Empowerment and Leadership Processes

Burnout, well-being, mindfulness, job satisfaction, staff turnover, stress and work-life balance seem to be common discussion threads in healthcare, and in particular the critical care environments. The multi-modal issues identified mean we have provided a suite of resources that look at the leadership and process elements to support the work environment and also the all important team members.  Quality care can then be delivered from an effective, well resourced and supported team.

Leadership Process To Support The Environment    

Supporting Articles 

Dorman, T. (2017) From Command and Control to Modern Approaches to Leadership. ICU Management & Practice, 17 (3).

Guille C, Frank E, Zhao Z, Kalmbach DA, Nietert PJ, Mata DA, Sen S. (2017) Work-Family Conflict and the Sex Difference in Depression Among Training PhysiciansJAMA Intern Med. doi:10.1001/jamainternmed.2017.5138

Institute for Health Improvement (IHI). (2017) ICU Daily Goals Worksheet. http://www.IHI.org

Moneke, N., & Umeh, O. J. (2013). How leadership behaviors impact critical care nurse job satisfactionNursing Management. 44(1), 53-55.

Reader, T. W., & Cuthbertson, B. H. (2011). Teamwork and team training in the ICU: Where do the similarities with aviation end?Critical care15(6), 313.

van Schijndel, R. J. S., & Burchardi, H. (2007). Bench-to-bedside review: Leadership and conflict management in the intensive care unitCritical care11(6), 234.

Wiseman L (2010) Multipliers: how the best leaders make everyone smarter. New York: Harper Collins.

Wong, A. V. K., & Olusanya, O. (2017). Burnout and resilience in anaesthesia and intensive care medicineBJA Education.


Clinical Reasoning Cycle

Book Club: Levett-Jones, T. (Ed.). (2013). Clinical reasoning: Learning to think like a nurse. Pearson Australia.

Clinical Reasoning Cycle

Define reasoning as “the process by which nurses (and other clinicians) collect cues, process the information, come to an understanding of a patient problem or situation, plan and implement interventions, evaluate outcomes, and reflect on and learn from the process”.

“Clinical reasoning is often confused with the terms ‘clinical judgement’, ‘problem solving’, decision making’ and ‘critical thinking’. While in some ways these terms are similar to critical reasoning, clinical reasoning is a cyclical process that often leads to a series or spiral of linked clinical encounters” (pg.4 Levett-Jones, 2013).

Stages of the Clinical Reasoning Cycle

  1. Consider the patient
  2. Collect cues/information
  3. Process information
  4. Identify problems/issues
  5. Establish goals
  6. Take action
  7. Evaluate outcomes
  8. Reflect on process and new learning

Why is this book important?

For nurse training and education delivery, the stages of clinical reasoning can be incorporated into training sessions to discuss the clinical judgments and decision making during a care intervention and applying the ‘nursing process’.  Simulated nursing environments are an ideal educational approach to challenge clinical decision making and clinical reasoning skills. Nurses are the constant presence on the ward level, providing the monitoring and making judgments form the clinical reasoning encounters every shift over a patients hospital journey. Responding to complex and time critical events requires sophisticated abilities which expand further than pure theoretical knowledge, such as assessing and responding to clinical deterioration.

In the current economic drive for cost cutting measures across healthcare (nurses make up the majority of the healthcare workforce, so are often seen as a costly element), the drive to replace with lower skilled, trainees and eventually robots are factors for the nursing profession to consider. Nurses need to be able to understand and explain the role they play and have a voice to raise the profile of what it entails to be a nurse and the efficacy of such skills to maintain levels of care and safety.


Thinking on the go and decision making are skills to develop over time and with experience but need to be incorporated into nurse training. Nurses with effective clinical reasoning skills have a positive impact on patient outcomes (School of Nursing and Midwifery Faculty of Health, 2009). It’s important to remember, during all this consideration of the patient and reflective process that you (the nurse) are human and as such wont get everything correct all the time.


Levett-Jones, T. (Ed.). (2013). Clinical reasoning: Learning to think like a nurse. Pearson Australia.

Alfaro-LeFevre, R. (2015). Critical Thinking, Clinical Reasoning, and Clinical Judgment E-Book: A Practical Approach. Elsevier Health Sciences.

Interprofessional Ambulatory Care Unit. Clinical Reasoning User Manual. Edith Cowan University.

School of Nursing and Midwifery Faculty of Health (2009) Clinical Reasoning Instructor Resources. University of Newcastle.

The Underbelly of Research: Delving Deeper

There is a murky side to publication that can really push the boundaries of ethics and the integrity of how we may portray research and evidence based practice. As nurses we are trained to critique an article and question the quality, merits and transferability of the result findings. Now if you think your skilled at critiquing an article, think again and listen to this enlightening talk by Simon Finfer (Intensivist) on The Light & Dark Side of Research & Publication.

Take a read of Boldt: The great pretender which outlines one of the biggest research scandals of recent times about an internationally renowned researcher and the impact on the colloid versus crystalloid fluid debate.

Some terminology to delve further into from Elliott (2010):

  • Publication planning
  • Publish or perish
  • Ghost writing
  • Reprint revenue
  • Predatory journals
  • Predatory conferences
  • Medical Education & Communications Companies (MECC)
  • Medical Education Service Suppliers (MESS)



Colquhoun, D. (2011) Publish-or-perish: Peer review and the corruption of science. The Guardian.

Elliott, C. (2010). White coat, black hat: adventures on the dark side of medicine. Beacon Press [GoodReads Review]

Finfer, S. (2014) The Light & Dark Side of Research & Publication. Intensive Care Network.

Kolata, G. (2017) Many academics are eager to publish in worthless journals. The New York Times.

Parr, C. (2014) Imperial College professor Stefan Grimm ‘was given grant income target’. Times Higher Education.

Wise, J. (2013) Boldt: The great pretenderBMJ. 346:f1738.

Dunning-Kruger Effect

Journal Club Article: Kruger, J., & Dunning, D. (1999). Unskilled and unaware of it: how difficulties in recognizing one’s own incompetence lead to inflated self-assessmentsJournal of personality and social psychology77(6), 1121.

Dunning-Kruger effect

“In the field of psychology, the Dunning–Kruger effect is a cognitive bias wherein persons of low ability suffer from illusory superiority, mistakenly assessing their cognitive ability as greater than it is. The cognitive bias of illusory superiority derives from the metacognitive inability of low-ability persons to recognize their own ineptitude. Without the self-awareness of metacognition, low-ability people cannot objectively evaluate their actual competence or incompetence” (Wikipedia, 2017).

  • Over confidence and low self-awareness.
  • Compentency vs incompetence.
  • Doubt and low confidence.

“Incompetent individuals have more difficulty recognizing their true level of ability than do more competent individuals and that a lack of metacognitive skills may underlie this deficiency” (Kruger & Dunning, 1999.pg. 31).

Dunning-Kruger Study


Explored their predictions between competence, metacognitive ability, and inflated self-assessment.


Participants would overestimate their ability and performance.


  • 4 studies.
    • Humour: 30 item questionnaiare
    • Logical Reasoning: 20 item logical reasoning test
    • Grammar and Awareness
    • Competence: Group study tests.
  • Psychology undergraduates (earned credit for participation in the study).
  • Participants asked to assess their ability and test performance.


The participants with limited knowledge reach mistaken conclusions and make errors, this is coupled with an inability to recognise these limitations.

Limitations of the Study

Small numbers of participants.  Not across a variety of professions, also undergraduate setting.

The authors recognise the limits of the testing method, and subsequently could a fault lie in the logic or methodology of the testing and thus provided incorrect results.

Relevance in Healthcare

Take a read and listen to this by PHARM: Prehospital and Retrieval Medicine (2017) and the great discussion points about the difficulty of competency in rare event situations. The considerations in education when discussing skills or best practice, not everyone is working in a big city hospital with support teams, technology and resources. Healthcare is delivered across the world in varied resource settings by individuals or teams and so it’s very easy to become judgmental when looking at care- it all goes way deeper into the wider healthcare landscape than just looking at the individuals metacognitive ability.

Keywords: Cognitive; feedback; metacognitive competence; skilled; unskilled; training; education.


Kruger, J., & Dunning, D. (1999). Unskilled and unaware of it: how difficulties in recognizing one’s own incompetence lead to inflated self-assessmentsJournal of personality and social psychology77(6), 1121.

Nursing Education Network (2016) Johari Window and Feedback.

PHARM: Prehospital and Retrieval Medicine (2017) Needle vs knife the view from the bottom of Mount Stunning Trueger.

Staub, S., & Kaynak, R. (2014). Is an Unskilled Really Unaware of it?Procedia-Social and Behavioral Sciences150, 899-907.

Wikipedia (2017) Dunning-Kruger effect.


Diffusion of Innovations by Everett Rogers (Book Club)

Book Club: Rogers, E. M. (1995) Diffusion of innovations. (5th ed.) Simon and Schuster, New York, USA. [summary article]

What is Diffusion?

“Diffusion is the process in which an innovation is communicated through certain channels over time among the members of an social system” (pg. 5).

What are Innovations

“An idea, practice, or object that is perceived as new to an individual or another unit of adoption” (pg. 137).


Innovation-Development Process

  1. Recognising a problem or need.
  2. Basic and applied research.
  3. Development- from idea into actual use.
  4. Commercialisation.
  5. Diffusion & adoption.
  6. Consequences of the innovation and adoption.

Diffusion of Innovations

4 main elements:

  1. The innovation.
  2. Communication through interpersonal networks and wider channels of communication.
  3. It takes time.
  4. Disseminates among the members of a social system.

The Adopters

Adopters within the social system do not take up the innovation at the same time. They adopt in an “over-time sequence”. Individuals can be classified into adopter categories of innovators, early adopters, early majority, late majority and laggards.

The S-shaped Diffusion Curve 

Diffusion of ideas

Early Adopters


Importance of Time

New ideas are difficult to adopt, from the time they become available to the time they become adopted. It is also difficult to measure adoption as this occurs over time, and trying to identify the why factors or causalities is part of this difficulty.

Drivers of Change

The importance of interpersonal networks in the adoption or rejection of an innovation. Opinion leaders can lead and influence others through their behaviour and actions to engage with the innovation.  Diffusion networks and the interpersonal communication aspects are vital drivers on the diffusion process. The role of champions, are the drivers who throw everything behind the innovation and support unflinchingly to increase uptake of a new idea.

The Role of the Change Agent

  1. To develop a need for change.
  2. To establish an information an information relationship.
  3. To diagnose problems.
  4. To create an intent to change in the client/organisations.
  5. To translate an intent into action.
  6. To stablise adoption and prevent discontinuance.
  7. To achieve a terminal relationship.

Relevance in Healthcare

The innovation to be successful must be client orientated (this is vital in healthcare for consumers to provide a experiential view). The book provides some great stories of successful and failed innovations. One theme that comes across in the failed stories is one of not understanding or considering local customs or practices, failing innovations due to a discordance with social behaviours, means adoption does not take place.

Not every innovation should be diffused and adopted, so a rigorous process (research) should be in place to prevent bad or low value innovations. Questions to ask of an innovation:

  1. What is the innovation?
  2. How does it work?
  3. Why does it work?


The diffusion of innovations provides a framework to engage in change, but the healthcare team still need to mindful to avoid bad innovations, especially wasting valuable time and resources (#culture). The innovation and change management perspective and the view of the early adopters and change agents can assist in developing ideas. Client orientated innovations must be considered, which links with human centred design philosophy. I was informed that this book would change my perspective on so many things and by page 10 I was hooked on the change process, the use of stories are used effectively to convey the important messages.

Thanks to the very knowledgeable Dr Kay Rolls (@Kay_Rolls) for the excellent book recommendation.


Rogers, E. M. (1995) Diffusion of innovations. (5th ed.) Simon and Schuster, New York, USA. [summary article]

Ross, P. (2017) Deimplementation of Practice. Nursing Education Network.

Ross, P. (2016) Human Centred Design. Nursing Education Network.


An Integrative Literature Review of Evidence-Based Teaching Strategies for Nurse Educators

Journal Club Article: Breytenbach, C., ten Ham-Baloyi, W., & Jordan, P. J. (2017). An Integrative Literature Review of Evidence-Based Teaching Strategies for Nurse Educators. Nursing Education Perspectives38(4), 193-197. [abstract]


Evidence-based teaching strategies in nursing education are fundamental to promote an in-depth understanding of information. The teaching strategies of nurse educators should be based on sound evidence or best practice.

“To teach these skills, knowledge, behaviors, and attitudes, nurse educators must utilize a variety of teaching strategies that actively engage their students (Billings & Halstead, 2012).

Students, who are increasingly skilled in technology, benefit from a diversity of teaching strategies based on their needs, including experiential and active learning (Samarakoon, Fernando, & Rodrigo, 2013).”

The principles of adult learning where the strategies encourage and allow ownership for one’s own learning.


Integrative literature review of sixteen studies.


Eight teaching strategies were identified:

  1. E-learning
  2. Concept mapping
  3. Internet-based learning (IBL)
  4. Web-based learning
  5. Gaming
  6. Problem-based learning (PBL)
  7. Case studies
  8. Evidence-based learning (EBL)

The following three strategies of concept mapping, IBL and EBL demonstrated the most increase in knowledge.

“Based on the findings from this review, the authors propose that multiple teaching strategies should be encouraged in a nursing curriculum to allow for the use of a set of strategies that are suitable for different learning styles and student needs.”

The authors recommend that nurse educators be trained to understand the different educational strategies and the benefits to learning that they offer to aid critical thinking, knowledge acquisition and decision making.


All teaching strategies enhanced the learning experience, but more research is needed. In summary a multi-modal approach to teaching and delivering content is required.

Keywords: Evidence-Based Teaching; integrative review; teaching; nurse educator.


Breytenbach, C., ten Ham-Baloyi, W., & Jordan, P. J. (2017). An Integrative Literature Review of Evidence-Based Teaching Strategies for Nurse Educators. Nursing Education Perspectives38(4), 193-197. [abstract]

Book Club: Daniel Goleman: Emotional Intelligence

Book Club: Goleman, D. (2006). Emotional Intelligence. Bantam. [Goodreads blurb]

Phew, this was a tough read for me, maybe a sign of my own emotional intelligence! I have decided not to add my notes and comments, instead provide some links to reviews that may expand on the theory discussed by Daniel Goleman and inspire you, like so many have been by this author. I have had to admit defeat on this one and say it didn’t bring many new ideas or inspiration for me, but will return to read again in the future.

“If your emotional abilities aren’t in hand, if you don’t have self-awareness, if you are not able to manage your distressing emotions, if you can’t have empathy and have effective relationships, then no matter how smart you are, you are not going to get very far” (Daniel Goleman).

“True compassion means not only feeling another’s pain but also being moved to help relieve it” (Daniel Goleman).

More quotes from Daniel Goleman

Follow Daniel Goleman on social media:


Keywords: EI; Emotional Intelligence; Self control; Empathy; Alexithymia.


Goleman, D. (1998). Working with emotional intelligence. Bantam.