Leadership and management in nursing

• Being the largest group of workers in the health system, nurses increasingly occupy management and leader positions in medical teams.

Health systems have undergone significant changes in recent years, and along with this, the role of nurses is changing as well. We must consider that nurses are the largest group of licensed health workers and hence their presence and participation are much more significant than that of doctors. Medical teams are increasingly coming to include personnel from different specialties, and they all must collaborate to achieve quality medical care for the patients. Nurses are present in almost all areas of medical practice, and many of them have assumed management positions. That is why current education programs for nurses include the development of leadership and management skills in students.

Leadership is considered a process that occurs in interpersonal relationships and tends to influence other people so that they reach their goals or those of the group to which they belong. Management, on the other hand, is based solely on the fulfillment of the tasks or goals assigned to an individual or group. Several theories help define leadership and management according to how the leader/manager accomplishes his functions. Among them we can distinguish the Charismatic based on the personal qualities of the leader, Quantum based on maintaining an adequate balance between tension and order, Relational founded on collaboration and teamwork, Servant based on the ability to serve others, Shared established on sharing responsibility among all group members, Transactional based on the principles of social exchange, and finally Transformational based on individual commitment to the group promoting changes that help reach the common goal.

Once defined the concepts of leadership and management and their bases of work, it is important to know that these people can assume different styles or ways to exert the leadership and management. These are the most significant:

• Autocratic: The leader or manager dominates the group and issues orders without listening to the suggestions of the group members. He is entirely focused and able to attend to all problems, make decisions, and maintain total control of the group.
• Democratic: The leader or manager allows the participation of all members and listens to their ideas. Decisions are made in consensus with the opinion of all members. It is also known as a participatory method and is closer to collective management as it is much less authoritarian.
• Laissez-faire: This type of leader is one who delegates all responsibility to the group, assuming an entirely passive attitude to problems. There is no guide or support to members, and it is the group who should make its own decisions.
• Situational: This style is a combination of all the above and is based on analyzing the specific circumstances surrounding the task and group to apply one or other of the methods described above.
• Bureaucratic: As the word implies, in this style decisions are made based on the procedures and policies defined by the organization. It comes from the belief that group members are motivated by external forces and that everything is already decided in advance by the agency.

Good leadership depends in no small extent on the leader's character and behavior. He must be an excellent communicator and a credible person by his subordinates, among whom he will promote a spirit of collaboration at all times. Must have critical thinking and be capable of detecting all the risks present in a particular situation, but at the same time must be a person who assumes those risks naturally and in correspondence initiate the actions needed at any time. All these qualities will allow him to persuade and influence the people he leads.

It is useless for a leader or manager to have an appropriate character and exert considerable influence in his group if his behavior is not capable of supporting those qualities. A good leader should always be visible and accessible to his subordinates, and he will treat them as individuals with their particular characteristics. His thinking should be critical regarding old problems for which he will try to look for new solutions. The leader should motivate his group to reach their goals by stimulating them and communicating the vision of the organization or company to which they belong. He should never fear to delegate responsibilities to other members, and this means promoting the participation of his employees in decision making, empowering them to fulfill their duties.

Perhaps the most crucial challenge a leader can face is to get his subordinates feel the group's mistakes as their own, but also the triumphs that they can achieve working as a team. It is not an easy task, but all of us who ever had the opportunity to work with a great leader, know that work will no longer be a burden when we are motivated and that proper management benefits both employees and the organization.

Phases that lead us to anxiety (13)

Anxiety is not something that appears suddenly. We go through a process of several stages that can end in an anxious state.                             

The four stages or phases that lead to a state of anxiety were classified by Dr. Albert Ellis (1913-2007) as A, B, C, D. Stage A is known as the activator. It is usually an adverse event that occurs in our lives which is capable of triggering the process. For example, a person that for specific reasons has not been able to perform well in his work that day begins to have thoughts such as not being able to achieve success in anything, being unable to perform his tasks, etc.

Stage B is known as the basis of our reasoning. Here the individual builds a series of negative arguments that will be in correspondence with the A phase or activator, and reinforce it. This stage is also known as of the catastrophic thoughts because all kinds of negative thoughts occur. Following the previous example, at this stage, the individual would draw hasty conclusions regarding his disability. Another example could be a young man who invites a girl out and is rejected by her. This is the activating fact; then he concludes that he is very unattractive, that he is not suitable for women, that he will never marry, and this kind of ideas that are nothing more than a distorted reflection of reality.

Stage C is the consequence of all the above and is considered as the result of the whole process that leads to the state of anxiety, sometimes even to depressive states. It is important to emphasize that the individual does not transit directly from stage A to stage C. It is not the adverse or activating fact what automatically produces the anxious state. It is stage B, where the negative conclusions are developed, which definitely leads us to the state of anxiety.

The state or phase D is the possibility we have of getting out of this process that leads to more anxiety. It is known as the deduction, and there, the individual should make an objective internal analysis of the situation and thus make a correct decision. This internal dialogue is essential because through it we can leave the state of anxiety or we can even avoid falling into it. It is our only weapon against the whole process because as we know, the use of pills and other means are only transitory outputs to the problem. The activating facts will always be there in our life, but the anxious individual will be waiting for conditions to arise to reproduce the process that leads to the state of anxiety.

We must not let ourselves be led by a failure in our life at any given time. No one is perfect, and everyone makes mistakes every day. The world and history are full of cases of famous people who had a life plagued by difficulties. Pasteur once was disapproved in an entrance examination to the university, and once there he was considered a mediocre student. Einstein was not accepted to attend a Mathematics course once. Edison was expelled from school on one occasion and considered by teachers to be a student impossible to educate. We could compile a long list of people who at some point in their lives had difficulties, and yet their perseverance was higher and in the long run, they achieved their goals.

The correct understanding of the process of anxiety, and knowing our reactions, is the best weapon we have for not to end up being our own victims. For us, as ordinary people, there is an important idea we can take from Dr. Ellis' legacy: There will always be adverse events in our lives wanting to trigger an anxious state, but they are not the cause, but our erroneous and catastrophic conclusions the ones who can lead us to anxiety. Luckily, there is a phase D, our common sense, which could avoid us all this suffering.

Understanding the relaxation process (12)

• Reprogramming our subconscious mind through relaxation is possible. It is necessary to understand what happens during this process to benefit from its regular practice.  

Our mind works on two different levels: the conscious and the subconscious. At the conscious level, we find everything that we notice in the external environment, that is, the direct contact with the world through our five senses. The subconscious level is responsible for directing other processes that we do not realize, such as digestion, heartbeat and other bodily activities of which we are not directly aware. On the other hand our subconscious mind stores all our past experiences, as well as the opinion we have of about ourselves.

In our previous post, we analyzed the different phases of sleep, those are called beta, alpha, gamma, and delta, according to the frequency of the electrical impulses emitted by the brain. Of these, the alpha level is an intermediate state between wakefulness and sleep (beta and gamma). When we perform the relaxation exercise, we place ourselves at the alpha level, and it is at that level that we make contact with the subconscious mind. We open a communication bridge between our subconscious and the conscious mind.

In that state, we will have the possibility of improving our physical capacity and health through concentration in some area or functioning of the body. We will also have the opportunity to reprogram our subconscious mind through the repetition of positive phrases or the visualization of some desired goal.

When we reach the alpha level, we should not waste the opportunity to benefit from the repetition of positive phrases that will be accepted by our subconscious mind. Some phrases that you could use are: "Every day I feel better physically and mentally," or this one: "I am in control of my life and my actions," "I am learning to use my mind more effectively." You can write your own phrases which apply to your specific problems. These will be imbued in the subconscious mind and will make you create a more positive personal image, as well as give you the ability to overcome specific difficulties and fears that you may have.

Remember, our subconscious mind is highly receptive at the alpha level. In alpha, we reach a state where we are neither awake nor asleep, but completely relaxed. We reached the alpha level through the relaxation exercise that we explained in previous posts.

The successes of our life, the failures, interpersonal relationships and everything that has happened to us, has created a personal image of ourselves. Many of our current shortcomings are due to subconscious programming. The data accumulated in the subconscious mind can be allies to achieve our growth as human beings, but they can also be an obstacle to our development.

The repetition of positive phrases, once reached the alpha level, can benefit us enormously to make the subconscious mind work in our favor. To receive the benefits of relaxation exercises, these should be practiced at least once a day and preferably three times. If practiced correctly, in a period of 8 to 12 weeks you will notice considerable benefits in physical health, greater self-confidence and an increased ability to face problems. The most important thing is to create the habit since without continuity the received benefits will not be permanent.

The sleep stages (11)

To understand the process of physical and mental relaxation is necessary to carefully study the different states the person transits when relaxing and thus understand the benefits that one can obtain from this practice.

Our brain emits a certain amount of electrical energy with a frequency measured in cycles per second. This rate varies according to the degree of activity of our conscious mind and can be measured using an encephalograph. When we are awake and active, the brain emits waves known with the name of beta, and these go from 14 to 21 cycles. Depending on the mental activity degree, when a person is very agitated, he will possibly be emitting beta waves around 19, 20 or 21 cycles.

When we are relaxed, with our eyes closed, but without being asleep, we will be emitting waves known by the name of alpha. These range from 7 to 14 cycles per second. When we are asleep, during the first stage of sleep, these waves become longer and slower as the sleep deepens and they are known as gamma waves, ranging from 4 to 7 cycles per second.

At the deepest stage of the sleep, we emit delta waves ranging from 0 to 4 cycles per second. Of course, 0 would indicate a dead brain with no mental activity, and therefore no living person reaches 0. Even an individual in a coma state emits delta waves.

This cycle from beta (awake), alpha (relaxed), gamma (sleep) to delta (the deepest sleep), we all go over it every night while we sleep, possibly about 8 to 10 times. We lay down in beta, then we relax and reach the alpha point that is the condition in which we are not asleep nor awake; then we reach the first levels of sleep and continue to deepen till reaching the delta levels. It is precisely at that delta level where dreams occur, and it is known as the phase of rapid eye movement. If we approach a person who is deeply asleep, we will notice that their eyelids move continuously. Due to this, it is called phase of the rapid movement of the eyes, and it is in this stage where the person dreams. Then we go back and go over this cycle in reverse.

From deep sleep in delta, we go back to gamma and continue till we reach the alpha level. There we will not be asleep nor awake, and some even wake up, go out briefly to beta, drink water, go to the bathroom and then repeat the cycle about eight or ten times each night. That is to say that we all transit through this cycle at night and we all dream, although many times we do not remember the dreams.

Of these four mind stages, we are interested in the second level, or the alpha level, since it is the most important for the physical and mental relaxation, as also for the development and mind control. Recent studies on the alpha level are being carried out by psychologists, psychiatrists, and scholars of human potential. In following articles, we will explain these discoveries, how we benefit from the practice of relaxation and what the alpha level represents.

The tension vicious cycle (10)

Vicious Cycle: A sequence of reciprocal cause and effect in which two or more elements intensify and aggravate each other, leading inexorably to a worsening of the situation

Many psychological problems of today's man as anxiety and depression, are generated through a sequence of negative attitudes or thoughts that feed the state of tension, creating a vicious circle.

Most anxious people feel good in the morning on waking up, but as the pressure builds up for the rest of the day, they feel tenser. By 3 or 5 pm they have accumulated so much tension that they can not even enjoy the supper quietly with their family. Later, watching television, listening to the radio or at bedtime, they experience all kinds of physical discomfort such as heartburn, muscle tension in the chest, headache or back and a general feeling of discomfort. In other words, the person can not relax.

During the day small difficulties and problems accumulate tension, and this translates into anxiety. Possibly already in the afternoon the person feels somewhat uncomfortable and begins to worry. Not only concerns about the current day's problems, but also the next day's ones, and consequently, worries about his future in general. It is here where the person fills himself with fears because he begins to doubt his ability to face and solve his problems.

Problems cause tension that creates a state of concern, and this becomes a vicious cycle. Instead of dissipating, it feeds itself, and at the end of the day, it will produce a state of anxiety that often becomes difficult to tolerate.

If we practice the relaxation exercises regularly, we can significantly reduce the level of tension and anxiety. Just as physical exercise prepares and strengthens muscles making it possible to carry out activities that would be impossible without proper training, so relaxation exercises help us develop a more enthusiastic and positive attitude towards life and empower us to manage more efficiently the emotional stress caused by the everyday problems.

Of course, the changes in the nervous system will not be visible like they would be visible in the muscles. Our nervous system won't be stronger or larger, but through the relaxation exercises, its functional capacity will benefit considerably.

The discoveries in the field of psychology indicate that people can exert control over many basic psychological processes, which have traditionally been considered automatic. Using techniques and the proper training, many people have learned to control the heartbeat, the blood pressure, body temperature, brain waves and other body functions.

Experiments have been performed to facilitate training: For example, to teach a person to control the heartbeats, he connects to a machine that shows him on a screen when the heart rate is accelerating and when it slows down. Through physical and mental relaxation it is possible to quickly learn to control these and other functions without the need for electronic devices.

That is why we give so much importance to the regular practice of relaxation and meditation exercises since they are our most effective weapon against tension and anxiety. There will always be problems to solve, but they are not the cause of anxiety and stress, but the way we handle and face those problems. The tension vicious cycle is entirely avoidable.

Systematic desensitization versus anxiety (9)

We have previously analyzed the concept of systematic desensitization to treat anxiety. We explained that when a person confronts a particular situation, phobia or any circumstance that causes him what is known as an anxiety attack, he must learn to overcome that fear through a process where he will confront the object or event he fears, but gradually.

The process will be carried out in different stages until dominating the situation. Imagine, for example, that the person is afraid to cross the street. Maybe the first step would be to stand on the sidewalk, look at the road, watch cars pass by and analyze where the fear resides. The next step could be to cross the street accompanied by another person. The third stage would be to cross the road calmly while another person waits at the other side. The fourth would be to cross the street alone.

The most important thing in all of this is to have an action plan designed to act with a coordinated and efficient strategy so that we can win the battle against anxiety. Do not forget the simple exercise that we can carry out anytime we confront a situation that we are worried about: take several deep breaths, exhale slowly and visualize that we act in full control of ourselves. We can't succeed with only a couple of attempts if we want to be in control of our emotions. We need to plan and work on this project because the conditioning to the anxiety that we have become accustomed to over the years will not be eradicated in two or three days.

In the process of systematic desensitization, it is preferable to start working with an area that does not cause us too much anxiety. That way we do not get discouraged in the task since when we manage to overcome in a particular field, this will encourage us to continue working in other areas of our life.

With each experience we learn more, we will possibly have some failures, but we will not let this discourage us if we want to succeed. When we fail in the attempt, let us analyze why and this will help us to be more prepared next time. The most difficult part of this process is to determine what particular thing causes us stress, as this is somewhat confusing to define. However, we must do our best to find the causes of anxiety. The human being, under no circumstances, should stop to wonder why.

Overcoming anxiety is not a matter of logic. Each of us knows that there is no logic in those situations that paralyze us by fear. Anxiety can be overcome very effectively through the treatment we have analyzed: systematic desensitization.

Designing an action plan against anxiety (8)

We will further explain the concept of systematic desensitization through direct experience. For example, suppose that you are a shy person in your social environment, which causes you a high degree of anxiety. For direct confrontation, you must start dealing with a situation that gives you little anxiety and gradually you increase it until you overcome it.

Let's take for example a person who is anxious or afraid to relate with others, especially when they are unknown people. This situation is causing you severe limitations and suffering in his life and he wants to apply the gradual desensitization techniques to overcome the problem. In this case, to lose the fear of social interaction, he can design an action plan consisting of the following stages:

• Stage 1: Establish an insignificant conversation with a stranger. Maybe in the street, in a doctor's office, no matter the place, just has to be your own initiative. 
• Stage 2: Establish that same conversation like the previous stage, but this time should be something more extensive, say 1 or 2 minutes more.
• Stage 3: This stage will consist of establishing a casual conversation in a social activity, whether in a party, a class or the workplace and of course, also with someone unknown. 
• Stage 4: Here you should hold a conversation like the previous one, with an unknown person, but this time it should take several minutes.
• Stage 5: This stage will consist of sharing with a group of people formed by a mixture of known and unknown. You should actively talk and participate in the group.
• Stage 6: In this step, you must meet a new person and try to become his or her friend. After several meetings you should invite him to dinner, take him for a walk or visit him. Anything that causes more mutual contact in a friendly relationship.
• Stage 7: This would be the last stage and will consist of finding a group of unknown people anywhere, engaging in an active conversation and joining the group as a regular member. This stage could take you several meetings with this same group until you completely integrate as one of its members.

As you can see, there is a huge difference between the first stage of simply meeting a stranger engaging in a short conversation and the seventh which is the experience of being self-introduced to a group of completely unknown people and become one of its members. This plan will be much more effective and bearable if one combines each stage with the practice of systematic desensitization through the relaxation and visualization exercises. It would be very convenient, before carrying out any action, to previously practice it and mentally visualizing oneself in total control of the situation.

As we have explained in previous articles, if in the direct confrontation one feels paralyzed by anxiety at any stage, he should go back to the previous stage and don't continue. Do not go ahead if you are experiencing restlessness or panic and continue practicing the previous stage. Only when you manage to completely overcome one stage, then and only then, you can move on to the next stage.

Of course, this has been just an example. You can design your own program to beat anxiety and apply it to any situation in life you want. The most important thing is to have an action plan designed to act and coordinate a strategy to win the battle against anxiety. And do not forget the simple exercise that we can do at any moment that we are confronted with a situation that worries us: several deep breaths, exhaling slowly, and moments of visualization in which we contemplate ourselves acting in total control of the situation.

This process of self-therapy requires strong will and a genuine desire to overcome that problem which causes us anxiety and affects our lives. We can achieve nothing with just a couple of attempts and then abandon the process. If we want to be in control of our emotions we need to plan and work on the project with perseverance, because the conditioning that has been affecting us and limiting our lives for so many years, is not supposed to be eradicated in two or three attempts.

As you persevere in the project and overcome different stages, you will feel great satisfaction to start mastering your own limitations and be in control of your life. That feeling of self-affirmation is extremely pleasant for anyone, but even more so for those who for years have suffered fears, panics and paralyzing experiences such as anxiety. The battle is well worth it.