As a nurse, you are already familiar with aspects of decision-making. You engage in decision-making within daily practice through the use of critical thinking and clinical judgment. As a baccalaureate-prepared nurse, the level of decision-making deepens. Decision-making involves not only identifying a problem but also mapping out several complex pieces within the problem. The map might be straightforward, but it often consists of multiple options leading in multiple directions.  Even though different decisions might be made, the plan to solve the problem may lead to similar outcomes or dead ends. Carefully mapping out a problem and utilizing critical thinking, clinical judgment, and problem-solving can help navigate the nurse through the best possible path for that given situation. Decision-making not only consists of finding a solution but also identifying the root of the problem. The nurse utilizes the nursing process to explore all possibilities that may have contributed to the problem and to strategize to prevent it from reoccurring. An example might be doing a post-fall huddle on an inpatient unit (i.e., after addressing the needs of the patient and ensuring the patient is safe, the team comes together to discuss ways to prevent the patient’s fall in the future along with identifying what went well and could be improved).

There are several ways for a nurse to strengthen their decision-making skills through the following activities: case studies, simulation, and problem-based learning. The Marquis-Huston Model for Teaching Critical Thinking facilitates effective decision-making skills among nurse leaders (Marquis & Huston, 2021). The model discusses four categories that are necessary for nurses to elevate their decision-making skills to those of leadership and management. The four categories include didactic theory, personalized learning, problem-solving, and group process. Each of these categories can be easily translated to your leadership and management course within the RN to BSN completion program.

There are many more theoretical models that guide nurse leaders in the decision-making process, all of which fundamentally contain the nursing process.

Decision-making occurs in several aspects of nursing practice. While determining an action, one must consider the ethical aspects, the role of communication, whether it warrants delegation or supervision, and what type of leadership is involved. Each of these pieces will be discussed in greater detail.

Ethical Considerations

Nurses are positioned to promote a culture and environment that embodies healthy, positive, ethically moral, and holistic behaviors among others in the healthcare arena. It is not only pivotal that nurses identify behaviors that are concerning but role model behaviors that are acceptable in practice. By evaluating ethical considerations within practice, the nurse is engaging in authentic leadership. Authentic nurse leaders are able to self-assess, identify who they are as a nurse and person, and remain true to their values and beliefs in practice (Giordano-Mulligan & Eckardt, 2019). To remain ethically sound, the nurse must possess characteristics of trust, satisfaction, organizational commitment, performance, and a sense of community with fellow team members. Nurses not only role model ethical standards but also are able to discuss these standards with their peers and fellow healthcare professionals. 

By emulating authentic leadership, nurses are seen as positive role models, honest, and actively engaged (Giordano-Mulligan & Eckardt, 2019). Remaining true authentically and upholding ethics is important, but it is also essential to educate others on these attributes. As a nurse leader, it is your role to prepare your team for potential ethical situations and how they might respond or handle these situations.

Role of Communication

Communication is essential in every aspect of nursing. Ineffective communication contributes to medical errors, decreased patient outcomes, and increased patient harm and deaths (Boerner, 2016; Starmer et al., 2014). Additionally, ineffective handoff communication leads to 80% of patient adverse events (The Joint Commission International, 2018). Nurses need to learn the tools to communicate effectively and how to demonstrate these tools in practice. These tools are used in every method of communicating: verbal and nonverbal, face-to-face, written, telephone, etc. Nurses communicate with many different people, including members of the healthcare team and patients and their family members. The delivery of communication is as important as the information that is being relayed. The delivery plays a pivotal role in establishing a rapport with others.

Delegation vs. Supervision

Nurses make use of both delegation and supervision regularly in practice. As a practicing nurse, you are more than likely familiar with both skills. Do you feel comfortable and competent when delegating to and supervising others? Do you feel ready to delegate to peers and be a nurse leader? If not, it is okay. Let’s elevate your delegation and supervision skills.

Delegation can be defined in various ways. The American Nurses Association (2012) states that delegation involves assigning tasks to others while holding accountability for the outcome. Ultimately, you are still responsible for what happens. The five rights of delegation must be considered when assigning a task: right task, right circumstance, right person, right direction/communication, and right level of supervision. Nurse leaders may also delegate to those they lead, whether in the capacity of charge nurse, supervisor, manager, or another role. Delegating allows the nurse leader to address more complex and higher-level tasks within the scope of the job. For instance, a nurse leader may delegate post-fall chart audits to a nurse who is experienced with post-fall investigations.

Supervision involves observing and watching others while they are performing tasks. This may occur to determine the individual’s level of comprehension and competency, such as during orientation, skills check-off, and rollout of new practices. Supervision may be required when there are concerns over one’s ability to carry out certain aspects of their role.

Leadership can take on many different forms. It can be in formal roles such as charge nurse, nurse manager, director of nursing, etc. It can also take on informal roles; all nurses possess some level of leadership. The amount of leadership a nurse exhibits can be based on several factors such as degree, experience, and intrinsic and extrinsic motivators. The ANA’s Nursing: Scope and Standards of Practice (2021) outlines in Standard 12 that leadership consists of 10 competencies that a nurse should possess regarding leadership. These standards provide the framework in which nursing practice provides quality patient care. As a BSN-prepared nurse, it is important to demonstrate each of the competencies in order to be able to support other nurses in developing their own nursing practice.

These competencies promote leadership and encourage nurses to initiate various actions such as leading change, mentoring, appropriately delegating, engaging in professional activities and organizations, etc. (ANA, 2021). Our discussion regarding informal leadership will focus on three areas: taking the lead, role modeling, and accountability.

Taking the Lead

Taking the lead can occur in many ways. Nurses can take the lead by identifying issues or concerns and proposing ways to make improvements to address those issues. Likewise, nurses can take the lead in providing recognition to fellow nurses and healthcare professionals. Recognizing staff for doing a job well done, especially during a difficult or challenging situation helps establish comradery and sets the tone for the team. Another way can be by volunteering for new and challenging situations. Taking the lead can also mean doing what is right when others are not (such as following a new policy that was just implemented even if you’re resistant to it).

Role Modeling

Taking the lead can look much like role modeling. In many instances, they are one and the same. As a leader, a nurse must role model desired behaviors and actions for the team, especially when situations are challenging and morale might be low. As nurse leader, you may also be role modeling what it looks like to be a leader both informally and formally. Whether you realize it or not, there are members of your team who are looking to you to set an example they can learn from. These team members might be the new nurse who is trying to find their way, a CNA who is unsure of some of the tasks delegated to them, the social worker who is nervous to engage in difficult conversations, etc. Other areas in which nurses can model behaviors include promoting a culture of diversity, equity, and inclusion (National Academy of Sciences, 2021).

Accountability

As nurses, we are responsible and accountable for many things. Taking ownership of what we are responsible for is a characteristic of a nurse leader. Accountability involves taking ownership of the consequences of one’s actions. These actions could be a lack of action as well. One can take ownership for consequences that have both positive and negative outcomes. It is important that nurses and leaders exemplify accountability in their profession. An example of this may be acknowledging medical errors that occur whether the error solely lies upon oneself or involves multiple members of the healthcare team. In this case, you should not only acknowledge the error but take it to the next step by completing a report as outlined by your facility’s policies and procedures.

Creating relationships is an important and natural part of any job. It is equally important to determine the type of relationship. Role modeling the type of professional relationship one has with team members, patients, and family members is very important as well. As a baccalaureate-prepared nurse and leader, there are other ways to build relationships that will enhance your role as a nurse leader. A few examples include mentoring, precepting, and networking. As a mentor and preceptor, you are recognized by others for your leadership, experience, and practice as a nurse.

Mentoring and precepting are often perceived as one and the same. There are both similarities and differences between the two. Both have an individual who takes on the role of the more experienced and knowledgeable nurse who provides guidance to a less experienced and knowledgeable nurse.

Mentoring

The mentor tends to be a nurse who has been asked by the mentee to volunteer as a mentor. The mentor establishes a relationship with the mentee who tends to have less experience. The relationship of the mentor and mentee oftentimes is reciprocal in nature, as both individuals may benefit from mentoring. The relationship between the two may also last much longer than that with a preceptor.

Precepting

A preceptor may possess similar characteristics as a mentor but are assigned to new nurses or nurses of lesser experience to orient and acclimate the preceptee to the role and work environment. Some facilities may require preceptors to take a formal course on being a preceptor as a prerequisite. The preceptor and preceptee work one-on-one for a specified period. Something to consider once you have completed your BSN is to be a preceptor for other ADNs pursuing their bachelor’s degrees.

Role of Mentor and Preceptor

Both roles of mentor and preceptor can be something that you as a nurse may take on, but there may be times when you are also in the role of mentee and preceptee. You may remember being a preceptee as a new graduate nurse, starting a new job, and in your clinical capstone course. You may want to consider whether in the future being a preceptor would be a good stepping-stone as a leader in your department. Discuss with your manager or direct leader what steps would be involved in taking on this role. Likewise, you may also find yourself in the position of mentor or mentee. As a more experienced nurse, you might be asked to guide less experienced nurses on their journey as a mentor or coach. Additionally, as a new baccalaureate-prepared nurse, you may be seeking out the next steps in your professional journey and might want to have a mentor.

Selecting your own mentor is equally as important as being a mentor. You might select a mentor for a specific growth and development opportunity, or you might select an individual you find to be a role model. Consider someone that embodies the characteristics and role that you wish you possess. For instance, if you want to elevate your leadership skills, you may seek a mentor who exhibits exemplary qualities of a leader. Additionally, you may also want to consider the role or title of the potential mentor. For example, if you are looking to become a nurse educator, perhaps you connect with someone in this role.

Networking

Another way to establish relationships within nursing and the healthcare professional arena is through networking. Networking can occur organically or deliberately in nature. For instance, networking might naturally occur through your workplace or relationships established through nursing school. More intentional ways to network might be through social media platforms, professional nursing organizations, and participation in committees at the workplace. As discussed in Chapter 2, professional organizations offer a multitude of benefits not only regarding certifications and professional development but also the ability to network with fellow nurses on a given specialty, topic, or cause. You may be drawn to one or more professional organizations depending on your interests; you might choose one for professional development and another for networking. You have the opportunity to carry out interactions that fit your needs.

Collaboration is an instrumental part of providing safe, quality patient care. It occurs among two or more individuals, such as nurses, healthcare professionals, and patients. The Institute of Medicine (IOM) created a series of reports that illustrate the importance of collaboration, including To Err is Human Building a Safer Health System (2000), Crossing the Quality Chasm: A New Health System for the 21st Century (1999), and The Bridge to Quality: Health Professions Education (2001). These reports have been a driving force in nursing, healthcare, and educational settings. Additionally, collaboration occurs in the forms of communication and coordination of care.

Interprofessional collaboration encompasses collaboration, communication, and coordination of care (Foronda, MacWilliams, & McArthur, 2016). It is a patient-centered approach inclusive of key healthcare professionals, patients, and families as equal contributors to the plan of care (Golom & Schreck, 2018). The team creates an environment that promotes shared decision-making consisting of collegiality, respect, trust, and support (Rose, 2011). By forming an interprofessional team, this approach allows for efficient collaboration and communication leading to improved patient safety and outcomes. It is important for the nurse to lead or guide interprofessional efforts because the nurse is often the most familiar with the patient and can readily advocate for the patient’s needs. As a baccalaureate-prepared nurse, you are equipped with knowledge from the National Academy of Medicine (NAM) and the ANA’s Scope and Standards of Practice, which articulate the following competencies for healthcare professionals: patient-centered care, interprofessional teamwork, evidence-based practice, quality improvement, and informatics (Institute of Medicine, 2010). The primary nurse can help foster effective teamwork among the interprofessional team by identifying purpose, establishing social rapport, fostering a supportive environment, and leading collaboration (Smith et al., 2018).

Interprofessional collaboration can take on many forms. It should ideally be integrated into the education of healthcare professionals. However, in practice, it should be performed with handoff communication, whether a bedside report or providing updates on patient status to another healthcare professional. Handoff communication should include not only the key healthcare professionals but also the patient and their family. Interprofessional rounding is another way that healthcare professionals and patients can engage in collaboration. Interprofessional rounding brings the team together for daily rounds on patients to discuss patient status, needs, and goals (Verhaegh et al., 2017). Another type of collaboration is interprofessional bedside rounding, where the healthcare team goes to the patient bedside to discuss patient status, needs, and goals. The rounds consist of a standardized communication tool to ensure all disciplines are contributing to the shared decision-making process (Henkin et al., 2016).