHS practice cation (Leininger 2002; Siantz and Meleis 2007;
partners and academic staff alike. GANES 2011). Although the culture of nursing
The student nurse accepted for a learning within the USA differs from that of the UK, much
abroad experience in Europe is encouraged to can be learned about the ways in which the US
engage in fundraising activities to complement the nursing profession has faced the challenge of being
grant they will receive from the British Council, in able to provide culturally congruent nursing and
order to minimize the impact of the costs involved, health care to diverse patient population groups.
and they are advised to contact the Royal College It is anticipated that UK student nurses and RNs
of Nursing (RCN) to determine the availability of seeking to develop their cultural competence in
professional indemnity insurance required for professional practice will find a plethora of useful
practice learning in Europe (RCN 2012). material via the internet to increase their cultural
209
knowledge and ability to provide quality nursing Practice learning through observation is avail-
care to culturally diverse groups in the USA. able to our third-year student nurses to experi-
Within the School of Nursing and Midwifery ence nursing and health care in the USA by par-
at the Robert Gordon University, we have specifi- ticipating in a two-week observational learning
cally appointed a link teacher for the USA, who experience. The student selection process is com-
has devolved management responsibility for the petitive and results in two student nurses being
student nurse exchanges to and from that country selected by each university (USA and the UK) to
and maintains collaborative relationships with the participate in the exchange programme and to act
partner institutions and key stakeholders. The US as ‘buddies’ to the visiting students. They jointly
link teacher is responsible for maintaining a live attend and present at civic events, visit university
audit trail of partner institutions, indicating their learning environments, observe clinical practice
suitability as practice learning environments to sup- in a variety of health care settings and partici-
port student learning. Furthermore, they are also pate in a range of cultural activities (an important
central to the effective management of the UK stu- part of the learning experience). This learning
dent nurse selection process and provide academic abroad experience does not involve an exchange
and pastoral support to the UK and US student of academic credit as there is no formal assess-
nurses throughout their learning abroad exchange ment attached to the exchange programme at this
experience. moment in time.
Case Study 14.2: Reflections of a third-year student nurse (USA)

Participation in the American exchange programme provided me with an incredibly valuable
experience, way beyond anything I had imagined. From day one, when I first applied for the opportunity,
I found the whole experience to be very beneficial to me personally and professionally. Writing a sup-
porting statement about why I should be chosen for the opportunity and promoting my personal and
professional attributes at the selection interview was challenging and character building. I was delighted
to be selected and felt proud that I was recognized as someone who could be an ambassador for the
nursing profession, the School of Nursing and Midwifery and my country.
Prior to my visit to the USA, I shared the responsibility of ‘hosting’ the American exchange students
during their two-week observational experience in Aberdeen. It was a fantastic experience for me to
show off our beautiful country, and to explain how our health care systems works and how nurses are
educated to provide person-centred care. I had never done this kind of thing before and it made me
really appreciate my own culture, my nursing knowledge, and how this all fitted into the patient care I
provided.
My experience in the USA was incredible. The private hospitals look like high-class office buildings
and patients receive every service you can imagine, despite the cost. The public hospitals are different,
less spacious with a greater demand for limited services in comparison to the private hospitals. It made
me really appreciate the National Health Service we have in the UK.
My communication skills and confidence have improved immensely, particularly because of my
ambassador role. I was able to hold conversations with so many new people who held a variety of senior
professional or civic roles, which I executed with professionalism and dignity. I am confident that this
experience will enhance my patient care, professional development and future career as a nurse. I am
proud of my achievements and feel that I have proved that I was indeed worthy of this opportunity and
responsibility. Maybe, one day, I will return to the USA to work there as a nurse.
210
Challenges of undertaking nursing Europe, it doesn’t currently extend to the USA or

practice in the USA Canada (RCN 2012).
In our experience, student nurses often ask about Figure 14.1 shows the support networks in
the possibility of extending their observational place to enrich the learning abroad experience.
experience to one that involves ‘hands-on’ direct
patient care. Practice learning through direct
participation in health care is an innovative en-
Preparation for a learning abroad
deavour to provide a student nurse exchange that
experience
facilitates a deeper learning and understanding of Theoretical preparation for a learning abroad
the professional and cultural differences of health experience is an essential component of any
care provision in the USA. The School undertook exchange. At Robert Gordon University a spe-
audits of selected US practice learning environ- cific credited theoretical module is a compulsory
ments, which clearly indicated a wealth of oppor- aspect of the learning experience to ensure that
tunity available to UK student nurses to obtain our student nurses are prepared for the multi-
valuable observational learning experiences. faceted benefits and challenges that any such
Within selected health care organizations there exchange can bring. Preparation includes the
is also scope for UK student nurses to access student nurses exploring key health and social
dedicated educational units that provide appro- care issues in a global context and comparing
priate mentorship and assessment to facilitate the nurse education and practice, health issues,
practice learning through direct participation in and policy drivers impacting on health care pro-
nursing and health care. However, the current US vision in the UK and in the country selected for
immigration rules and requirements are complex their learning abroad exchange. The summative
in relation to which visa you as a student nurse assessment for the module includes a reflective
would require, including the purpose and dura- analysis of the student nurse’s learning abroad
tion of the exchange, and whether or not enrol- experience and the impact on their personal and
ment at the partner university is necessary. It is professional development. It is our belief that you
therefore imperative that UK universities and as a student are expected to be an ambassador
student nurses seek guidance and confirmation for your profession, school, university, and indeed
from an appropriate professional source about the UK.
these issues before considering an opportunity Preparation for learning abroad includes meet-
to observe or directly participate in health care ing the admission requirements for each partner
in the USA. institution. For example, various vaccinations and
Professional and personal indemnity insurance screening for methicillin-resistant staphylococ-
is another prerequisite to being able to partici- cus aureus (MRSA) and salmonella are required
pate in a practice learning experience in the USA. by some northern European countries and the
As a student you must purchase this for practice UK. At Robert Gordon University our link teachers
learning, and it is available at a reasonable cost liaise with the relevant occupational health pro-
from US insurance providers. We recommend that vider and each institution to ensure all exchange
consultation between the participating UK uni- nurses meet the necessary requirements. In addi-
versity and an appropriate professional source is tion they are also responsible for ensuring that
recommended to ensure that you have the correct students comply with the required health screen-
insurance protection required prior to observing ing process and application requirements referred
or directly participating in health care in the USA. to earlier and that they obtain approval from the
Although membership of the RCN provides pro- Protecting Vulnerable Groups Scheme (Scottish
fessional indemnity for your work in the UK and Government 2011).
211
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Figure 14.1 The support networks in place for students studying abroad
Table 14.2 provides you with some key con- following initial registration. In this respect it differs
siderations regarding general prerequisites for a from the UK. Our exchange students often report that
learning abroad experience. they were overwhelmed by the impact the different
cultural contexts had on their own cultural views,
Understanding cultural contexts but that this subsided as they adjusted to their new
In many countries across Europe, and in the USA, environment. Greatrex-White (2008: 537) makes ref-
nurse education differs from that in the UK by being erence to similar encounters experienced by the par-
generic in principle with specialist options available ticipants in her research and describes the process
212
Table 14.2 Key personal and professional prerequisites for a learning

abroad experience
Insurances Health screening and immunizations

You will need to consider obtaining the professional You will need to comply with the health
liability insurance you require for clinical learning in screening requirements of the country
Europe; make sure you are familiar with the insurance you are visiting as well as the health care
cover provided organization(s) providing you with clinical
You will need to consider obtaining the personal and learning opportunities
professional liability insurance you require for clinical Consult with your GP to determine if
learning outside Europe (the host organization may you require any vaccinations or other
be able to provide you with the details of insurance preventative measures prior to booking
providers); make sure you are familiar with the your trip
insurance cover provided
Criminal record status and protecting
vulnerable groups Immigration rules and visa requirements
You may be required to provide evidence that you You will need to comply with the
are safe to enter the country you plan to visit and immigration rules and visa requirements of
to be able to access the health care organizations the country you will be visiting
providing you with clinical learning opportunities. As Information is available via the internet and
this evidence is also required by the UK for you to be the international department (usually) at
a student nurse, your university will be able to guide the host organization you are planning to
you through this process visit, and your own university
as a ‘disturbance that profoundly affects cultural per- years to come. The CIHE (Diamond et al. 2011a)
spectives’. Nevertheless, she seems to suggest that highlights that the business and industry sector
such a culture shock may be just what is required to already recruit from around the globe. Fielden et al.
develop culturally competent nurses. Wimpenny et (2007) suggest that prospective employers want to
al. (2005) also advocate the value of such personal recruit graduates who have experience of living
confrontations to facilitate a greater awareness and and working in another culture or country, have
understanding of the cultural values and practices an understanding of global issues, economies and
influencing self and others, in order to prepare stu- cultures, and can manage complex international
dent nurses and RNs for work in an increasingly and intercultural relationships. Although Fielden
international workplace and multicultural society. et al. and the CIHE are discussing globalization
However, there are several key aspects to and the international workforce in relation to
your preparation that will facilitate a good learn- business and industry, these concepts are also
ing experience. Table 14.3 highlights some key relevant to health professionals. Indeed, the
tips from a cultural, social, professional and per- current economic situation in some parts of the
sonal perspective, suggested by our students and UK has led to limited job opportunities for nurses
academic staff who have participated in learning with a resultant increase in the migration of nurses
opportunities abroad. to other parts of the UK or overseas. As with other
professions, we believe that you as a nurse need
to become more globally aware and to develop
The future the attributes and competencies that not only
The job market for graduates is predicted to reflect your graduate status but also demonstrate
become increasingly more international in the that you are truly a global citizen. Learning abroad
213
Table 14.3 Key tips for a learning abroad experience
Cultural Social
Learn the language of the country you will be visiting, You can meet students from all over the world, so be
especially the basics: please, thank you, good morning, prepared to embrace different cultures and learn as
etc. much as you can about others and yourself
Check the weather forecast so that you pack the clothes You can make lifelong friendships with the people
you will need you meet because you are in a new situation and will
Find out the cost of food, etc. so you can budget need to build trusting relationships very quickly
appropriately Remember you are not on holiday. You will need to
Make sure you know the full cost of your accommodation be independent and adventurous to pursue the social
(you may need to buy bedding, crockery, electricity) activities available during your visit
Find out bus fare/train costs and timetables You may be unusually tired because of the
Know where to find the nearest food shop/24-hour adjustments you need to make to living and working
supermarket in a new country, so planning your social activities is
Identify the tourist attractions you want to see during essential for maximum enjoyment
your visit and build the costs into your budget Always let someone know where you are
Know where the safe areas to visit are and where you
should not go
Know what the time difference is and inform your friends
and family
Be familiar with the laws and customs of the country
you are visiting (e.g. you may be arrested in the USA for
photographing federal buildings)
Know if the public transport systems are safe for you to
use
Personal Professional
Be open-minded Be prepared to clarify and negotiate your specific
Don’t worry about going on your own as you will soon learning needs with your mentor abroad and to
learn to be confident and independent in a foreign ensure there is a clear understanding about the
country, but be wary of doing so at night completion of the documentation required for your
Be adventurous but stay safe nurse education programme
Check how best to access the internet and the costs Be assertive and put yourself forward to learn as
involved much as you can about nursing in another country
There will always be costs you didn’t expect. Be Remember, the patients are vulnerable and you are a
prepared by saving more than you think you will need professional student nurse
Make sure friends and family know where you are and You will be amazed at how quickly you learn to
who to contact if unable to reach you communicate in different ways with patients and staff
Register your visit with the British Embassy in another country
Know how to access the police, the British Embassy, staff You will quickly learn to confidently speak the
from host institutions and at home should you require language spoken in the country you are visiting, if it
any assistance is different to your own
Ensure you have adequate medical and travel insurance Remember to access your own university for
(obtain the European Health Insurance Card, free online, academic, professional and pastoral guidance if
for travel within Europe) required
Don’t book your flights until your learning abroad Finish all the coursework that you can prior to your
placement has been confirmed and all the paperwork visit to ensure maximum enjoyment of your learning
has been approved (e.g. health screening, criminal abroad experience
record check) Make sure you have access to any learning resources
Be mindful of customs regulations and baggage you require to support your learning abroad
allowances experience
214
experiences such as that offered by the ELLP and as well as that of patients and mentors. Further-
funded by the British Council enable you to realize more, the actual learning environment needs to be
your potential in the global job market in a safe audited to determine the suitability of the learning
learning environment. As noted earlier, the NMC experiences and mentor support available for you
recognizes the benefits of a learning abroad expe- as a student. In addition to this, practical issues
rience and has provided scope for student nurses such as vaccinations, health screening, visas and
to undertake a learning opportunity of up to six work permits, personal and professional indem-
months outside the UK. In doing this it is acknowl- nity, accommodation and living conditions, and
edging the forces of change and the need to edu- in some instances the equivalent of the Protecting
cate and develop an internationally aware nursing Vulnerable Groups Scheme, all need to be consid-
workforce that is fit to work, lead and deliver health ered and addressed well in advance of any pro-
care in the globally diverse world of the future. posed learning abroad experience.
As the global economy evolves, technology
advances and travelling becomes increasingly
Conclusion easier, the need for you as a nurse to develop
The opportunity to live, work and study overseas global as well as graduate competence has never
as part of your education provides an invaluable been so important. Opportunities for nurses to
and life-changing experience that can be an asset travel and work abroad are increasing and nurses,
to your personal and professional growth and therefore, need to be culturally aware and tolerant
which offers many benefits as you journey through as not only may they be working alongside col-
life and a career in nursing. An overseas experi- leagues from other nationalities, they will also be
ence can add a new dimension to your education, required to sensitively care for patients from other
taking your learning to a higher plane. You may cultures, whether working in the UK or overseas.
learn about the theory underpinning concepts such In addition to developing core graduate attributes,
as culture, politics, economics, injustice and in- you as a student nurse will need to embrace the
equity in the classroom, however, an overseas concept of global competence and demonstrate
experience can synthesize this learning and make your leadership to become a fully fledged global
these subjects meaningful and relevant in so many citizen and international leader in nursing.
ways within and outwith nursing. It is our belief
that you as a student nurse will not only learn In summary:
about the new culture and factors influencing
health care and health care delivery in the over- Learning abroad offers a unique opportunity
seas country, but that you will be able to reflect on to enhance your awareness of cultural compe-
your own culture and beliefs as well as the politi- tence as well as refine specific graduate attri-
cal influences that may impact on health, well- butes.
being and quality of life. The learning from such an Careful attention to planning both academi-
experience is immense and difficult to fully articu- cally and practically is required to ensure a
late in words alone. successful experience.
A note of caution: learning abroad experiences Nursing is becoming an increasingly global
should not be embarked upon lightly. They require profession and the future will hold opportuni-
meticulous planning in order to ensure your safety, ties for a more mobile workforce.

www.britishcouncil.org/erasmus-about-erasmus.htm. The webiste for the British Council.
http://uk.embassyhomepage.com. The website for the British Embassy, London.
215
http://bit.ly/wAISY. The website for the British Foreign and Commonwealth Office (FCO). There is a section here
on travelling abroad and staying safe when doing so: www.fco.gov.uk/en/travel-and-living-abroad/staying-
safe/. This contains a sub-section on health: http://www.fco.gov.uk/en/travel-and-living-abroad/staying-safe/
health/.
www.lifelonglearningprogramme.org.uk/programme/erasmus. The website of the ELLP.
http://bit.ly/YIBzUC. Information on the European Health Insurance Card (EHIC).
https://estaapply.net/uk. Information on ESTA US business travel visa applications.
http://www.fnif.org/index.html. The International Council of Nurses (ICN).
http://bit.ly/Yfj25X. The National Union of Students (NUS).
www.oxfam.org.uk/education/gc/Oxfam. Information on global citizenship.
http://bit.ly/XGS96Z. The Quality Assurance Agency for Higher Education (graduate attributes).
http://bit.ly/14vqI7O. The website for Robert Gordon University School of Nursing and Midwifery.
www.rcn.org.uk/support/legal/indemnityscheme. Information from the RCN about professional indemnity
exclusions (i.e. USA and Canada).
http://travel.state.gov/visa/visa_1750.html. Information from the United States Department of State (USDS)
on US visa applications.
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content.htm.
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Domains Appendix
NMC Competencies for entry to the register: Adult nursing

Generic standard for competence
All nurses must act first and foremost to care for and safeguard the public. They must practise
autonomously and be responsible and accountable for safe, compassionate, person-centred, evidence-
based nursing that respects and maintains dignity and human rights. They must show professionalism
and integrity and work within recognised professional, ethical and legal frameworks. They must work
in partnership with other health and social care professionals and agencies, service users, their carers
and families in all settings, including the community, ensuring that decisions about care are shared.
Field standard for competence

Adult nurses must also be able at all times to promote the rights, choices and wishes of all adults
and, where appropriate, children and young people, paying particular attention to equality, diversity
and the needs of an ageing population. They must be able to work in partnership to address people’s
needs in all healthcare settings.
Competencies
1 All nurses must practise with confidence according to The code: Standards of conduct, performance
and ethics for nurses and midwives (NMC 2008), and within other recognised ethical and legal
frameworks. They must be able to recognize and address ethical challenges relating to people’s
choices and decision-making about their care, and act within the law to help them and their
families and carers find acceptable solutions.
1.1 Adult nurses must understand and apply current legislation to all service users, paying
special attention to the protection of vulnerable people, including those with complex
needs arising from ageing, cognitive impairment, long-term conditions and those
approaching the end of life.
2 All nurses must practise in a holistic, non-judgmental, caring and sensitive manner that avoids
assumptions, supports social inclusion; recognises and respects individual choice; and acknowl-
edges diversity. Where necessary, they must challenge inequality, discrimination and exclusion
from access to care.
3 All nurses must support and promote the health, wellbeing, rights and dignity of people, groups,
communities and populations. These include people whose lives are affected by ill health,
disability, ageing, death and dying. Nurses must understand how these activities influence public
health.
4 All nurses must work in partnership with service users, carers, families, groups, communities
and organisations. They must manage risk, and promote health and wellbeing while aiming to
empower choices that promote self-care and safety.
219
Domains Appendix
5 All nurses must fully understand the nurse’s various roles, responsibilities and functions, and
adapt their practice to meet the changing needs of people, groups, communities and populations.
6 All nurses must understand the roles and responsibilities of other health and social care profes-
sionals, and seek to work with them collaboratively for the benefit of all who need care.
7 All nurses must be responsible and accountable for keeping their knowledge and skills up to date
through continuing professional development. They must aim to improve their performance and
enhance the safety and quality of care through evaluation, supervision and appraisal.
8 All nurses must practise independently, recognising the limits of their competence and knowl-
edge. They must reflect on these limits and seek advice from, or refer to, other professionals
where necessary.
9 All nurses must appreciate the value of evidence in practice, be able to understand and appraise
research, apply relevant theory and research findings to their work, and identify areas for further
investigation.
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Domains Appendix
Domain 2: Communication and interpersonal skills

All nurses must use excellent communication and interpersonal skills. Their communications must
always be safe, effective, compassionate and respectful. They must communicate effectively using a
wide range of strategies and interventions including the effective use of communication technologies.
Where people have a disability, nurses must be able to work with service users and others to obtain
the information needed to make reasonable adjustments that promote optimum health and enable
equal access to services.

Adult nurses must demonstrate the ability to listen with empathy. They must be able to respond
warmly and positively to people of all ages who may be anxious, distressed, or facing problems with
their health and wellbeing.
Competencies
1 All nurses must build partnerships and therapeutic relationships through safe, effective and non-
discriminatory communication. They must take account of individual differences, capabilities
and needs.
2 All nurses must use a range of communication skills and technologies to support person-centred
care and enhance quality and safety. They must ensure people receive all the information they
need in a language and manner that allows them to make informed choices and share decision
making. They must recognise when language interpretation or other communication support is
needed and know how to obtain it.
3 All nurses must use the full range of communication methods, including verbal, non-verbal
and written, to acquire, interpret and record their knowledge and understanding of people’s
needs. They must be aware of their own values and beliefs and the impact this may have
on their communication with others. They must take account of the many different ways in
which people communicate and how these may be influenced by ill health, disability and
other factors, and be able to recognise and respond effectively when a person finds it hard to
communicate.
3.1 Adult nurses must promote the concept, knowledge and practice of self-care with
people with acute and long-term conditions, using a range of communication skills and
strategies.
4 All nurses must recognise when people are anxious or in distress and respond effectively,
using therapeutic principles, to promote their wellbeing, manage personal safety and resolve
conflict. They must use effective communication strategies and negotiation techniques to
achieve best outcomes, respecting the dignity and human rights of all concerned. They must
know when to consult a third party and how to make referrals for advocacy, mediation or
arbitration.
5 All nurses must use therapeutic principles to engage, maintain and, where appropriate, disen-
gage from professional caring relationships, and must always respect professional boundaries.
6 All nurses must take every opportunity to encourage health-promoting behaviour through educa-
tion, role modelling and effective communication.
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7 All nurses must maintain accurate, clear and complete records, including the use of electronic
formats, using appropriate and plain language.
8 All nurses must respect individual rights to confidentiality and keep information secure and
confidential in accordance with the law and relevant ethical and regulatory frameworks, taking
account of local protocols. They must also actively share personal information with others when
the interests of safety and protection override the need for confidentiality.
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All nurses must practise autonomously, compassionately, skilfully and safely, and must maintain dig-
nity and promote health and wellbeing. They must assess and meet the full range of essential physical
and mental health needs of people of all ages who come into their care. Where necessary they must
be able to provide safe and effective immediate care to all people prior to accessing or referring to
specialist services irrespective of their field of practice. All nurses must also meet more complex and
coexisting needs for people in their own nursing field of practice, in any setting including hospital,
community and at home. All practice should be informed by the best available evidence and comply
with local and national guidelines. Decision-making must be shared with service users, carers and
families and informed by critical analysis of a full range of possible interventions, including the use of
up-to-date technology. All nurses must also understand how behaviour, culture, socioeconomic and
other factors, in the care environment and its location, can affect health, illness, health outcomes and
public health priorities and take this into account in planning and delivering care.

Adult nurses must be able to carry out accurate assessment of people of all ages using appropriate
diagnostic and decision-making skills. They must be able to provide effective care for service users
and others in all settings. They must have in-depth understanding of and competence in medical and
surgical nursing to respond to adults’ full range of health and dependency needs. They must be able to
deliver care to meet essential and complex physical and mental health needs.
Competencies
1 All nurses must use up-to-date knowledge and evidence to assess, plan, deliver and evaluate
care, communicate findings, influence change and promote health and best practice. They must
make person-centred, evidence-based judgments and decisions, in partnership with others
involved in the care process, to ensure high quality care. They must be able to recognise when
the complexity of clinical decisions requires specialist knowledge and expertise, and consult or
refer accordingly.
1.1 Adult nurses must be able to recognise and respond to the needs of all people who
come into their care including babies, children and young people, pregnant and postna-
tal women, people with mental health problems, people with physical disabilities, people
with learning disabilities, older people, and people with long term problems such as cog-
nitive impairment.
2 All nurses must possess a broad knowledge of the structure and functions of the human body,
and other relevant knowledge from the life, behavioural and social sciences as applied to health,
ill health, disability, ageing and death. They must have an in-depth knowledge of common
physical and mental health problems and treatments in their own field of practice, including
co-morbidity and physiological and psychological vulnerability.
3 All nurses must carry out comprehensive, systematic nursing assessments that take account of
relevant physical, social, cultural, psychological, spiritual, genetic and environmental factors, in
partnership with service users and others through interaction, observation and measurement.
3.1 Adult nurses must safely use a range of diagnostic skills, employing appropriate
technology, to assess the needs of service users.
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4 All nurses must ascertain and respond to the physical, social and psychological needs of people,
groups and communities. They must then plan, deliver and evaluate safe, competent, person-
centred care in partnership with them, paying special attention to changing health needs during
different life stages, including progressive illness and death, loss and bereavement.
4.1 Adult nurses must safely use invasive and non-invasive procedures, medical devices,
and current technological and pharmacological interventions, where relevant, in medical
and surgical nursing practice, providing information and taking account of individual
needs and preferences.
4.2 Adult nurses must recognise and respond to the changing needs of adults, families
and carers during terminal illness. They must be aware of how treatment goals and
service users’ choices may change at different stages of progressive illness, loss and
bereavement.
5 All nurses must understand public health principles, priorities and practice in order to recognise
and respond to the major causes and social determinants of health, illness and health inequali-
ties. They must use a range of information and data to assess the needs of people, groups, com-
munities and populations, and work to improve health, wellbeing and experiences of healthcare;
secure equal access to health screening, health promotion and healthcare; and promote social
inclusion.
6 All nurses must practise safely by being aware of the correct use, limitations and hazards of
common interventions, including nursing activities, treatments, and the use of medical devices
and equipment. The nurse must be able to evaluate their use, report any concerns promptly
through appropriate channels and modify care where necessary to maintain safety. They must
contribute to the collection of local and national data and formulation of policy on risks, hazards
and adverse outcomes.
7 All nurses must be able to recognise and interpret signs of normal and deteriorating mental
and physical health and respond promptly to maintain or improve the health and comfort of the
service user, acting to keep them and others safe.
7.1 Adult nurses must recognise the early signs of illness in people of all ages. They must
make accurate assessments and start appropriate and timely management of those who
are acutely ill, at risk of clinical deterioration, or require emergency care.
7.2 Adult nurses must understand the normal physiological and psychological processes
of pregnancy and childbirth. They must work with the midwife and other professionals
and agencies to provide basic nursing care to pregnant women and families during
pregnancy and after childbirth. They must be able to respond safely and effectively in an
emergency to safeguard the health of mother and baby.
8 All nurses must provide educational support, facilitation skills and therapeutic nursing
interventions to optimise health and wellbeing. They must promote self-care and management
whenever possible, helping people to make choices about their healthcare needs, involving
families and carers where appropriate, to maximise their ability to care for themselves.
8.1 Adult nurses must work in partnership with people who have long-term conditions that
require medical or surgical nursing, and their families and carers, to provide therapeutic
nursing interventions, optimise health and wellbeing, facilitate choice and maximise
self-care and self-management.
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9 All nurses must be able to recognise when a person is at risk and in need of extra support and
protection and take reasonable steps to protect them from abuse.
10 All nurses must evaluate their care to improve clinical decision-making, quality and outcomes,
using a range of methods, amending the plan of care, where necessary, and communicating
changes to others.
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Domain 4: Leadership, management and team working

All nurses must be professionally accountable and use clinical governance processes to maintain and
improve nursing practice and standards of healthcare. They must be able to respond autonomously
and confidently to planned and uncertain situations, managing themselves and others effectively.
They must create and maximise opportunities to improve services. They must also demonstrate the
potential to develop further management and leadership skills during their period of preceptorship and
beyond.

Adult nurses must be able to provide leadership in managing adult nursing care, understand and
coordinate interprofessional care when needed, and liaise with specialist teams. They must be
adaptable and flexible, and able to take the lead in responding to the needs of people of all ages in
a variety of circumstances, including situations where immediate or urgent care is needed. They
must recognise their leadership role in disaster management, major incidents and public health
emergencies, and respond appropriately according to their levels of competence.
Competencies
1 All nurses must act as change agents and provide leadership through quality improvement and
service development to enhance people’s wellbeing and experiences of healthcare.
2 All nurses must systematically evaluate care and ensure that they and others use the findings to
help improve people’s experience and care outcomes and to shape future services.
3 All nurses must be able to identify priorities and manage time and resources effectively to ensure
the quality of care is maintained or enhanced.
4 All nurses must be self-aware and recognise how their own values, principles and assumptions
may affect their practice. They must maintain their own personal and professional development,
learning from experience, through supervision, feedback, reflection and evaluation.
5 All nurses must facilitate nursing students and others to develop their competence, using a range
of professional and personal development skills.
6 All nurses must work independently as well as in teams. They must be able to take the lead in
coordinating, delegating and supervising care safely, managing risk and remaining accountable
for the care given.
7 All nurses must work effectively across professional and agency boundaries, actively involving
and respecting others’ contributions to integrated person-centred care. They must know when
and how to communicate with and refer to other professionals and agencies in order to respect
the choices of service users and others, promoting shared decision making, to deliver positive
outcomes and to coordinate smooth, effective transition within and between services and
agencies.
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Competencies for entry to the register: Mental health nursing

All nurses must act first and foremost to care for and safeguard the public. They must practise
autonomously and be responsible and accountable for safe, compassionate, person-centred, evidence-
based nursing that respects and maintains dignity and human rights. They must show professionalism
and integrity and work within recognised professional, ethical and legal frameworks. They must work
in partnership with other health and social care professionals and agencies, service users, their carers

Mental health nurses must work with people of all ages using values-based mental health frame-
works. They must use different methods of engaging people, and work in a way that promotes positive
relationships focused on social inclusion, human rights and recovery, that is, a person’s ability to live a
self-directed life, with or without symptoms, that they believe is meaningful and satisfying.
Competencies
1 All nurses must practise with confidence according to The code: Standards of conduct, perfor-
mance and ethics for nurses and midwives (NMC 2008), and within other recognised ethical and
legal frameworks. They must be able to recognize and address ethical challenges relating to
people’s choices and decision-making about their care, and act within the law to help them and
their families and carers find acceptable solutions.
1.1 Mental health nurses must understand and apply current legislation to all service users,
paying special attention to the protection of vulnerable people, including those with
complex needs arising from ageing, cognitive impairment, long-term conditions and
those approaching the end of life.
2.1 Mental health nurses must practise in a way that addresses the potential power
imbalances between professionals and people experiencing mental health problems,
including situations when compulsory measures are used, by helping people exercise
their rights, upholding safeguards and ensuring minimal restrictions on their lives. They
must have an in depth understanding of mental health legislation and how it relates to
care and treatment of people with mental health problems.
communities and populations. These include people whose lives are affected by ill health,
disability, inability to engage, ageing or death. Nurses must act on their understanding of how
these conditions influence public health.
3.1 Mental health nurses must promote mental health and wellbeing, while challenging
the inequalities and discrimination that may arise from or contribute to mental health
problems.
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4 All nurses must work in partnership with service users, carers, groups, communities and organi-
sations. They must manage risk, and promote health and wellbeing while aiming to empower
choices that promote self-care and safety.
4.1 Mental health nurses must work with people in a way that values, respects and
explores the meaning of their individual lived experiences of mental health problems, to
provide person-centred and recovery-focused practice.
5 All nurses must fully understand the nurse’s various roles, responsibilities and functions, and adapt
their practice to meet the changing needs of people, groups, communities and populations.
where necessary.
8.1 Mental health nurses must have and value an awareness of their own mental health
and wellbeing. They must also engage in reflection and supervision to explore the
emotional impact on self of working in mental health; how personal values, beliefs and
emotions impact on practice, and how their own practice aligns with mental health
legislation, policy and values-based frameworks.
investigation.
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equal access to services,

Mental health nurses must practise in a way that focuses on the therapeutic use of self. They must
draw on a range of methods of engaging with people of all ages experiencing mental health problems,
and those important to them, to develop and maintain therapeutic relationships. They must work alongside
people, using a range of interpersonal approaches and skills to help them explore and make sense of their
experiences in a way that promotes recovery.
Competencies
and needs.
1.1 Mental health nurses must use skills of relationship-building and communication to
engage with and support people distressed by hearing voices, experiencing distressing
thoughts or experiencing other perceptual problems.
1.2 Mental health nurses must use skills and knowledge to facilitate therapeutic groups
with people experiencing mental health problems and their families and carers.
3 All nurses must use the full range of communication methods, including verbal, non-verbal and
written, to acquire, interpret and record their knowledge and understanding of people’s needs.
They must be aware of their own values and beliefs and the impact this may have on their
communication with others. They must take account of the many different ways in which people
communicate and how these may be influenced by ill health, disability and other factors, and be
able to recognise and respond effectively when a person finds it hard to communicate.
4 All nurses must recognise when people are anxious or in distress and respond effectively, using
therapeutic principles, to promote their wellbeing, manage personal safety and resolve conflict.
They must use effective communication strategies and negotiation techniques to achieve best
outcomes, respecting the dignity and human rights of all concerned. They must know when to
consult a third party and how to make referrals for advocacy, mediation or arbitration.
4.1 Mental health nurses must be sensitive to, and take account of, the impact of abuse
and trauma on people’s wellbeing and the development of mental health problems.
They must use interpersonal skills and make interventions that help people disclose and
discuss their experiences as part of their recovery.
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5.1 Mental health nurses must use their personal qualities, experiences and interpersonal
skills to develop and maintain therapeutic, recovery-focused relationships with people
and therapeutic groups. They must be aware of their own mental health, and know when
to share aspects of their own life to inspire hope while maintaining professional bound-
aries.
6.1 Mental health nurses must foster helpful and enabling relationships with families, car-
ers and other people important to the person experiencing mental health problems. They
must use communication skills that enable psychosocial education, problem-solving and
other interventions to help people cope and to safeguard those who are vulnerable.
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All nurses must practise autonomously, compassionately, skilfully and safely, and must maintain
dignity and promote health and wellbeing. They must assess and meet the full range of essential
physical and mental health needs of people of all ages who come into their care. Where necessary
they must be able to provide safe and effective immediate care to all people prior to accessing or
referring to specialist services irrespective of their field of practice. All nurses must also meet more
complex and coexisting needs for people in their own nursing field of practice, in any setting including
hospital, community and at home. All practice should be informed by the best available evidence and
comply with local and national guidelines. Decision-making must be shared with service users, carers
and families and informed by critical analysis of a full range of possible interventions, including the
use of up-to-date technology. All nurses must also understand how behaviour, culture, socioeconomic
and other factors, in the care environment and its location, can affect health, illness, health outcomes
and public health priorities and take this into account in planning and delivering care.

Mental health nurses must draw on a range of evidence-based psychological, psychosocial and
other complex therapeutic skills and interventions to provide person-centred support and care
across all ages, in a way that supports self-determination and aids recovery. They must also promote
improvements in physical and mental health and wellbeing and provide direct care to meet both the
essential and complex physical and mental health needs of people with mental health problems.
Competencies
refer accordingly.
1.1 Mental health nurses must be able to recognise and respond to the needs of all
people who come into their care including babies, children and young people, pregnant
and postnatal women, people with physical health problems, people with physical
disabilities, people with learning disabilities, older people, and people with long term
problems such as cognitive impairment.
and other relevant knowledge from the life, behavioral and social sciences as applied to health,
3.1 Mental health nurses must be able to apply their knowledge and skills in a range of
evidence-based individual and group psychological and psychosocial interventions, to
carry out systematic needs assessments, develop case formulations and negotiate goals.
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4.1 Mental health nurses must be able to apply their knowledge and skills in a range of
evidence-based psychological and psychosocial individual and group interventions to
develop and implement care plans and evaluate outcomes, in partnership with service
users and others.
inclusion.
5.1 Mental health nurses must work to promote mental health, help prevent mental health
problems in at-risk groups, and enhance the health and wellbeing of people with mental
health problems.
6.1 Mental health nurses must help people experiencing mental health problems to make
informed choices about pharmacological and physical treatments, by providing education
and information on the benefits and unwanted effects, choices and alternatives. They must
support people to identify actions that promote health and help to balance benefits and
unwanted effects.
7.1 Mental health nurses must provide support and therapeutic interventions for people
experiencing critical and acute mental health problems. They must recognise the health
and social factors that can contribute to crisis and relapse and use skills in early inter-
vention, crisis resolution and relapse management in a way that ensures safety and
security and promotes recovery.
7.2 Mental health nurses must work positively and proactively with people who are at
risk of suicide or self-harm, and use evidence-based models of suicide prevention,
intervention and harm reduction to minimise risk.
8 All nurses must provide educational support, facilitation skills and therapeutic nursing interven-
tions to optimise health and wellbeing. They must promote self-care and management whenever
possible, helping people to make choices about their healthcare needs, involving families and
carers where appropriate, to maximise their ability to care for themselves.
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8.1 Mental health nurses must practise in a way that promotes the self-determination and
expertise of people with mental health problems, using a range of approaches and tools
that aid wellness and recovery and enable self-care and self-management.
9.1 Mental health nurses must use recovery-focused approaches to care in situations that
are potentially challenging, such as times of acute distress; when compulsory measures
are used; and in forensic mental health settings. They must seek to maximise service
user involvement and therapeutic engagement, using interventions that balance the
need for safety with positive risk-taking.
changes to others.
233
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beyond.

Mental health nurses must contribute to the leadership, management and design of mental health
services. They must work with service users, carers, other professionals and agencies to shape future
services, aid recovery and challenge discrimination and inequality.
Competencies
4.1 Mental health nurses must actively promote and participate in clinical supervision and
reflection, within a values-based mental health framework, to explore how their values,
beliefs and emotions affect their leadership, management and practice.
5.1 Mental health nurses must help raise awareness of mental health, and provide advice
and support in best practice in mental health care and treatment to members of the
multiprofessional team and others working in health, social care and other services and
settings.
for the care given.
6.1 Mental health nurses must contribute to the management of mental health care
environments by giving priority to actions that enhance people’s safety, psychological
security and therapeutic outcomes, and by ensuring effective communication, positive
risk management and continuity of care across service boundaries.
234
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agencies.
235
Domains Appendix
Competencies for entry to the register: Learning disabilities nursing

All nurses must act first and foremost to care for and safeguard the public. They must practise autono-
mously and be responsible and accountable for safe, compassionate, person-centred, evidence-based
nursing that respects and maintains dignity and human rights. They must show professionalism and
integrity and work within recognised professional, ethical and legal frameworks. They must work in
partnership with other health and social care professionals and agencies, service users, their carers

Learning disabilities nurses must promote the individuality, independence, rights, choice and social
inclusion of people with learning disabilities and highlight their strengths and abilities at all times while
encouraging others do the same. They must facilitate the active participation of families and carers.
Competencies
1 All nurses must practise with confidence according to The code: Standards of conduct, perfor-
mance and ethics for nurses and midwives (NMC 2008), and within other recognised ethical and
legal frameworks. They must be able to recognize and address ethical challenges relating to
people’s choices and decision-making about their care, and act within the law to help them and
their families and carers find acceptable solutions.
1.1 Learning disabilities nurses must understand and apply current legislation to all
service users, paying special attention to the protection of vulnerable people, including
those with complex needs arising from ageing, cognitive impairment, long-term condi-
tions and those approaching the end of life.
2.1 Learning disabilities nurses must always promote the autonomy, rights and choices
of people with learning disabilities and support and involve their families and carers,
ensuring that each person’s rights are upheld according to policy and the law.
communities and populations. These include people whose lives are affected by ill health, disabil-
ity, inability to engage, ageing or death. Nurses must act on their understanding of how these
conditions influence public health.
3.1 Learning disabilities nurses must use their knowledge and skills to exercise profes-
sional advocacy, and recognise when it is appropriate to refer to independent advocacy
services to safeguard dignity and human rights.
236
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4.1 Learning disabilities nurses must recognise that people with learning disabilities are
full and equal citizens, and must promote their health and wellbeing by focusing on and
developing their strengths and abilities.
where necessary.
investigation.
237
Domains Appendix

equal access to services,

Learning disabilities nurses must use complex communication and interpersonal skills and
strategies to work with people of all ages who have learning disabilities and help them to express
themselves. They must also be able to communicate and negotiate effectively with other professionals,
services and agencies, and ensure that people with learning disabilities, their families and carers, are
fully involved in decision-making.
Competencies
and needs.
1.1 Learning disabilities nurses must use the full range of person-centred alternative and
augmentative communication strategies and skills to build partnerships and therapeutic
relationships with people with learning disabilities.
2.1 Learning disabilities nurses must be able to make all relevant information accessible
to and understandable by people with learning disabilities, including adaptation of
format, presentation and delivery.
3.1 Learning disabilities nurses must use a structured approach to assess, communicate
with, interpret and respond therapeutically to people with learning disabilities who have
complex physical and psychological health needs or those in behavioural distress.
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4.1 Learning disabilities nurses must recognise and respond therapeutically to the complex
behaviour that people with learning disabilities may use as a means of communication.
239
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All nurses must practise autonomously, compassionately, skilfully and safely, and must maintain
dignity and promote health and wellbeing. They must assess and meet the full range of essential
physical and mental health needs of people of all ages who come into their care. Where necessary
they must be able to provide safe and effective immediate care to all people prior to accessing or
referring to specialist services irrespective of their field of practice. All nurses must also meet more
complex and coexisting needs for people in their own nursing field of practice, in any setting including
hospital, community and at home. All practice should be informed by the best available evidence and
comply with local and national guidelines. Decision-making must be shared with service users, carers
and families and informed by critical analysis of a full range of possible interventions, including the
use of up-to-date technology. All nurses must also understand how behaviour, culture, socioeconomic
and other factors, in the care environment and its location, can affect health, illness, health outcomes
and public health priorities and take this into account in planning and delivering care.

Learning disabilities nurses must have an enhanced knowledge of the health and developmental
needs of all people with learning disabilities, and the factors that might influence them. They must aim
to improve and maintain their health and independence through skilled direct and indirect nursing
care. They must also be able to provide direct care to meet the essential and complex physical and
mental health needs of people with learning disabilities.
Competencies
refer accordingly.
1.1 Learning disabilities nurses must be able to recognise and respond to the needs of all
people who come into their care including babies, children and young people, pregnant
and postnatal women, people with mental health, people with physical health problems
and disabilities, older people, and people with long term problems such as cognitive
impairment.
3.1 Learning disabilities nurses must use a structured, person-centred approach to assess,
interpret and respond therapeutically to people with learning disabilities, and their often
240
Domains Appendix
complex, pre-existing physical and psychological health needs. They must work in part-
nership with service users, carers and other professionals, services and agencies to agree
and implement individual care plans and ensure continuity of care.
inclusion.
5.1 Learning disabilities nurses must lead the development, implementation and review
of individual plans for all people with learning disabilities, to promote their optimum
health and wellbeing and facilitate their equal access to all health, social care and
specialist services.
8.1 Learning disabilities nurses must work in partnership with people with learning dis-
abilities and their families and carers to facilitate choice and maximise self-care and self-
management and co-ordinate the transition between different services and agencies.
changes to others.
241
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beyond.

Learning disabilities nurses must exercise collaborative management, delegation and supervision
skills to create, manage and support therapeutic environments for people with learning disabilities.
Competencies
1.1 Learning disabilities nurses must take the lead in ensuring that people with learning
disabilities receive support that creatively addresses their physical, social, economic,
psychological, spiritual and other needs, when assessing, planning and delivering care.
1.2 Learning disabilities nurses must provide direction through leadership and education
to ensure that their unique contribution is recognised in service design and provision.
2.1 Learning disabilities nurses must use data and research findings on the health of peo-
ple with learning disabilities to help improve people’s experiences and care outcomes,
and shape of future services.
for the care given.
6.1 Learning disabilities nurses must use leadership, influencing and decision-making
skills to engage effectively with a range of agencies and professionals. They must also be
able, when needed, to represent the health needs and protect the rights of people with
learning disabilities and challenge negative stereotypes.
6.2 Learning disabilities nurses must work closely with stakeholders to enable people
with learning disabilities to exercise choice and challenge discrimination.
242
Domains Appendix
agencies.
243
Domains Appendix
Competencies for entry to the register: Children’s nursing

All nurses must act first and foremost to care for and safeguard the public. They must practise autono-
mously and be responsible and accountable for safe, compassionate, person-centred, evidence-based
nursing that respects and maintains dignity and human rights. They must show professionalism and
integrity and work within recognised professional, ethical and legal frameworks. They must work in
partnership with other health and social care professionals and agencies, service users, their carers

Children’s nurses must understand their role as an advocate for children, young people and their
families, and work in partnership with them. They must deliver child and family-centred care; empower
children and young people to express their views and preferences; and maintain and recognise their
rights and best interests.
Competencies
1 All nurses must practise with confidence according to The code: Standards of conduct, performance
and ethics for nurses and midwives (NMC 2008), and within other recognised ethical and legal
frameworks. They must be able to recognize and address ethical challenges relating to people’s
choices and decision-making about their care, and act within the law to help them and their fami-
lies and carers find acceptable solutions.
1.1 Children’s nurses must understand the laws relating to child and parental consent,
including giving and refusing consent, withdrawal of treatment and legal capacity.
2.1 Children’s nurses must recognise that all children and young people have the right to
be safe, enjoy life and reach their potential. They must practice in a way that recognises,
respects and responds to the individuality of every child and young person.
communities and populations. These include people whose lives are affected by ill health, dis-
ability, inability to engage, ageing or death. Nurses must act on their understanding of how these
conditions influence public health.
3.1 Children’s nurses must act as advocates for the right of all children and young people
to lead full and independent lives.
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4.1 Children’s nurses must work in partnership with children, young people and their fam-
ilies to negotiate, plan and deliver child and family-centred care, education and support.
They must recognise the parent’s or carer’s primary role in achieving and maintaining
the child’s or young person’s health and wellbeing, and offer advice and support on par-
enting in health and illness.
where necessary.
investigation.
245
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equal access to services.

Children’s nurses must take account of each child and young person’s individuality, including their
stage of development, ability to understand, culture, learning or communication difficulties and health
status. They must communicate effectively with them and with parents and carers.
Competencies
and needs.
1.1 Children’s nurses must work with the child, young person and others to ensure that
they are actively involved in decision-making, in order to maintain their independence
and take account of their ongoing intellectual, physical and emotional needs.
2.1 Children’s nurses must understand all aspects of development from infancy to young
adulthood, and identify each child or young person’s developmental stage, in order to
communicate effectively with them. They must use play, distraction and communication
tools appropriate to the child’s or young person’s stage of development, including for
those with sensory or cognitive impairment.
3.1 Children’s nurses must ensure that, where possible, children and young people understand
their healthcare needs and can make or contribute to informed choices about all aspects
of their care.
246
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247
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All nurses must practise autonomously, compassionately, skilfully and safely, and must maintain dig-
nity and promote health and wellbeing. They must assess and meet the full range of essential physical
and mental health needs of people of all ages who come into their care. Where necessary they must
be able to provide safe and effective immediate care to all people prior to accessing or referring to
specialist services irrespective of their field of practice. All nurses must also meet more complex and
coexisting needs for people in their own nursing field of practice, in any setting including hospital,
community and at home. All practice should be informed by the best available evidence and comply
with local and national guidelines. Decision-making must be shared with service users, carers and
families and informed by critical analysis of a full range of possible interventions, including the use of
up-to-date technology. All nurses must also understand how behaviour, culture, socioeconomic and
other factors, in the care environment and its location, can affect health, illness, health outcomes and
public health priorities and take this into account in planning and delivering care.

Children’s nurses must be able to care safely and effectively for children and young people in all
settings, and recognise their responsibility for safeguarding them. They must be able to deliver care
to meet essential and complex physical and mental health needs informed by deep understanding of
biological, psychological and social factors throughout infancy, childhood and adolescence.
Competencies
refer accordingly.
1.1 Children’s nurses must be able to recognise and respond to the essential needs of
all people who come into their care including babies, pregnant and postnatal women,
adults, people with mental health problems, people with physical disabilities, people with
learning disabilities, and people with long term problems such as cognitive impairment.
1.2 Children’s nurses must use recognised, evidence-based, child-centred frameworks to
assess, plan, implement, evaluate and record care, and to underpin clinical judgments
and decision-making. Care planning and delivery must be informed by knowledge of
pharmacology, anatomy and physiology, pathology, psychology and sociology, from
infancy to young adulthood.
2 All nurses must possess a broad knowledge of the structure and functions of the-human body,
3 All nurses must carry out comprehensive, systematic nursing assessments that take account
of relevant physical, social, cultural, psychological, spiritual, genetic and environmental
248
Domains Appendix
factors, in partnership with service users and others through interaction, observation and
measurement.
3.1 Children’s nurses must carry out comprehensive nursing assessments of children and
young people, recognising the particular vulnerability of infants and young children to
rapid physiological deterioration.
4 All nurses must ascertain and respond to the physical, social and psychological needs
of people, groups and communities. They must then plan, deliver and evaluate safe, com-
petent, person-centred care in partnership with them, paying special attention to changing
health needs during different life stages, including progressive illness and death, loss and
bereavement.
inclusion.
5.1 Children’s nurses must include health promotion, and illness and injury prevention,
in their nursing practice. They must promote early intervention to address the links
between early life adversity and adult ill health, and the risks to the current and future
physical, mental, emotional and sexual health of children and young people.
common interventions, including nursing activities, treatments, the calculation and administra-
tion of medicines, and the use of medical devices and equipment. The nurse must be able to
evaluate their use, report any concerns promptly through appropriate channels and modify care
where necessary to maintain safety. They must contribute to the collection of local and national
data and formulation of policy on risks, hazards and adverse outcomes.
6.1 Children’s nurses must have numeracy skills for medicines management, assessment,
measuring, monitoring and recording which recognise the particular vulnerability of
infants and young children in relation accurate medicines calculation.
7 All nurses must be able to recognise and interpret signs of normal and deteriorating mental and
physical health and respond promptly to maintain or improve the health and comfort of the ser-
vice user, acting to keep them and others safe.
8.1 Children’s nurses must use negotiation skills to ensure the best interests of children
and young people in all decisions, including the continuation or withdrawal of care.
Negotiation must include the child or young person, their family and members of the
multidisciplinary and interagency team where appropriate.
protection and take reasonable steps to safeguard them against abuse.
249
Domains Appendix
9.1 Children’s nurses must understand their central role in preventing maltreatment,
and safeguarding children and young people. They must work closely with relevant
agencies and professionals, and know when and how to identify and refer those at risk
or experiencing harm.
changes to others.
250
Domains Appendix

beyond.

Children’s nurses must listen and respond to the wishes of children and young people. They must
influence the delivery of health and social care services to optimise the care of children and young
people. They must work closely with other agencies and services to ensure seamless and well-
supported transition to adult services.
Competencies
1.1 Children’s nurses must understand health and social care policies relating to the health
and wellbeing of children and young people. They must, where possible, empower and
enable children, young people, parents and carers to influence the quality of care and
develop future policies and strategies.
1.2 Children’s nurses must ensure that, wherever possible, care is delivered in the child
or young person’s home, or in another environment that suits their age, needs and
preferences.
for the care given.
6.1 Children’s nurses must use effective clinical decision-making skills when managing
complex and unpredictable situations, especially where the views of children or young
people and their parents and carers differ. They must recognise when to seek extra help
or advice to manage the situation safely.
251
Domains Appendix
agencies.
7.1 Children’s nurses must work effectively with young people who have continuing health
needs, their families, the multidisciplinary team and other agencies to manage smooth
and effective transition from children’s services to adult services, taking account of
individual needs and preferences.
252
Index
Abraham, A. 54 key learning points 160, 162, 169
active listening 57 leadership and management skills, impact in acute
activities, suggestions for care settings 160–62
acute care, leadership, management and team leadership in acute care settings 160–62
working in 158, 161, 163, 165, 167, 168 learning to lead and manage 162–7
advanced decision-making involving patients and NMC Standards for Pre-registration Nursing Education
relatives 116, 119, 120, 121 (2010) 157–8
clinical decision-making in practice 101, 104, 107 NMC Standards to Support Learning and Assessment in
communication, effectiveness in development of Practice (2006) 161–2
interpersonal skills and 54, 56, 57, 58, 60 patient as partner in care 160
community settings, enhancement of leadership and patient safety, importance of 167–9
management in 143, 145, 147, 148, 150, 153 Patient Safety Curriculum Guide (WHO, 2011) 167
difficult situations, communication in 83, 84, 85, 88, person-centred nursing framework 159–60
89, 92 person-centred outcomes of care 160
evidence-based practice 7, 8, 9, 11, 16 personal attributes required 158
leadership, management and team working, effective prerequisites for person-centred nursing 159
skills in 128, 130, 131, 133, 134, 135, 137, 138 professional attributes required 158–9
learning abroad, nursing in international contexts roles and responsibilities 159
204, 205, 209 safe environments, development of 168
mentors, working with 190, 191, 192, 195, 198, 199 SBAR (Situation, Background, Assessment,
professional values 23, 25, 27, 31, 32 Recommendation) 168, 169
simulation, crafting care through 177, 180, 184 skills of leadership and management in acute
solution-focused interactions, development of settings 163
skills in 69, 71, 75 skills required from acute care perspective 158–9
standards of care, ownership of 39, 45, 46, 47 team leadership, effectiveness in 161
see also key learning points team working in acute settings 163–5
acute care, leadership, management and team working components for building a safe and effective
in setting of 157–71 team 165–7
activities, suggestions for 158, 161, 163, 165, 167, 168 distinguishing factors of effective team
acute care members 166
definition of 160 poor teamwork, potential impact on patient care
older people’s experiences of 120 and safety 167
care environment for person-centred nursing 159 qualities of effective team members 164
care processes for person-centred nursing 159–60 quality care, teamwork vital component of 165
case studies Adair, J.E. 129, 131, 134
conflict situations, resolution in 170 Adair, J.E. and Thomas, N. 131, 136
prioritization complexities in A&E 167 Adair, J.E., Thomas, N. and Adair, J.E. 131
SBAR tool, effective use of 169 adaptability 196, 205, 226
teamwork in A&E 166, 167 Addo, M. and Smith, I. 56
conflict situations, leading resolution in 170 Addo, Mary ix, 53–65
destructive leadership 161, 162 advanced decision-making involving patients and
further reading, resources and 171 relatives 113–22
Implementing Human Factors in Healthcare (NHS) 168 actions to take, identification of 115
interprofessional learning 165 activities, suggestions for 116, 119, 120, 121
253
Index
advanced decision-making involving patients and Bakalis, N.A. and Watson, R. 108, 110
relatives (continued) Baker, D. and Rawlinson, M. 148
acute care, older people’s experiences of 120 Baker, Mary-Jane ix, 97–112
advocating for patients making decisions 119–20 Balanda, K.P., Barron, S., Fahy, L. and McLaughlin, A.
assessments, pitfalls for decision-making in 116–17 146
availability heuristic 116 Banks, Debbie ix–x, 37–49
bias and impact on decision-making 115–17 Banning, M. 98, 129
capacity and consent, resources on 121 Barker, P. 55
case study, stroke victim in acute care situation 118 Barr, J. and Dowding, L. 149
cognitive biases in decision-making 116–17 Barr, Owen x, 21–36
confirmatory bias 117 Basford, L. and Kershaw, B. 39
cues, recognition of 114, 115 Bass, B.M. and Stogdill, R.M. 131
expectations, formation of 115 Beauchamp, T.L. and Childress, J.F. 30
experience, expertise and 115 Beebe, S.A., Beebe, S.J. and Redmond, M.V. 57
expert decision-making 114–15 Belbin, R.M. 136
further reading, resources and 122 benchmarks, use to inform practice 12
illusory correlation 117 benificence 30
key learning points 115, 117, 120, 121 Benner, P.E. 15, 108, 129
multidimensional situations 113 ‘best evidence’ 6
NMC Standards for Pre-registration Nursing ‘best guesses’ 105
Education (2010) 113–14 bias
overconfidence 117 cognitive biases in decision-making 116–17
patients and relatives, involvement in decisions confirmatory bias 117
117–22 impact on decision-making 115–17
patients unable to be fully involved in decision- Black, Pauline x, 157–72
making 120–22 Bluebond-Langner, M. 86
recognition-primed decision-making 114–15 body language 56, 57, 84, 89, 93, 180
example of 115 body mass index (BMI) 26
representativeness heuristic 116 BOE (brief, ordinary and effective) health
strategies for competence in decision-making 122 communication 61
types of goals 114, 115 Bologna Declaration (2000) 207, 209
aesthetic knowledge 106 Bologna Process (European Higher Education
Allcock, N. and Day, R. 7 Area, 2007) 207, 209
altruism 26, 62 Bond, S. and Cooper, S. 114, 115
American Association of Colleges of Nursing (AACN) 26 Borrill, C.S., Carletta, J., Carter, A.J., Dawson, J.F.,
Andrews, M. and Chilton, F. 191 Garrod, S., Rees, A., Richards, A., Shapiro, D.
Archer, J.C. 183 and West, M.A. 131, 136
Arnold, E. and Boggs, K.U. 55, 56, 170 Boscart, V. 71
Aslan, M. and Smith, M. 28 Botti, M. and Reeve, R. 105, 110
assessments, pitfalls for decision-making in 116–17 Boud, D., Cohen, R. and Walker, D. 178
Atherton, H.L. and Crickmore, D.J. 84 Boud, D., Keogh, R. and Walker, D. 109
Atwal, A. and Caldwell, K. 136 Bowles, N., Mackintosh, C. and Torn, A. 71
audit data, use of 12 Brannon, L.A. and Carson, K.L. 116, 117
autonomy Bridges, J., Flatley, M. and Meyer, J. 120
nursing in international contexts 207 Bridges, Jackie x, 113–23
professional values 26, 30, 32 Brief Family Therapy Center 71
availability heuristic 116 Bristol Royal Infirmary Inquiry (2001) 62, 137
British Council 204, 207, 208
Bach, S. and Ellis, P. 141 British Medical Association (BMA) 121
Baile, W., Buckman, R., Lenzi, R., Glober, G., Beale, E. British Medical Journal 14
and Kudelka, A. 91 Brown, Alison x, 53–65
Bain, H. and Adams, D. 146 Brown, C. 47
Bain, H. and Baguley, F. 148, 149 buddies 190, 210
Bain, Heather ix, 141–55 Bullock, I., Macleod Clark, J. and Rycroft-Malone, J. 8
254
Index
Bulman, C. and Schutz, S. 184 Chilton, S. 144, 145, 146

Bunning, K. 88 Chinn, P. and Kramer, M. 105, 106
Burnard, P. 59 choice making 108–9
clarity
care communication, effectiveness in development
care at or close to home 147–8 of interpersonal skills and 58
delivery process 145–6 in planning for clinical decision-making 104–5
in difficult situations, communication and 83–4 on procedure for evidence-based practice,
environment for person-centred nursing 159 lack of 14–15
high standards, learning to achieve 47 Clark, C.E., Smith, L.F.P., Taylor, R.S. and
of individual patients 6–7 Campbell, J.L. 14
integrated care 39 Clarke, D. and Ketchell, A. 160
processes for person-centred nursing 159–60 client-centred therapy 60
professional values 28, 32 clinical decision-making in practice 97–111
use of evidence in decision making for 107 activities, suggestions for 101, 104, 107
Care and Compassion? (Parliamentary and Health aesthetic knowledge 106
Service Ombudsman, 2009) 25, 29 alternatives, assessment of 98
Care and Compassion? (Parliamentary and Health ‘best guesses’ 105
Service Ombudsman, 2011) 29, 43 care, use of evidence in decision making for 107
Care Quality Commission (CQC) 12, 43 choice making 108–9
care standards 39–41 clarity in planning 104–5
nursing leaders’ concerns about 42 clinical decision-making 98
Carper, B. 105, 106 as two-phase process 98, 99
case management 151–3 collaboration, success in 109
components of 152 communication, reflection and decision-making
elements of 151 109–10
factors for success in 152–3 complexity of context of decision-making 98–101
case studies confirmatory process 103
anorexia nervosa 26–7 consequences of decisions 97
cancer patient, discharge meeting 55 context, interpretation of 102
case management 153 cues, collection of 104
conflict situations, resolution in 170 decision-making process 98
dementia 24 key stages in 100
diabetes instability 72–3, 74–5 possible stages in 102–3
Down’s syndrome adult, dealing with 55 emancipatory knowledge 106
eight-year-old osteosracoma patient 87 empirical knowledge 106
elderly aggressiveness and confusion 130 ethical knowledge 106
group care and concept mapping 144, 145 evidence-based practice (EBP) 107
learning disabilities 31 evidence in decision making for care, use of 107
learning how to learn in practice 179 feedback, responding to 103
moving and handling patients 137, 138 field-specific qualities 98
practical patient care, sleep patterns and 134 further reading, resources and 111
prioritization complexities in A&E 167 hypothetico-deductive model 98, 99
SBAR tool, effective use of 169 influencing factors 100
stroke victim in acute care situation 118 informing patient and others involved 103
teamwork in A&E 166, 167 key learning points 99, 104, 105, 107, 109
traumatic amputation and death of partner 68–9 knowing, patterns of 105–6
volunteer patient programme 182–3 knowledge sources, identification of 105–7
caseloads 148–50 moving forward 110
caseload management 149–50 NMC Standards for Pre-registration Nursing Education
Chant, S., Jenkinson, T., Randle, J. and Russell, G. 55, 59, 62 (2010) 97–8
children’s nursing nurse-patient relationship 100
competence statements 34 nursing practice and decision-making generic
dying children, communications with 85–7 competence 97–8
255
Index
clinical decision-making in practice (continued) Egan’s skilled helper model 61

organization in thought and action 108–9 empathy, responding with 59
personal knowledge 106 feedback, responding to 63
picking up cues 104 further reading, resources and 63
political factors 100 genuineness, responding with 60
prioritization 108–9 Heron’s intervention model 61
professional factors 100 immediacy, responding to 60
purpose, identification of 102 interpersonal skills 59–60
purpose in planning 104–5 and qualities for effective nursing helpers 59–60
reflecting on your decision-making processes 101–4 key learning points 55, 58, 59
reflection 103 leading questions 58
reflection model, stages in 109, 110 NMC Standards for Pre-registration Nursing Education
resources (2010) 53
clarification and gathering of 102 non-verbal communication 57
consideration of 102 nurses, core values for 62
evaluation of 102 nursing as interpersonal profession 54
usefulness of, consideration of 102 open-ended questions 58
sharing decision-making 98 open questions 58
skilled activities in changing practice situations 103 paraphrasing 57
sociopolitical knowledge 106 personal styles of communication 56
thought and action, organization in 108–9 personal values and professionalism, relationship of
unknowing knowledge 106 communication to 62
working environment and other personnel 100 probing 58
clinical governance 42–6 quality patient care, importance of personal
clinical guidelines, use to inform practice 12 communication as lifelong approach to
Clinical Human Factors Group (CHFG) 163 delivery of 62
Clinical Leadership Competency Framework (NHS reflecting 57
Institute for Innovation and Improvement, respect, responding with 59–60
2011) 143 silence 57
closed questions 58 skilled helpers 61
cognitive biases in decision-making 116–17 SOLER strategy 59
collaboration, success in 109 summarization 57–8
Collins English Dictionary 128 therapeutic communication strategies 59
communication, effectiveness in development of therapeutic relationship 54–5
interpersonal skills and 53–63 touch, use of 58
active listening 57 warmth, responding with 60
activities, suggestions for 54, 56, 57, 58, 60 communication and interpersonal skills
barriers to effective interpersonal communication 59 difficult situations, communication in 81–93
BOE (brief, ordinary and effective) health effectiveness in, development of 53–63
communication 61 solution-focused interactions, development of skills
case studies in 67–78
cancer patient, discharge meeting 55 communication skills
Down’s syndrome adult, dealing with 55 development of 55–8
clarifying 58 good leadership and 134
client-centred therapy 60 learning abroad, nursing in international contexts 205
closed questions 58 community settings, enhancement of leadership and
communication management in 141–54
definition of 56 activities, suggestions for 143, 145, 147, 148, 150, 153
good and bad techniques 57–8 care at or close to home 147–8
importance of 54–5 care delivery process 145–6
strategies, models for development of 60–61 case management 151–3
types of 56 components of 152
compassionate engagement 62 elements of 151
development of communication skills 55–8 factors for success in 152–3
256
Index
case studies leadership, management and team working 226

case management 153 nursing practice and decision-making 223–5
group care and concept mapping 144, 145 professional values 219–20
caseloads 148–50 children’s nursing
caseload management 149–50 communication and interpersonal skills 246–7
Clinical Leadership Competency Framework (NHS competences 244–5, 246–7, 248–50, 251–2
Institute for Innovation and Improvement, field standard for competence 244, 246, 248, 251
2011) 143 generic standard for competence 244, 246, 248, 251
communities leadership, management and team working 251–2
characteristics of 145–6 nursing practice and decision-making 248–50
WHO definition of 145 professional values 244–5
community nursing, political context and influences learning disabilities nursing
on 146–7 communication and interpersonal skills 238–9
community placements, conceptualization from competences 236–7, 238–9, 240–41, 242–3
user’s perspective 142–3 field standard for competence 236, 238, 240, 242
context of care 145–6 generic standard for competence 236, 238, 240, 242
coordination, caseload management and 149 leadership, management and team working 242–3
delegation, caseload management and 149–50 nursing practice and decision-making 240–41
district nursing teams 145–6 professional values 236–7
further reading, resources and 154 mental health nursing
Health and Social Care Model (DoH, 2005) 150–51 communication and interpersonal skills 229–30
key learning points 147, 150 competences 227–8, 229–30, 231–3, 234–5
leadership, importance of 143–4 field standard for competence 227, 229, 231, 234
learning needs, anticipation of 142–3 generic standard for competence 227, 229, 231, 234
learning opportunities in life 141 leadership, management and team working 234–5
management of long-term conditions in the nursing practice and decision-making 231–3
community 150–53 professional values 227–8
management of nursing care in the community mentors, working with
148–50 conscious and unconscious 189
NMC Standards for Pre-registration Nursing Education practical applications 188–9
(2010) 141–2 confidence 2, 22, 37–8, 46, 55, 59, 128, 130, 199,
nursing in the community 144–5 204, 207
organizational skills, caseload management and 149 assertiveness and 136
point-of-care delivery, relationships established at 148 in decision-making for care 107, 108, 109, 110
priority setting, caseload management and 149 in emotional situations 90
self-care 150 lack of skills or 86, 113
compassion 28, 29, 40, 42, 44, 82, 83, 176, 180, 197, 205 in nurse-patient relationship 100
Care and Compassion? (Parliamentary and Health overconfidence 117
Service Ombudsman) 25, 29, 43 public confidence 39
Compassion in Practice (DoH, 2012) 28 self-confidence 179
compassionate engagement 62 teamwork and 137, 163, 165
The Point of Care: Enabling Compassionate Care in confirmatory bias 117
Acute Hospital Settings (King’s Fund 2009) 25, 29 confirmatory process 103
competences 28 conflict situations, leading resolution in 170
achievement of Connolly, M., Perryman, J., McKenna, Y., Orford, J.,
learning abroad, nursing in international contexts Thomson, L., Shuttleworth, J. and
203–16 Cocksedge, S. 90
mentors, working with 187–200 conscientiousness 6
simulation, crafting care through 175–85 conscious competence model (Howell) 189
adult nursing control knowledge, Eraut’s concept of 178, 185
communications and interpresonal skills 221–2 conversations
competences 219–20, 221–2, 223–5, 226 about dying, fears, misconceptions and beliefs 85
field standard for competence 219, 221, 223, 226 conversational analysis 69–71
generic standard for competence 219, 221, 223, 226 conversational shaping 90
257
Index
Cooper, J. and Barnett, M. 83 case study, eight-year-old osteosracoma patient 87

coordination, caseload management and 149 children who are dying, communications with 85–7
Council for Industry in Higher Education (CIHE) 205, communication and end-of-life care 82–3
207, 213 communication difficulties for person you are
courage 29 speaking to 85
Cowan, L. 199–200 conversational shaping 90
Cowie, Jean x, 203–17 conversations about dying, fears, misconceptions
Cowley, S. 146 and beliefs 85
Crawford, P. and Brown, B. 56 difficulty in conversations, contributions to 85–8
Crawford, P., Brown, B. and Bonham, P. 60, 61 emotional support, communication and 89–90
criminal record status 213 emotions, impact of difficult communication
cues situations on 89
collection of 104 end-of-life care 81
observation skills and recognition of 180 National End-of-Life Care Programme (2011) 83, 86
recognition of 114, 115 euphemisms 88
cultural agility 205 fears, beliefs and challenges which hamper effective
cultural competence, development of 212–13 communication 86
cultural tips 214 finding words 85
culturally sensitive workforces, development of 203–4 further reading, resources and 93
Curtis, E.A., De Vries, J. and Sheerin, F.K. 128, 131, key learning points 83, 84, 88, 90, 91
133, 134 mutual pretence 86
Curtis, E.A., Sheerin, F.K. and De Vries, J. 129 mutual understanding, key of 88
NMC Standards for Pre-registration Nursing Education
Darzi, A. 128 (2010) 82
Day, L. 32 non-verbal communication 84
De Shazer, S. and Dolan, Y. 71 Palliative Care Nursing: Principles and Evidence for
De Shazer, S., Berg, I.K., Lipchik, E., Nunnally, E., Practice (Payne et al. 2008) 81
Molnar, A., Gingerich, W. and parents and children in end-of-life care 87
Weiner-Davis, M. 71 patients, fears, beliefs and challenges for 86
decision-making process professionals, fears, beliefs and challenges for 86
clinical decision-making in practice 98 Sage and Thyme model for support in distress
key stages in 100 situations 90
possible stages in 102–3 SPIKES model for breaking bad news 91
field-specific scenarios and 181 work ‘persona’ 91–2
use of evidence in practice 10–11 Dignity at the Heart of Everything We Do (RCN, 2008) 62
Defining Nursing (RCN, 2003) 30 district nursing teams 145–6
delegation, caseload management and 149–50 Doenges, M.E. and Moorhouse, M.F. 55
destructive leadership 161, 162 Donnelly, E. and Neville, L. 84, 89
Developing and Sustaining Effective Teams, Guide 1: Dowie, J. 98
What is a Team? (RCN, 2007) 135, 136 Downey, M., Parslow, S. and Smart, M. 133, 134
Diamond, A., Walkley, L. and Scott-Davies, S. 204, 205, Driscoll, J. 109
207 Duffy, K. and Hardicre, J. 198
Diamond, A., Walkley, L., Forbes, P., Hughes, T. and Duke, S. and Bailey, C.D. 89, 90, 91
Sheen, J. 204, 205, 207, 213
Dickson, C., Gough, H. and Bain, H. 146 Education for Global Citizenship: A Guide for Schools
Dickson, D.A., Hargie, O. and Morrow, N.C. 59 (Oxfam, 2006) 204–5
difficult situations, communication in Egan, G. 56, 59, 60, 89
activities, suggestions for 83, 84, 85, 88, 89, 92 skilled helper model 61
body language 84 Egan, T. and Jaye, C. 188
caring Ekeberg, V. 32, 83
communication and 83 Elcock, K. 195
in difficult circumstances, communications and Elstein, A.S. and Bordage, G. 114
83–4 Elstein, A.S. and Schwarz, A. 115
interrelated concepts of 83 Elwyn, G. and Miron-Shatz, T. 105
258
Index
emancipatory knowledge 106 clarity on how to proceed, lack of 14–15

emotions clinical decision-making in practice 107
confidence in emotional situations 90 clinical guidelines, use to inform practice 12
emotional support, communication and 89–90 conscientiousness 6
impact of difficult communication situations on 89 contemporary health care and concept of 5
empathy, responding with 59 decision-making, use of evidence in practice 10–11
empirical knowledge 106 definition of 6–9
end-of-life care 81 evidence
End of Life Care Strategy: Promoting High Quality Care balance of 8
for all Adults at the End of Life (DoH, 2008) 83 creation of 11
National End-of-Life Care Programme (2011) 83, 86 critical assessment of 13
parents and children in 87 in decision making for care, use of 107
Equity and Excellence: Liberating the NHS (DoH, 2010) 54, integration into practice of 5–6
146, 148, 150 RCN information literacy competences and 12–13
mentors, working with 188 sources of 7–8
Erasmus Lifelong Learning Programme (ELLP) 203, systematic review identifying lack of, example of 14
207–8, 209, 215 use in practice of 11–12
Studying in Europe and More (2010) 204, 207 use of different types to answer practice
Eraut, M. 178, 185 questions 13
Ervin, N.E. 149, 150 external clinical evidence 7
Essence of Care (DoH, 2003) 30 further reading, resources and 16
Essence of Care (DoH, 2010) 12 importance within current nursing context 9–11
essential skill clusters (ESCs) 197–8 individual clinical expertise 7
ethics informed and knowledgeable practitioners,
ethical considerations in nursing practice 30–31 importance of 15
ethical drift 41 key learning points 9, 13
ethical knowledge 106 knowledge and skills required for 11–13
NMC Code: Standards of Conduct, Performance and NMC Standards for Pre-registration Nursing
Ethics for Nurses and Midwives (2008) 22–3, 28, Education (2010) 6
30, 37–8, 40, 54, 100, 130, 135, 137, 138, 145, nursing practice and decision-making 6
149, 190, 198 patient-focused care 8–9
euphemisms 88 problem-solving, use of evidence in practice 10–11
Europe, learning abroad in 207–9 process of 11
European Commission 208 professional values 6, 15
The Bologna Process: Towards the European Higher promotion of, role in 10
Education Area (2011) 207 protocols, use to inform practice 12
Erasmus Programme: Studying in Europe and More RCN competencies, finding and using
(2010) 204, 207 information 10
European Credit Transfer and Accumulation System reality of, complexity of 16
(ECTS, 2011) 209 reflection in and on practice, importance of 15–16
European Directive 2005/36/EC 203 research, deficiencies in 14
European Higher Education Area (EHEA) 207, 209 research-based information 8
Green Paper: Promoting the Learning Mobility of Young standards of care, ownership of 40
People (2009) 204, 207 expectations
Standards and Guidelines for Quality Assurance in the formation of 115
European Higher Education Area (2009) 207 reality and, students’ comparisons of 179
events, highlighting of 182 experience, expertise and 115
evidence-based practice (EBP) 5–16 experiential learning 178
activities, suggestions for 7, 8, 9, 11, 16 expert decision-making 114–15
audit data, use of 12
benchmarks, use to inform practice 12 Fahey, T., Schroeder, K., Ebrahim, S. and Glynn, L. 14
‘best evidence’ 6 Farrell, C., McAvoy, H., Wilde, J. 146
care of individual patients 6–7 Faulkner, A. 54, 87
challenges and limitations of 13–16 Fawcett, T. and Rhynas, S. 55
259
Index
feedback, responding to Gallagher, A. and Hodge, S. 30

accurate feedback 184 Gambrill, E. 98
balanced feedback 184 GANES (Global Alliance for Leadership in Nursing
clinical decision-making in practice 103 Education and Science) 209
communication, effectiveness in development of genuineness, responding with 60
interpersonal skills and 63 Gibbs, G. 38
constructive feedback 184 Gibbs, G,
depersonalized feedback 184 reflective model 38
effective feedback 184–5 Giles, S.J., Morris, M. and Cook, G.A. 54
simulation, crafting care through 183–5 Gillespie, M. 98, 100, 102–3
standards of care, ownership of 46 Gillespie, M. and Paterson, B.L. 113
Fielden, J., Middlehurst, R. and Woodfield, S. 205–6, Girvin, J. 133, 134
207, 213 global citizenship 204–5
Finding, Using and Managing Information: Nursing, global demographics 204
Midwifery Health and Social Care Information global knowledge 205
Literacy Competences (RCN, 2010) 10 Global Standards for the Initial Education of Professional
Flannery Wainwright, S., Shepard, K., Harman, L. and Nurses and Midwives (WHO, 2009) 204, 209
Stephens, J. 98, 99, 107, 108 goal coherence, teamwork and 136
flexibility 39, 61, 205 Gobbi, M. 207
Flin, R., Yule, S., McKenzie, L., Paterson-Brown, S. and Gobbi, M.O., Monger, E.J., Weal, M.J., McDonald, J.,
Maran, N. 163 Michaelides, D. and DeRoure, D. 180
Forchuk, C. and Boyd, M.A. 56 Goffman, E. 196
Frances, R. 43 Gonzalez, C. 48
French, P. 14 Goode, Debbie x, 157–72
Frye, N. 178 Goodhand, Kate x, 175–86
Fulford, K.W.M. 26 Gopee, N. and Galloway, J. 150
Fulford, K.W.M., Peile, E. and Carroll, H. 26 Gould, J. 149
further reading, resources and graduate attributes, development of 175
acute care, leadership, management and team Gray, B. 84, 91
working in setting of 171 Gray, M.A. and Smith, L.N. 191
advanced decision-making involving patients and Greatrex-White, S. 204, 212
relatives 122 Green Paper: Promoting the Learning Mobility of Young
clinical decision-making in practice 111 People (2009) 204, 207
communication, effectiveness in development of Griffiths, J., Speed, S., Horne, M. and Keeley, P. 54
interpersonal skills and 63 Griffiths, P., Bennett, J. and Smith, E. 14
community settings, enhancement of leadership and Guidance for Mentors of Nursing Students and Midwives
management in 154 (RCN, 2007) 195
difficult situations, communication in 93
evidence-based practice 16 Hack, T.F., Degner, L.F. and Parker, P.A. 62
leadership, management and team working, effective Haig, K.M., Sutton, S. and Whittington, J. 168
skills in 139 Ham, C. 153
learning abroad, nursing in international contexts Hamilton, S.J. and Martin, D.J. 59
215–16 Hannon, L. and Clift, J. 84, 85
mentors, working with 200 Harbison, J. 114
professional values 34–5 Hattie, J. and Timperley, H. 183
simulation, crafting care through 185 Haycock-Stuart, E., Jarvis, A. and Daniel, K. 148
solution-focused interactions, development of Hayes, J. 59
skills in 78 Health and Social Care Model (DoH, 2005) 150–51
standards of care, ownership of 48 health care
future prospects for learning abroad 213–15 changes in 39
quality in, dimensions of 40
Gaba, D.M. 176 screening, immunizations and 213
Gaberson, K.B. and Oermann, M.H. 177 Health Department (DoH) 121, 146
Gale, Chris 32 Healthcare Commission 12, 29
260
Index
Heijkenskjold, K.B., Ekstedt, M. and Lindwall, L. 29 Kean, S. and Haycock-Stuart, E. 134, 136
Helping Students Get the Best From Their Practice Kennedy, I. 137
Placements (RCN, 2006) 193 key learning points
Hendry, C. and Walker, A. 108 acute care, leadership, management and team
Heron, J. 56, 89 working in 160, 162, 169
intervention model 61 advanced decision-making involving patients and
Hersey, P., Blanchard, K.H. and Johnson, D.E. 132 relatives 115, 117, 120, 121
Heyland, D.K., Dodek, P., Rocker, G. et al. 87 clinical decision-making in practice 99, 104, 105,
Hillyer, D. 71 107, 109
Horton, K., Tschudin, V. and Forget, A. 62 communication, development of interpersonal skills
Hounsell, D. 204, 205 and 55, 58, 59
House of Commons Health Committee (2003) 43 community settings, enhancement of leadership and
Howell, W.S. 189 management in 147, 150
Huckabay, L. 105, 109 difficult situations, communication in 83, 84, 88,
human dignity 23, 24, 26, 28, 32 90, 91
Humphries, R. and Curry, N. 146 evidence-based practice 9, 13
Hutt, R., Rosen, R. and Macauley, J. 151 leadership, management and team working, effective
Huynh, T., Alderson, M. and Thompson, M. 91, 92 skills in 130, 132, 133
Hwang, H.-L., Tu, C.-T., Chen, S. and Wang, H.-H. 83 learning abroad, nursing in international contexts 214
hypothetico-deductive model 98, 99 mentors, working with 188, 189, 191, 193, 194, 199
professional values 26, 28, 32
illusory correlation 117 simulation, crafting care through 178, 182, 185
immediacy, responding to 60 solution-focused interactions, development of skills
immigration rules 213 in 70, 77
Implementing Human Factors in Healthcare (NHS) 168 standards of care, ownership of 40, 47
Independent Commission on Dignity in Care 21 see also activities, suggestions for
informed and knowledgeable practitioners, Kinchin, I., Cabot, L. and Hay, D. 107, 110
importance of 15 King’s Fund 25, 29, 146
insurance for learning abroad 213 Kitson, A. 7, 8–9, 10
integrated care 39 Klein, G.A. 114
International Council of Nurses (ICN) 207 Klein, J.G. 115, 116–17
International Journal of Nursing Studies 7 Kleinman, C.S. 39, 41, 42
interpersonal communication 53, 54, 55, 56 Kneebone, R., Nestel, D., Yadollahi, F., Brown, R.,
barriers to effectiveness in 59 Nolan, C., Durack, J., Brenton, H., Moulton, C.,
importance in delivery of quality care 62 Archer, J. and Darzi, A. 176
interpersonal relationships 205 knowledge
interpersonal skills patterns of knowing 105–6
communication and effectiveness in development personal knowledge 106
of 59–60 and skills required for evidence-based practice 11–13
and qualities for effective nursing helpers 59–60 sociopolitical knowledge 106
interprofessional care 39–40 sources of, identification of 105–7
interprofessional learning 165 unknowing knowledge 106
Iveson, C. 71 Kokko, R. 204
Kolehmainen, N., Francis, J., Duncan, E. and
Jasper, M. 184 Fraser, C. 149
Johns, C. 38, 109 Kozier, B., Erb, G., Berman, A., Snyder, S., Harvey, S.
Johns, C. and Freshwater, D. 38 and Morgan-Samuel, H. 55, 56, 57
Jonasson, L., Liss, P., Westerlind, B. and Berterö, C. 83 Kübler-Ross, E. 87
Junnola, T., Eriksson, E., Salantera, S. and Lauri, S. Kunyk, D. and Olson, J.K. 89
98, 99
justice 30 Ladyshewsky, R. 108
Lafasto, F. and Larson, C. 163, 165, 171
Kabat-Zinn, J. 38 Laming, W.H. 137
Kangasniemi, M. 83 LaSala, C. and Bjarnason, D. 83
261
Index
Laverack, G. 145–6 to lead

leadership 131–3 and manage 162–7
authoritarian leadership 132 as student nurse 133–4
definition of 131 learning agility 205
delegating style of leadership 132 learning relationships 176
importance in community settings of 143–4 learning theory, simulation and 177–8
participative leadership 132 needs in community settings, anticipation of 142–3
permissive leadership 132 opportunities in life 141
in practice, importance of 42 from patient care experiences 196–7
situational approach to 132 practical learning, standards of care and 40–41
traits approach to 131 in practice, importance of 187–8
transformational leadership 132 practice learning experiences, allocation of 188
leadership, management and team working preferred learning style, familiarity with 193
in acute care setting 157–71 theoretical learning, standards of care and 40–41
community settings, enhancement of volunteer patients, learning from 183
skills in 141–54 see also key learning points
development of effective skills in 127–39 learning abroad, nursing in international contexts
activities, suggestions for 128, 130, 131, 133, 203–16
134, 135, 137, 138 activities, suggestions for 204, 205, 209
case studies adaptability 205
elderly aggressiveness and confusion 130 autonomy 207
moving and handling patients 137, 138 Bologna Declaration (2000) 207, 209
practical patient care, sleep patterns and 134 The Bologna Process: Towards the European Higher
communication skills, good leadership and 134 Education Area (2011) 207
conflicting views on patient safety, dealing with caution, note on 215
130–31 communication skills 205
further reading, resources and 139 confidence 207
goal coherence, teamwork and 136 Council for Industry in Higher Education (CIHE)
key learning points 130, 132, 133 205, 207, 213
learning to lead as student nurse 133–4 criminal record status 213
management 128–31 cultural agility 205
management functions 129 cultural competence, development of 213
management qualities 129 cultural contexts, familiarity with 212–13
NHS Leadership Framework (National Leadership cultural tips 214
Council, 2012) 132, 134, 138 culturally sensitive workforces, development of 203–4
NMC Code: Standards of Conduct, Performance and Education for Global Citizenship: A Guide for Schools
Ethics for Nurses and Midwives (2008) 130 (Oxfam, 2006) 204–5
NMC Standards for Pre-registration Nursing Education Erasmus Lifelong Learning Programme (ELLP) 203,
(2010) 127–8, 130, 138 207–8, 209, 215
nursing management and leadership 128 reflections of student nurse on 208
patient, use of term 127 Erasmus Programme: Studying in Europe and More
patient care, making decisions and management (2010) 204, 207
of 129–31 Europe, learning abroad in 207–9
personal qualities of good leaders 133–4 European Credit Transfer and Accumulation System
team development, stages of 135–6 (ECTS, 2011) 209
team numbers 136 European Directive 2005/36/EC 203
team structures 135 European Higher Education Area (EHEA) 207, 209
teamwork 135–8 flexibility 205
characteristics of success in 136–7 further reading, resources and 215–16
skill requirements for success in 137–8 future prospects 213–15
leading questions 58 Global Alliance for Leadership in Nursing Education
learning and Science (GANES) 209
high care standards, learning to achieve 47 global citizenship 204–5
interprofessional learning 165 global demographics 204
262
Index
global knowledge 205 McAllister, M. 71

Global Standards for the Initial Education of Professional MacArthur, Chloe 200
Nurses and Midwives (WHO, 2009) 204, 209 McCabe, C. 55
Green Paper: Promoting the Learning Mobility of Young McCormack, B. and McCance, T.V. 158, 159
People (2009) 204, 207 McGarry, J. 148
health screening, immunizations and 213 McIntosh, Iain xiii–xiv
immigration rules 213 MacIntyre, Alasdair 28
insurance 213 McKenna, H., Cutcliffe, J. and McKenna, P. 15
International Council of Nurses (ICN) 207 McKenzie, K.M. 199
interpersonal relationships 205 McLean, C., Fulford, B. and Carpenter, D. 26
key learning points 214 McLean, Chris x, 21–36, 83
learning abroad, benefits of 205–7 McSherry, R., Pearce, P., Grimwood, K. and McSherry,
student evaluations 206 W. 42
learning abroad experience, key tips for 214 Mallik, M., Hall, C. and Howard, D. 59
learning agility 205 management 128–31
making it work, Robert Gordon University’s case management 151–3
experience 209 caseload management 149–50
NMC Standards for Pre-registration Nursing Education of long-term conditions in the community 150–53
(2010) 203, 204, 205 management functions 129
nursing career, impact on 206 management qualities 129
opportunities, growth of 207 of nursing care in the community 148–50
patient care, impact on 206 nursing management and leadership 128
personal advantages 206 Manias, E., Aitken, R. and Dunning, T. 107
personal growth and development 207 Manser, T. 167
personal tips 214 Mantzoukas, S. 6, 16
preparation for learning abroad experience 211–13 Mason, J. 42, 47
prerequisites for learning abroad experience 213 Melia, K. 199
professional advantages 206 Melo, C.G. and Oliver, D. 83
professional tips 214 Mental Health Network (MHN) 13
Protecting Vulnerable Groups Scheme (Scottish Mental Welfare Commission, Scotland (MWC) 43
Government 2011) 211, 215 mentors, working with 187–200
resilience 205 activities, suggestions for 190, 191, 192, 195, 198, 199
Robert Gordon University, Aberdeen 203, 207, 208, buddies 190
209, 210, 211, 216 challenges while working in practice 199
self-awareness 205 competence
social advantages 206 conscious and unconscious 189
social tips 214 practical applications 188–9
Standards and Guidelines for Quality Assurance in the conscious competence model (Howell) 189
European Higher Education Area (2009) 207 Equity and Excellence: Liberating the NHS (DoH, 2010)
support networks for students abroad 212 188
team working 205 essential skill clusters (ESCs) 197–8
theoretical understanding, development of 204, 215 failure to achieve in practice 198–9
United States, learning abroad in 209–11 further reading, resources and 200
challenges in nursing practice in 211 key learning points 188, 189, 191, 193, 194, 199
reflections of student nurse on 210 learning in practice, importance of 187–8
visa requirements 213 mentors
Voluntary Services Organization (VSO) 207 associate mentors and buddies 190
Lee, N.J. 204 gatekeepers to profession 189–90
Lee, R.L.T., Pang, S.M.C., Wong, T.K.S. and Chan, M.F. personal relationships with 199–200
204 preparation for mentorship 190–91
Leininger, M. 209 student expectations of 191
Levett-Jones, T. and Lathlean, J. 199 misunderstandings and uncertainties, avoidance of 198
Lewis, S. 151 NMC Code: Standards of Conduct, Performance and
Luckmann, J. 59 Ethics for Nurses and Midwives (2008) 190
263
Index
mentors, working with (continued) Narayanasamy, A. 59

NMC Standards for Pre-registration Nursing Education National End-of-Life Care Programme (2011) 83, 86
(2010) 190 National Institute for Health and Clinical Excellence
personal information, sharing with practice area 188 (NICE) 7
placement values, acceptance of 199 National Leadership Council 128, 132, 134, 138
practice environments 188 National Service Framework for Older People
practice learning experiences, allocation of 188 (DoH, 2001) 29
practice placements, preparations for starting 191–5 Neary, M. 187, 191
care of patients and reflection afterwards 197 Neilson-Clayton, H. and Brownlee, K. 71
clinical area and experience to be gained, Ness, V., Duffy, K., McCallum, J. and Price, L. 101, 105
investigation of 192 Neumann, V., Gutenbrunner, C., Fialka-Moser, V.,
contacting ward or department by phone 192 Christodoulou, N., Varela, E., Giustini, A.
engagement with others 196 and Delarque, A. 165
first day in new placement 193–4 New Ambition for Old Age (DoH, 2006) 138, 146
honesty about lack of capabilities 193 Newell, R. and Gournay, K. 8, 12
initial assessments of patients 196–7 NHS Constitution (DoH, 2009) 29
introductions in new placements 193 NHS Education for Scotland 147
knowing where you’re going 192 NHS Improvement Plan: Putting People at the Heart of
learning from patient care experiences 196–7 Public Services (DoH, 2004) 54
mutual engagement 196 NHS Institute for Innovation and Improvement 143
practice areas and client groups, finding out NHS Leadership Framework (National Leadership
about 192 Council, 2012) 132, 134, 138
preferred learning style, familiarity with 193 Nightingale, Florence 104–5
preparedness 193 NMC (Nursing and Midwifery Council) 21, 39, 40
proactive and positive attitude, need for 192–3, 196 Code: Standards of Conduct, Performance and Ethics for
professional expectations, adherence to 192 Nurses and Midwives (2008) 22–3, 28, 30, 37–8,
punctuality 192 40, 54, 100, 130, 135, 137, 138, 145, 149, 190,
quality care 194 198
reflectiveness about practice 197 leadership, management and team working,
relationships, development of 193 effective skills in 130
working with mentors and other multidisciplinary mentors, working with 190
team members 195 professional values 22, 28
practice settings, progressing in 195–7 standards of care, ownership of 37–8, 40
skills and competences 197–8 competency framework 1, 5, 15, 22, 37–8, 67, 82,
support for students in practice, sources of 198 97–8, 113–14, 127–8, 141–2, 219–52
when things don’t go as planned 198 Good Health and Good Character: Guidance for
methicillin-resistant staphylococcus aureus (MRSA) 211 Approved Higher Education Institutions (2010)
Middlewick, Yvonne xi, 127–40 23, 32
Midgley, K. 187 Guidance on Professional Conduct for Nursing and
Millard, Claire 200 Midwifery Students (2011) 21, 23, 25, 28, 158–9
Milne, Avril xi, 203–17 Nursing and Midwifery Order (2001) 22–3
mindfulness, reflection and 38 Simulation and Practice Learning Project (2007) 176,
mindlessness 47–8 179
Mohr, W., Deatrick, J., Richmond, T. and Mahon, M. 23 Standards for Pre-registration Nursing Education (2010)
Monger, Eloise xi, 175–86 6, 22, 28, 29, 31, 32, 40, 53, 61, 62, 77–8, 98,
Montgomery, C. and Webster, D. 71 107, 116, 117, 127, 130, 133, 137, 138, 157–8,
Morse, J.M., Solberg, S.M., Neander, W.L., Bottorff, J.L. 160, 183, 190, 197, 203, 205
and Johnson, J.L. 83 acute care, leadership, management and team
Mullins, L.J. 128, 129, 131 working in 157–8
Mullins, L.J. and Christy, G. 128, 129, 131, 132, 136 advanced decision-making involving patients and
Munhall, P. 105, 106 relatives 113–14
mutual pretence 86, 88 clinical decision-making in practice 97–8
mutual understanding 56, 57, 88 communication, effectiveness in development of
Myall, M., Levett-Jones, T. and Lathlean, J. 189, 200 interpersonal skills and 53
264
Index
community settings, enhancement of leadership Papadopoulos, I., Tilki, M. and Lees, S. 203
and management in 141–2 paraphrasing 57
difficult situations, communication in 82 Parliamentary and Health Service Ombudsman 21, 25,
evidence-based practice 6 29, 32, 43
leadership, management and team working, patient care
effective skills in 127–8, 130, 138 impact of learning abroad on 206
learning abroad, nursing in international contexts impact of poor practice on 46
203, 204, 205 making decisions and management of 129–31
mentors, working with 190 patient-focused care 8–9
professional values 22, 28, 29, 31, 32 Patient Safety Curriculum Guide (WHO, 2011) 167
solution-focused interactions, development of patients
skills in 67 decision-making and inability to be fully involved
standards of care, ownership of 40 120–22
Standards to Support Learning and Assessment in fears, beliefs and challenges for 86
Practice: NMC Standards for Mentors, Practice as partners in care 160
Teachers and Teachers (2008) 190–91 patient safety, importance of 167–9
Standards to Support Learning and Assessment in Patients’ Association 21, 25
Practice (2006) 161–2 Patients Not Numbers, People Not Statistics (Patients’
non-clinical settings, solution-focused interactions in 77–8 Association, 2009) 25
non-malevolence 30 Patients’ Opinion 44
non-verbal communication relatives and, involvement in decisions 117–22
communication, interpersonal skills and 57 use of term ‘patient’ 127
difficult situations, communication in 84 Payne, S., Seymour, J. and Ingleton, C. 81
Norcini, J. 183 Pearson, A., Porritt, K.A., Doran, D., Vincent, L., Craig,
Northouse, P.G. 131 D., Tucker, D., Long, L. and Henstridge, V. 136
‘not knowing,’ technique of 70 Pearson, Liz 200
nurse education, programme of 21–2 Peck, E. and Dickinson, H. 134
nurse-patient relationship 28, 54, 62, 100 Peplau, H. 54, 60
core values for nurses 62 person-centred care
nursing as interpersonal profession 54 centrality of
nursing in the community 144–5 professional values 21
patient care, impact of poor practice on 46 standards of care, ownership of 37
point of delivery, importance of care at 41 nursing framework for 159–60
nursing practice and decision-making outcomes of 160
advanced decision-making involving patients and personal knowledge 106
relatives 113–22 Piaget, J. 86
clinical decision-making in practice 97–111 Pogson, Delia xi, 81–94
evidence-based practice 6 The Point of Care: Enabling Compassionate Care in Acute
Hospital Settings (King’s Fund 2009) 25, 29
observation skills and recognition of cues 180 Pollard, K. 159, 165
O’Hagan, J.J., Davis, L.J. and Pears, R.K. 176 Powell-Davies, G., Williams, A., Larsen, K., Perkins, D.,
open-ended (and open) questions 58 Roland, M. and Harris, M. 153
opportunities, learning abroad and growth of 207 practice placements, preparations for 191–5
organization in thought and action care of patients and reflection afterwards 197
clinical decision-making in practice 108–9 clinical area and experience to be gained,
organizational skills, caseload management and investigation of 192
community settings, enhancement of leadership and contacting ward or department by phone 192
management in 149 engagement with others 196
overconfidence 117 first day in new placement 193–4
Oxfam 204–5 honesty about lack of capabilities 193
initial assessments of patients 196–7
Padilla, A., Hogan, R. and Kaiser, R.B. 161 introductions in new placements 193
Palliative Care Nursing: Principles and Evidence for knowing where you’re going 192
Practice (Payne et al., 2008) 81 learning from patient care experiences 196–7
265
Index
practice placements, preparations for (continued) mental health nursing, competence statements 33
mutual engagement 196 National Service Framework for Older People
placement values, acceptance of 199 (DoH, 2001) 29
practice areas and client groups, finding out about NHS Constitution (DoH, 2009) 29
192 NMC Code: Standards of Conduct, Performance and
practice learning experiences, allocation of 188 Ethics for Nurses and Midwives (2008) 22, 28
preferred learning style, familiarity with 193 NMC Good Health and Good Character: Guidance for
preparedness 193 Approved Higher Education Institutions (2010)
proactive and positive attitude, need for 192–3, 196 23, 32
professional expectations, adherence to 192 NMC Guidance on Professional Conduct for Nursing and
punctuality 192 Midwifery Students (2011) 21, 23, 25, 28
quality care 194 NMC Nursing and Midwifery Order (2001) 22–3
reflectiveness about practice 197 NMC Standards for Pre-registration Nursing Education
relationships, development of 193 (2010) 22, 28, 29, 31, 32
working with mentors and other multidisciplinary non-malevolence 30
team members 195 nurse education, programme of 21–2
Principles of Nursing Practice (RCN, 2012) 154 Parliamentary and Health Service Ombudsman 21, 25,
professional values 21–35 29, 32
absence of value-based care 29–30 Patients’ Association 21, 25
activities, suggestions for 23, 25, 27, 31, 32 Patients Not Numbers, People Not Statistics (Patients’
adult nursing, competence statements 33 Association, 2009) 25
altruism 26 person-centred care, centrality of 21
attitudes and, possession of 21–2 The Point of Care: Enabling Compassionate Care in
autonomy 26, 30, 32 Acute Hospital Settings (King’s Fund 2009) 25, 29
benificence 30 professional conduct for student nurses 25–6
care 28, 32 professional standards, NMC and 22–3
Care and Compassion? (Parliamentary and Health standards of care, ownership of 37–48
Service Ombudsman, 2009) 25, 29 Transforming Care: A National Response to
Care and Compassion? (Parliamentary and Health Winterbourne View Hospital (DoH 2012) 29
Service Ombudsman, 2011) 29 values
case studies actions and 24
anorexia nervosa 26–7 character and 24, 32
dementia 24 nursing practice and 28–9, 32
learning disabilities 31 prioritization of 24–5, 32
children’s nursing, competence statements 34 thinking about 23–5
communication 29 variations in interpretations of 26–8
compassion 28 Protecting Vulnerable Groups Scheme (Scottish
Compassion in Practice (DoH, 2012) 28 Government 2011) 211, 215
competence 28 protectiveness 33, 45, 85, 86, 117, 190
competing values 30 protocols, use to inform practice 12
courage 29 Putman, D.A. 83
Defining Nursing (RCN, 2003) 30
in different fields of practice 31–2 quality care ambitions 40
Essence of Care (DoH, 2003) 30 quality patient care 62
ethical considerations in nursing practice 30–31 Queen’s Nursing Institute (QNI) 148
evidence-based practice 6, 15 questions 58
field specific competence statements 33–4 differential media for scaling questions 73
further reading, resources and 34–5 evidence and, use of different types to answer
generic standard of competence 22 practice questions 13
good life, criteria and values 24
human dignity 23, 24, 26, 28, 32 Randell, R., Mitchell, N., Dowding, D., Cullum, N. and
justice 30 Thompson, C. 13
key learning points 26, 28, 32 Rashotte, J. and Carnevale, F. 108, 109
learning disability nursing, competence statements 33–4 Rassin, M. 23
266
Index
Rawlinson, M., Baker, D. and Fergus, M. 146 Guidance for Mentors of Nursing Students and Midwives
Rawlinson, Mark xi, 141–55 (RCN, 2007) 195
Reading, Sheila ix, 1–3, 5–17, 187–201 Helping Students Get the Best From Their Practice
‘real time’ practice 47 Placements (RCN, 2006) 193
reality and simulation, reflection on 180–81 Principles of Nursing Practice (RCN, 2012) 154
recognition-primed decision-making 114–15 RCN competencies, finding and using information 10
example of 115 Rungapadiachy, D.M. 59
reflection Rycroft-Malone, J., Seers, K., Titchen, A., Harvey, G.,
clinical decision-making in practice 103 Kitson, A. and McCormack, B. 6, 14
communication, interpersonal skills and 57 Ryle, G. 177
debrief as ‘reflection on action’ 184–5
in and on practice, importance of 15–16 Sackett, D.L., Rosenberg, W.M.C., Muir Gray, J.A.,
on reality and simulation 180–81 Haynes, R.B. and Richardson, W.S. 6, 7
reflection model, stages in 109, 110 safe environments, development of 168
reflective practice and 38 Sage and Thyme model for support in distress situations
standards of care and 38–9 difficult situations, communication in 90
on your decision-making processes 101–4 SBAR (Situation, Background, Assessment,
Report of the Mid Staffordshire NHS Foundation Trust Recommendation) 168, 169
Public Inquiry (Francis 2013) 43 scenarios, simulation and 176, 177, 178, 179, 180, 181,
Report on the National Patient Choice Survey (DoH, 182, 183
2009) 54 Scherer, Y.K., Bruce, S.A. and Runkawatt, V. 176
representativeness heuristic 116 Schön, D.A. 6, 184
research Schwartz, S.H. 23, 24
evidence-based practice and deficiencies in 14 Scottish Executive 54, 60
research-based information 8 Scottish Government 39, 40, 54, 62, 146, 211
resilience 205 Scottish Intercollegiate Guidelines Network (SIGN) 7
resources self-awareness 57, 59, 106, 117, 184, 195, 205, 208
clarification and gathering of 102 self-care, safety and 22, 30, 72, 114, 150, 151
consideration of 102 Sellman, D. 28
evaluation of 102 Sepion, Beth xi, 81–94
usefulness of, consideration of 102 sharing decision-making 98
see also further reading, resources and Sharples, K. 62
respect, responding with 59–60 Sheldon, L.K., Barrett, R. and Ellington, L. 62
Review of Compliance: Castlebeck Care (Teesdale) Ltd Siantz, M.L.D. and Meleis, A.F. 209
(CQC 2011) 43 Siegel, R.D. 38
Ricketts, B. 176 silence 57
Riley, S., Rodham, K. and Gavin, J. 27 Silverman, J., Kurtz, S. and Draper, J. 54
Robert Gordon University, Aberdeen Silverman, P.R. 85
nursing in international contexts 203, 207, 208, 209, simulation, crafting care through 175–85
210, 211, 216 accurate feedback 184
simulation, crafting care through 175, 178, 182 activities, suggestions for 177, 180, 184
Rogers, C.R. 54, 59, 60, 89 adult field 177
Rolfe, G. 15 balanced feedback 184
Rolfe, G. and Gardner, L. 7 case studies
Ross, S., Curry, N. and Goodwin, N. 149, 151, 152 learning how to learn in practice 179
Royal College of Nursing (RCN) 10, 12–13, 30, 62, 135, volunteer patient programme 182–3
193, 195, 209, 211 child field 177
Defining Nursing (RCN, 2003) 30 constructive feedback 184
Developing and Sustaining Effective Teams, Guide 1: control knowledge, Eraut’s concept of 178, 185
What is a Team? (RCN, 2007) 135, 136 debrief as ‘reflection on action’ 184–5
Dignity at the Heart of Everything We Do (RCN, 2008) 62 decision making, field-specific scenarios and 181
Finding, Using and Managing Information: Nursing, depersonalized feedback 184
Midwifery Health and Social Care Information effective feedback 184–5
Literacy Competences (RCN, 2010) 10 events, highlighting of 182
267
Index
simulation, crafting care through (continued) solution-focused interactions, development of skills

expectation and reality, students’ comparisons in 67–78
of 179 activities, suggestions for 69, 71, 75
experiential learning 178 big problems don’t need big solutions 76
feedback, responding to 183–5 Brief Family Therapy Center 71
further reading, resources and 185 case studies
graduate attributes, development of 175 diabetes instability 72–3, 74–5
key learning points 178, 182, 185 traumatic amputation and death of partner 68–9
learning disability field 177 conversation, analysis of 69–71
learning relationships 176 differential media for scaling questions 73
learning theory, simulation and 177–8 further reading, resources and 78
limiting self-reliance 181–3 key learning points 70, 77
mental health field 177 NMC Standards for Pre-registration Nursing Education
observation skills and recognition of cues 180 (2010) 67
performance under simulation, students’ thoughts non-clinical settings, solution-focused interactions
on 179–80 in 77–8
physical reality of simulation, students’ comments not broken?, don’t fix it 75
on 179 ‘not knowing,’ technique of 70
preparation for simulation 178–85 not working?, stop doing it 76
professional skills and competence, simulation and pre-suppositional language 73
enhancement of 175–8 solution-building 67
reality and simulation, reflection on 180–81 process for 77
scenarios 176, 177, 178, 179, 180, 181, 182, 183 solution-focused interactions
simulation 176 background to 71
skills stacking 180–81 key principles of 75–7
Southampton University 175, 178, 179, 180 values and principles of 72–5
strategic initiatives, opportunities for practice working?, do more of it 76
of 181–2 Southampton University 32, 92, 200
theory with practice, students’ linking of 179–80 simulation, crafting care through 175, 178, 179, 180
volunteer patients, learning from 183 SPIKES model for breaking bad news 91
Sitiver, B. 184 Spouse, J. 191, 196
skills Standards and Guidelines for Quality Assurance in the
acute care perspective, requirements from European Higher Education Area (2009) 207
158–9 standards of care, ownership of
competences and, mentoring and 197–8 activities, suggestions for 39, 45, 46, 47
of leadership and management in acute settings 163 Care and Compassion? (Parliamentary and Health
skilled activities in changing practice situations 103 Service Ombudsman, 2011) 43
skilled helpers 61 care standards 39–41
skills stacking 180–81 nursing leaders’ concerns about 42
Skills for Health (SfH) 147 clinical governance 42–6
Skisland, A., Bjørnestad, J.O. and Söderhamn, O. 83 ethical drift 41
Smith, S., Adam, D., Kirkpatrick, P. and McRobie, G. 71 evidence-based practice 40
Smith, Steve xi, 67–79 feedback, responding to 46
social advantages, learning abroad and 206 further reading, resources and 48
Social Care Institute for Excellence (SCIE) 121 Gibbs’ reflective model 38
social tips for learning abroad 214 health care, changes in 39
sociopolitical knowledge 106 health care quality, dimensions of 40
SOLER strategy 59 high standards of care, learning to achieve 47
solution-building 67 integrated care 39
process for 77 interprofessional care 39–40
solution-focused interactions key learning points 40, 47
background to 71 leadership in practice, importance of 42
key principles of 75–7 mindfulness, reflection and 38
values and principles of 72–5 mindlessness 47–8
268
Index
NMC Code: Standards of Conduct, Performance Taylor, R. and Brannan, J. 39

and Ethics for Nurses and Midwives (2008) Taylor, Ruth xii, 37–49
37–8, 40 teamwork
NMC Standards for Pre-registration Nursing Education in acute settings 163–5
(2010) 40 components for building a safe and effective
nursing care outcomes 41 team 165–7
patient care, impact of poor practice on 46 distinguishing factors of effective team
person-centred care, centrality of 37 members 166
point of delivery, importance of care at 41 poor teamwork, potential impact on patient care
poor care standards and safety 167
impact of 41–8 qualities of effective team members 164
inquiries into 43 quality care, teamwork vital component of 165
poor practice characteristics of success in 136–7
allegations of 45 leadership, management and, effective skills
illustrations of 44 in 135–8
practical learning, standards of care and 40–41 nursing in international contexts 205
professional values 37–48 skill requirements for success in 137–8
protectiveness 45 team development, stages of 135–6
quality care ambitions 40 team leadership, effectiveness in 161
‘real time’ practice 47 team numbers 136
reflection, reflective practice and 38 team structures 135
reflection and 38–9 Teamwork: Success Through People (Acas, 2007)
Report of the Mid Staffordshire NHS Foundation Trust 136
Public Inquiry (Francis 2013) 43 terminology 3
Review of Compliance: Castlebeck Care (Teesdale) Ltd theoretical learning, standards of care and 40–41
(CQC 2011) 43 theoretical understanding, development of 204, 215
role as nurse, importance of 47–8 theory with practice, students’ linking of 179–80
Starved of Care: Summary Investigation Report therapeutic communication strategies 59
into the Care and Treatment of Mrs V therapeutic relationship 54–5
(MWC 2011) 43 Thich Nhat Hanh 47
student nurse behaviour 46 Thompson, C., Bucknall, T., Estabrookes, C.,
theoretical learning, standards of care and 40–41 Hutchinson, A., Fraser, K., de Vos, R.,
values-based practice 40 Binnecade, J., Barrat, G. and Saunders, J. 109
Victoria Climbié Inquiry Report (House of Commons Thompson, H. and Kagan, S. 107
Health Committee 2003) 43 Thorne, S.T. Gregory, H., Kuo, M. and Armstrong, E.A.
Standing, M. 104, 108 62
Stanley, D. 133, 134 thought and action, organization in 108–9
Stanley, D. and Sherratt, A. 128, 133, 134 touch, use of 58
Starved of Care: Summary Investigation Report into the Townsend, Kay xii, 81–94
Care and Treatment of Mrs V (MWC 2011) 43 Transforming Care: A National Response to Winterbourne
strategic initiatives, opportunities for practice of 181–2 View Hospital (DoH 2012). 29
student nurse behaviour 46 Trede, F. and Higgs, J. 105
Student Participation in Quality Scotland (2011) 184 Trenerry, Alison xii, 187–201
Sullivan, Cathy xi–xii, 187–201 Trepper, T.S., Dolan, Y., Mccollum, E.E. and Nelson, T.
Sullivan, E.J. and Decker, P.J. 129 71
summarization 57–8 Triggle, N. 89
support networks Truc, H., Alderson, M. and Thompson, M. 92
for students abroad 212 Tuckman, Bruce 135–6
for students in practice 198 Tuckman, B.W. and Jensen, M.A.C. 136
Suter, E., Arndt, J., Arthur, N., Parboosingh, J., Taylor, E.
and Deutschlander, S. 165 United States, learning in 209–11
challenges in nursing practice in 211
Tanner, C., Padrick, K., Westfall, U. and Putzier, D. 105 reflections of student nurse on 210
Taylor, C. 98, 99 unknowing knowledge 106
269
Index
values Watkins, P. 60
absence of value-based care 29–30 Webster, B.J., Goodhand, K., Haith, M. and Unwin, R.
competing values 30 182
good life, criteria and values 24 Webster, Brian ix, 1–3, 5–17, 203–17
personal values and professionalism, relationship Webster, D.C. 71, 72
of communication to 62 Welsh Assembly Government 54, 146
professional values Wenger, E. 195, 196
actions and 24 White, J. 105, 106
character and 24, 32 Wildman, S. and Reeves, M. 177
nursing practice and 28–9, 32 Wilgosh, R., Hawkes, D. and Marsh, I. 71
prioritization of 24–5, 32 Wilkes, Z. 198
thinking about 23–5 Wilkinson, R. and Marmot, M. 146
variations in interpretations of 26–8 Wilson, P. and Miller, S. 148
values-based practice 40 Wimpenny, P., Gault, B., MacLennan, V., Boast-Bowen,
Victoria Climbié Inquiry Report (House of Commons L. and Shepherd, P. 213
Health Committee 2003) 43 work ‚persona‘ 91–2
visa requirements, nursing in international contexts 213 World Health Organization (WHO) 145, 161, 163, 207
Voluntary Services Organization (VSO) 207 Global Standards for the Initial Education of Professional
volunteer patients, learning from 183 Nurses and Midwives (2009) 204, 209
Patient Safety Curriculum Guide (2011) 167
Walsh, T. 71
warmth, responding with 60 Yin, R. 182
Warriner, S. 128, 133, 134 Yoder-Wise, P.S. 15
270
Achieving Competencies
for Nursing Practice
“The must-have book on achieving competence for any nursing student in the UK.”
Melanie Jasper, Professor of Nursing and Head of the College of Human and Health
Sciences, Swansea University, UK

“To provide patient care without expertise in the competencies required would be like
starting a new journey without a map. This book is one of the best maps of the competency
terrain that I have come across. I recommend with enthusiasm this book to would-be
readers. It is a solid and significant contribution to the on-going development of best nursing
practice.” Professor Hugh P. McKenna CBE, Pro Vice Chancellor, University of Ulster, UK
Quality patient care relies on the demonstration of competencies by nurses at all stages of
their education and developing career. This exciting textbook is designed to help student
nurses better understand the competencies set out by the NMC and equip them to achieve
and demonstrate competency as they prepare to qualify as nurses.
The book is divided into sections that address the four domains of competency:
• Professional Values • Nursing practice and decision making
• Communication and interpersonal skills • Leadership, management and team working
Suitable for all student nurses on pre-registration degree programmes in nursing across the
UK, the book includes examples and insights from the fields of adult, child, mental health
and learning disability that reflect a range of clinical and community settings.
Written by experts, each chapter challenges you to reflect on your own values and beliefs,
giving you opportunities to learn and reflect on your nursing skills and knowledge. The
chapters include reflective activities, portfolio activities, case studies & vignettes, key
points and further resources. An essential purchase for all student nurses.
Sheila Reading is a Principal Teaching Fellow in the Faculty of Health Sciences,

University of Southampton. Sheila is a qualified Adult Nurse.
Brian Webster is Professor of Nursing and Assistant Dean at the Faculty of Health,
Life & Social Sciences at Edinburgh Napier University. Brian is a qualified Adult and
Mental Health Nurse.
Contributors: Mary Addo, Heather Bain, Debbie Banks, Mary-Jane Baker,

Owen Barr, Pauline Black, Jackie Bridges, Alison Brown, Jean Cowie,
Debbie Good, Ruth Taylor, Kate Goodhand, Chris McLean, Yvonne
Middlewick, Avril Milne, Eloise Monger, Delia Pogson, Mark Rawlinson,
Beth Sepion, Steve Smith, Cathy Sullivan, Kay Townsend, Alison Trenerry.
www.openup.co.uk

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Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC.

Not to be redistributed or modified in any way without permission.

Edited by Sheila Reading and Brian Webster

and Two Penn Plaza, New York, NY 10121-2289, USA

First published 2013

Copyright © Sheila Reading and Brian Webster 2014

A catalogue record of this book is available from the British Library

Library of Congress Cataloging-in-Publication Data

Typeset by Aptara, Inc.

1. The importance of evidence-based professional nursing practice 5

Section 1: Professional values 19

2. Professional values for nursing 21

3. Owning your standards of care 37

Section 2: Communication and interpersonal skills 51

4. Developing effective communication and interpersonal skills 53

5. Developing skills in solution-focused interactions 67

6. Com munication in difficult situations 81

Section 3: Nursing practice and decision-making 95

7. An introduction to clinical decision-making in practice 97

8. Advanced decision-making: involving patients and relatives

Section 4: Leadership, management and team working 125

9. Effective leadership, management and team working skills 127

10. Enhancing and developing leadership, management and team working

12. Simulation: crafting your care 175

14. Learning abroad: the student experience of nursing in a European

Yvonne Middlewick is a lecturer in the Faculty of communication skills as fundamental to achieving

Introduction nursing practice and decision-making;

Domain 3: Nursing practice and

Your role in promoting of supporting graduate student nurses in achiev-

to find and analyse evidence for use in the provi- Informs

assessing individual preferences and agreeing 6 Manage information.

which inevitably will have an impact on the patients

A lack of research undertaken A lack of clarity on how to proceed

Example of a systemic review identifying a lack of evidence to inform nursing

on best evidence rather than habitual practice.

Further reading and resources

Introduction been heightened with reports of poor nursing care

Table 2.1 A good life for me

Item Because a good life for me involves Therefore I value

We started this section by observing that our

by the institution providing your course, and will

integrity: acting in accordance with accepted

Case study 2.2: Chloe Arnold

Anorexia is a lifestyle not a disease.

The above activity may have helped you to begin

you draw on the knowledge developed during your

Appendix and ensuring minimal restrictions on their

Further reading and resources

Introduction this chapter is that as a student nurse you have

The policy context is clearly focused on the

health professionals. It is imperative that we work efficient;

Box 3.1 Inquiries into poor care

CHILDREN AND YOUNG PEOPLE

MENTAL HEALTH AND ADULT

Box 3.2 Illustration of poor practice

‘Excellent surgical team let down badly by some’

‘Concerned about poor communication and patient care’

‘Very, very bad’

‘Compassion is sometimes lacking’