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Case Presentation

This case is a model case, told from the perspective of a staff nurse that illustrates clinical leadership by a staff nurse.

We had a very long-term patient in our medical/surgical ICU who was with us from early October until January 1 when he died. He had amyotrophic lateral sclerosis and a very aggressive, untreatable cancer, but he and his family were not willing to accept his diagnosis, thus kept him as a full code. His mind was intact until the last few days when he developed renal failure.

His wife was very difficult, constantly criticizing our care, constantly "checking him over," looking for a sheet crease or something to pin his deterioration on. She was so difficult that most nurses gave up trying to even talk to her.

I spoke with my manager, who challenged me to understand her and to have her understand us and his prognosis. I remember telling my manager that I didn't need any more challenges, but I ended up taking it on! I spoke with all his doctors (even those who had "checked off" the case to understand their position[s]), used the social services and case management teams of nurses/social workers. I finally spoke with him alone to see what his end of life decision(s) were and then I spoke with her alone. He and she both wanted to maintain the Full Code status, so then we discussed his probable course. It took many conferences with her but she came to trust me and eventually called me "his favorite nurse." It taught me that patience is crucial and that was nothing I thought I had in my arsenal!

His room had a small window, but he hadn't been outside in many months other than his transfer from the ambulance from his rehab center to our hospital in October. The respiratory therapist and I decided to take him outside for some sun. We cleared it with the doctors, the charge nurse, and finally with the patient. He was terrified, and I explained we'd bag him while he was outside and then he could see the life outside. He agreed. It was a major undertaking, but he smiled in the slightly overcast day. We bundled him in warm blankets, and he was out there for about 15 minutes, with the wind blowing his hair, and he beamed. His wife was thrilled and asked if we could do it again, so we repeated the adventure the following day with her. That day was sunny, so we stayed out longer. We had four to five trips outside over the next 2 weeks.

His deterioration was substantial after Christmas; his code status was changed to No Code and she asked for a priest to come to give him a final blessing. Eventually, she agreed, on January 1, to take him outside, off the ventilator and allow him to go in peace in the sun where he had enjoyed some last pleasant days. It was a rainy day, but the sun came out for an hour and a half. He breathed for 45 minutes and had his family (real family and hospital family of RNs and "his" respiratory therapist, who had been with me on our first venture outside) around him when he finally passed away. It was one of the most beautiful experiences of my life and one I've learned a lot from!

 

Case Analysis

This RN showed her leadership in the following ways: She was a visible role model who demonstrated clinical competence and knowledge. She was an effective communicator, engaging other members of the interprofessional team, the patient, and the patient's family in making decisions about his care. Her care for the patient illustrated her professional values and use of ethical principles, particularly related to patient autonomy and dignity. Her actions illustrate how she functioned as a care coordinator and empowered, motivated, and opened others to new possibilities in caring for a difficult patient. In writing about this experience, she used reflection. This case also illustrates how a nurse manager can empower a staff nurse to become a clinical leader.

 

Answer the following question

How does this case study fit the definition of leadership as a concept presented in your text? Concepts for Nursing Practice by Jean Foret Giddens

Was the staff nurse acting as a formal or an informal leader?

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