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Nurses As Leaders Helen N Turner, DNP, RN-BC, PCNS-BC, FAAN Clinical Nurse Specialist, Pediatric Pain Management President, American Society for Pain Management Nursing turnerh@ohsu.edu

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Leaders Fidel Castro Che Guevara Alexander, The Great Asoka Winston Churchill Julius Caesar Franklin D Roosevelt Napoleon Bonaparte George Washington Adolf Hitler Mao Zedong Abraham Lincoln Martin Luther King Nelson Mandela Mahatma Gandhi Others??

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What is Leadership? Action of leading a group of people or organization State or position of being a leader Process of social influence Maximizes efforts of others Towards achievement of a goal

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Leadership is NOT Single style Static Management The style of leadership is dependent upon the prevailing circumstance Leaders exercise a range of management styles and deploy them as appropriate. (Robert Tannenbaum, R. & Schmidt, W.H., 1958, 1973)

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What is Management? Characteristic ways of making decisions and relating to subordinates. Styles Autocratic Permissive Paternalistic Democratic

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Management is NOT Single style Static Leadership

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Management Vs Leadership Manager's job is to plan, organize and coordinate; leader's job is to inspire and motivate Manager administers; leader innovates Manager is a copy; leader is an original Manager maintains; leader develops Manager focuses on systems and structure; leader focuses on people Manager relies on control; leader inspires trust (Warren Bennis, 1989)

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Management Vs Leadership Manager has a short-range view; leader has a long-range perspective Manager asks how and when; leader asks what and why Manager has his or her eye always on bottom line; leaders eye is on horizon Manager imitates; leader originates Manager accepts status quo; leader challenges it Manager is the classic good soldier; leader is his or her own person Manager does things right; leader does the right thing (Warren Bennis, 1989)

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What is Ethics? Systematic way to form value judgments on human actions Is organized and reflective Is NOT intuitive or based on gut feeling Principles of right conduct within a social system Critical concept: We make judgments all the time What results from these judgments?

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Ethics is NOT Morals Principles/habits related to right or wrong conduct Personal, subjective, more abstract Values Beliefs in which there is emotional investment Rules by which we decide between right/wrong, good/bad, should/shouldnt

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Healthcare Ethics Bioethics Clinical ethics In clinical care settings Ethics of the encounter between clinician and patient Research ethics Organizational ethics

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Guiding Constructs of Ethics Beneficence Nonmaleficence Autonomy Justice Fidelity Veracity View from 30,000 feet

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Beneficence Act for the patients benefit Relieve pain and suffering Keep society safe

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Nonmaleficence Do no harm Stopping a medication shown to be harmful Refusing to provide a treatment that has not been shown to be effective Increased opioid prescriptions = increased opioids on the street An decision is required To act or not Doing nothing may cause harm

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Autonomy Individual right to decide Pain may impair autonomy Assumption of incompetence maybe a violation Accepting or rejecting care or components of care Opioids only We do not always agree with patients decision Ritualistic mutilation

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Justice Equitable Access to care Resource utilization Discrimination Societal impact (abuse, misuse, death)

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Fidelity Faithfulness to obligations, duties, observances Loyalty to patients interests Fidelity by Briton Riviere

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Veracity Truth telling Trusting Truth by Bernini

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What is Conflict? Opposition Inherent incompatibility Internal or external

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Patient-centric Conflict Poorly controlled pain Conflict with patient/family Concerns about addiction/misuse Questioning patients experience/knowledge Determining competence Competence Vs capacity

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Clinician-centric Conflict Balancing beneficence and nonmaleficence Benefits of action Vs risks of action (or inaction!) Interprofessional conflict To prescribe or not Systems barriers

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Areas of Potential Conflict Pain management agreements Do patient rights supersede societal rights Multidisciplinary treatment Vs Interventional Managing pain Vs measuring disability Conflicting guidelines Direct to patient marketing

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Ethical Conflict Leads to Moral Distress HOWEVER,

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Moral Distress Unethical

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What Is Moral Distress? Feelings of frustration, anger, and anxiety when facing institutional obstacles and interpersonal conflicts about ones values Unruh, 2010

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Impact on Patient Care Safety Quality

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Living with moral distress does harm!!

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Recognizing Moral Distress Responses to moral distress Physical Emotional Behavioral Spiritual

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Physical Cues Fatigue Headaches Impaired sleep Lethargy Nausea Indigestion Heartburn

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Emotional Cues Anger Fear Guilt Sorrow Anxiety Grief

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Behavioral Cues Apathy Indifference Avoidance Agitation Hostility

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Spiritual Cues Loss of meaning Loss of control Crisis of faith

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Moral distress leads to professional burnout!

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Recognize Moral Distress American Association of Critical Care Nurses: The 4As to Rise Above Moral Distress.

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ASK Am I feeling distressed or showing signs of suffering? GOAL: Become aware of moral distress

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AFFIRM Your distress, your commitment to take care of yourself, and your professional responsibility to act GOAL: Make commitment to deal with your distress

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ASSESS Identify source of your distress, determine the severity of the situation, and contemplate your readiness to act GOAL: Ready to make an action plan

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ACT Prepare to act or not, take action, and maintain desired change or accept the outcome GOAL: Preservation of integrity and authenticity

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From Distress to Courage

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Intervene Reflect Support Communicate Self care

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What Is Moral Courage? The willingness to stand up for and act according to ones ethical beliefs Lachman et al, 2012 It is a virtue Morally courageous professionals persevere to stand up for what is right even if it means they do so alone.

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Developing Moral Courage Personal Professional Organizational Links of Courage by Larry Poncho

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Personal Attributes Awareness of own beliefs and values Take time for reflectionChoice Vs Judgment Support Strong skills in effective communication and advocacy Advance your moral reasoning Nurture your personal ethic of care

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Professional Attributes Debriefingpeer support Developing supportive environment Building consensus Promoting interprofessional collaboration Enhancing professional and cultural competence

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Professional Attributes Follow a professional model of nursing care that exemplifies nursings goal of enhancing lives of patients & colleagues Positively influence outcomes that support rather than oppose moral decision making Safety Quality

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Organizational Attributes Administrative support of moral courage Open communication at all levels Policies and procedures supporting ethical practice Staff empowerment and protection Healthy work environment Interdisciplinary engagementJust Culture Review Education Monitoring

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Applying Ethics In Management and Leadership

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Managing During Conflict Accept the inevitability of conflictit is part of life Dont be a conflict-avoiderit wont disappear, it will only get worse Stay calm Even when provoked, keep a close hold on your emotions Maintain the ethical high ground Dont think in terms of winning, so much as constructively resolving and moving forward It isnt easy A consistent, rational approach to managing conflict will make things less stressful Victor Lipman

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Leading During Conflict Find the opportunity in conflict Be a "Mediator" who works for the good of all using: Integral vision (the ability to see every point of view) Systems thinking (how parts of a conflict relate to each other) Presence and inquiry to gather necessary facts Conscious conversation (foundation for dialogue) how we speak to each other and how we listen Bridging (building alliances to enable innovative solutions) Innovations (bursts of creativity leading to new ways of negotiating) Mark Gerzon

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Be a Morally Courageous Leader! !

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Thank You for Your Attention Questions?