Crisis situations are common in the care of acutely and critically ill patients. A psychiatric crisis calls for de-escalation strategies, security personnel, sedation, and restraints. During a crisis, in addition to providing direct care in response to the patient’s urgent physiological needs for intervention, the nurse must also prepare, orchestrate, and coordinate multiple aspects of the environment. Acute and critical care environments are generally set up at all times for a possible emergency. Experiential leadership is seeing what needs to or must be done before or during a crisis and doing it, even though a physician is present. Recognizing clinical talent and marshaling skilled clinicians requires astute clinical judgment and skill and is a pervasive aspect of caring for critically ill patients in crisis. An aspect of skilled know-how required for smooth management of a crisis is modulating one’s emotional responses to assist others in their ability to function well.
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This chapter describes the work of creating a communicative context for everyday clinical problem solving and teamwork and point out areas of clinical judgment that are inherently ambiguous and therefore difficult to communicate to others. Learning to effectively communicate clinical interpretations to others requires thinking-in-action and the ability to name subtle changes that point to transitions in the patient’s condition. Changing patient care management practices that alter patient responses and trajectories necessarily create the need for developing new clinical knowledge and judgment skills in new contexts. Critical care is a locus of the development of experimental interventions, such as minimally invasive surgeries, fast-tracking, new immunosuppression therapies in transplant recipients, and thrombolytic therapy after cerebral vascular accidents. Members of the health care team are expected to maintain professional relationships by demonstrating communication and interpersonal skills that show respect for patients, families and health care team members.
This chapter presents some of the educational strategies and implications of integrative teaching and learning. It describes two major types of integrative strategies that follow the logic of practice. First, multiple examples of how to coach situated learning in actual practice that have proven successful in developing embodied knowledge and skillful, intelligent performance, are detailed. Second, a Thinking-In-Action approach to integrating classroom with clinical teaching exemplifies how to teach learners to use extensive scientific, technological, and theoretical knowledge in the context of an unfolding patient situation that changes over time, while imaginatively responding to the patient’s multiple needs and other demands in the situation. In order to be effective clinicians, the student and developing nurse must progress to grasping the nature of whole clinical situations, developing an experience-based sense of salience and using multiple frames of reference that encompass patient and family-focused care.
- Go to chapter: Clinical Imagination and Clinical Forethought: Anticipating and Preventing Potential Problems
Clinical forethought refers to the habits of thought that allow clinicians to anticipate likely clinical eventualities and to take the actions warranted. Clinical forethought requires prior experiential learning with similar patient care situations. It also requires clinical imagination. Effective clinical forethought requires the best scientific understandings of a particular patient problem and clinical wisdom gained through experience. Learning to think-in-action in any practice medicine, law, nursing, teaching, or social work is based on learning prototypical situations and then filling out these prototypes with actual clinical experience so that the prototypical cases become more nuanced and particularized in specific patient encounters. The nurse with a good map of the patient’s vulnerabilities, such as co-morbid conditions like diabetes, is in a better position to locate the risks and thereby anticipate and prevent problems for particular patients.
Sleep disorders are common in both children and adults. Untreated sleep disturbances pose significant, adverse daytime consequences and place individuals at considerable risk for adverse health outcomes. Nurses are well positioned to assess and intervene with sleep disorders because they care for people across all cultures, age groups, and health conditions in community and clinical settings. There is widespread agreement among clinical and research experts that sleep assessment should be an integral component of all health assessment, with the specific focus and scope dependent on the situation. This chapter familiarizes nurses with evidence-based approaches to the assessment of sleep. It addresses the basic components of sleep assessment for children and adults, including obtaining sleep-related history, detailed sleep evaluation, and physical examination. The chapter includes information on self-report and objective sleep measurement and resources on sleep assessment for nurses, patients, and their families.
This chapter explores various ethical issues that addressing religiosity in patient care can create for nurses. To provide ethical care, nurses must appreciate the power difference in the nurse-patient relationship. Because the patient is inherently in a vulnerable position, the nurse should only share personal religious beliefs and practices if the patient initiates a request for it. Nurses must remember that their role is not one of clergy or chaplain. While it may be ethical and therapeutic to share a personal religious belief or practice when a patient requests it, it is not the nurse’s role to provide religious education, encourage conversion, or challenge the efficacy of one’s religious experience. Rather, nurses must be consummately respectful and sensitive when discussing religious matters with a patient.
David C. Pate learned about nurses as leaders from an early experience as a volunteer in a busy surgical intensive care unit. The professional status imbalance between medicine and nursing is often learned in medical and nursing education, and certainly often is dominant in the clinical arenas. One of Pate’s most important messages is the potential for nursing leadership in health care delivery in the future. The chief nursing officer (CNO) was an integral part of the team expected to be able to explain the vision, inspire the employees to achieve their goals, demonstrate accountability, participate in setting the strategies, and engage in their team meetings whether the subject involved patient care or not. The CNO/nurse executive will be critical in redesigning the health care delivery system of the future. Nurses and nurse leaders can and must lead this change in the care model together with physicians and other providers.
Steven A. Wartman, the author, provides key advice for potential and aspiring nurse leaders. He advises to let go of the guild mentality, particularly important for nurses who aspire to leadership positions that transcend nursing. Nurse’s perspectives are invaluable in bridging the gap between the technical experience of health care and its meaning in the lives of patients and their families. Nurse leaders are advised to become transformational rather than transactional leaders, and to move beyond the rewards and punishments inherent in transactional leadership styles. Transformational leadership is especially challenging, given the traditional hierarchies in the medical fields and academia. To provide the most effective and “transformational” leadership, potential nurse leaders should focus their efforts on four areas: eliminate the “guild mentality”; change restrictive policies and regulations that weaken the role of nursing; seek to become a “transformational” leader; and learn to take the ego out of the job.
The author, Martin Alpert, presents a method by which individual nurses can be independent, improve patient care, have fun, and earn more money. He proposes that the nursing profession become the leader in a shift to sustainable, least invasive therapies and evaluations (LITE). LITE represents a major profit opportunity for nurses. Many of these new therapies require medical professionals, but not necessarily doctors. They can be administered by dedicated and trained nurses. The impact of LITE on the global society of nursing leading this area of medicine could be transformational for nursing, medicine, and society. Nursing could lead in diagnosis and treatment under the LITE paradigm. Acupuncture is becoming part of conventional therapy. It can be a part of nursing practice. Recently, the World Health Organization estimated that 80” of people worldwide rely on herbal medicines for some part of their primary health care.
Interprofessional education (IPE) and collaborative practice are increasingly called upon to improve these domains such as patient care, community health, health care delivery systems respective and overlapping spheres of activity with the larger goal of improving the overall health care system. Nurse leaders are moving the interprofessional collaboration agenda forward by serving in key leadership positions nationally and on local campuses. Nurse leaders, through a combination of their training, professional experiences, and personal preferences, have unique knowledge and skills for which they are enthusiastic champions. Effective leaders apply principles of good communication in their work with individuals and groups. Nurse leaders possess valuable professional knowledge and skills, and when coupled with individual talents and strengths, they offer important assets to the success of a collaborative effort. Nurse leaders should recognize how they can best capitalize on their leadership abilities and confidently apply them.