This video course has been developed to give nurses a better understanding of the responsibilities/requirements when using social media in the workplace and around patients/families.

1.0 contact hour of Law and Rules (Category A) will be awarded for successful completion of this webinar

NOTE: This session can be used to meet your one hour OBN requirement on law and rules which affects your nursing practice in Ohio.

The Ohio Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. (OBN-001-91)

Expires 12/1/2020

This webinar has been developed by: Kelli Schweitzer, MSN, RN-BC and Jessica Dzubak, BSN, RN. The author and planning committee members have declared no conflict of interest.

This webinar is presented by: Ohio Nurses Association, www.ohnurses.org 614-237-5414.

Criteria for Successful Completion

1. Watch the video in its entirety.

2. Complete the evaluation.

If you have any questions, please contact Sandy Swearingen, Continuing Education Specialist, Ohio Nurses Association at info@ce4nurses.org.

This independent study has been developed for nurses who wish to learn more about professional boundaries and sexual misconduct relative to nursing practice.

OUTCOMES: The nurse will have enhanced knowledge of professional boundary issues as well as identify what a nurse should do if a boundary crossing or violation should occur.

1.4 contact hours of Category A (Law and Rules) will be awarded for successful completion of this independent study.

The Ohio Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. (OBN-001-91)

Expires 11/1/2020

DIRECTIONS & CRITERIA FOR SUCCESSFUL COMPLETION:

1. Please read the below article carefully.

2. Complete the post-test, evaluation form and the registration form.

The post-test will be reviewed. If a score of 70 percent or better is achieved, a certificate will be sent to you. If a score of 70 percent is not achieved, a letter of notification of the final score and a second post-test will be sent to you.

We recommend that this independent study be reviewed prior to taking the second post-test. If a score of 70 percent is achieved on the second post-test, a certificate will be issued.

If you have any questions, please contact the Ohio Nurses Association’s CE department at sswearingen@ohnurses.org.

Originally developed by Jan Lanier, RN, JD, Previously reviewed by Kathleen Morris, MSA, BSN, RN, R. Wynne Simpkins, MS, RN and Cynthia Hasseman, MSN, Ed., RN. Revised 2018 by Jessica Dzubak, BSN, RN. The authors and planning committee members have declared no conflict of interest.

Disclaimer: Information in this study is intended for educational purposes only. It is not intended to provide legal and/or medical advice or to be a comprehensive compendium of evidence-based practice. For specific implementation information, please contact an appropriate professional, organization, legal source, or facility policy.

STUDY

Have you ever shared your personal problems with a patient (or client)? Given a patient a gift? Complained to a patient about a co-worker? Socialized, in person or via some form of social media, with a patient outside of your professional capacity? Accepted a gift of more than minimal value from a patient or family member? If you answered yes to any of these questions you may have crossed a professional boundary. Crossing a professional boundary is a violation of the Ohio Nurse Practice Act (Ohio Revised Code [ORC] Section 4723.28 [B.31], 2015b), and the rules adopted by the Ohio Board of Nursing (OBN) Ohio Administrative Code (OAC) 4723-4-06 (2015). While most nurses recognize that engaging in sexual misconduct with a patient is wrong both legally and ethically–what actually constitutes that “misconduct” is often difficult to define. For example, many nurses ask, “Isn¹t it all right to date a former patient?” The relationship between boundary crossings and sexual misconduct is often poorly understood.

Maintaining professional boundaries and avoiding inappropriate sexual involvement can pose dilemmas for nurses who frequently find themselves sharing in their patient’s most intimate life events. The very essence of nursing can be a “slippery slope” for many well-intentioned but naive, uninformed nurses. Patients trust that nurses will work in the patients’ best interest. When a nurse engages in a sexual relationship with a patient, or otherwise crosses a professional boundary, the nurse-patient relationship is being abused (National Council of State Boards of Nursing [NCSBN], 2018).

The purpose of this independent study is to make nurses more aware of and sensitive to the importance of maintaining a professional nurse/patient relationship and to identify some of the negative consequences that can occur, both for the nurse and for the patient, when these boundaries are crossed.

The OBN reported a relatively consistent number of complaints it received alleging sexual misconduct or boundary violations by its licensees between 2014 and 2016. But even at that, the numbers were not large with only 36, 45 and 25 cases reported in 2014, 2015, and 2016 respectively. (OBN, 2014, 2015, 2016).  This increase was likely the result of the changing face of the health care delivery system. Nursing care that previously would have been provided in an acute care setting now is being provided in patients’ homes or community settings. Such settings are less public and less supervised than the traditional health care setting such as a hospital or nursing home. Working with patients where they live often results in less formality and a loosening of the restraint that typically characterized the nurse/patient relationship in an acute care environment.

Sexual Misconduct: What is it?

Sexual misconduct is about power. It is an extreme abuse of the nurse/patient relationship. It is exploitation. It is about impairment and irresponsibility (NCSBN, 2009) Engaging in sexual activity with a patient, as well as conduct that could reasonably be interpreted as sexual, is explicitly recognized as a violation of acceptable standards of safe nursing practice in Ohio (OAC, 2015). Behavior, including verbal behavior, which is sexually demeaning, harassing, or seductive, is considered sexual misconduct by the OBN. Under Ohio law, a patient is always presumed incapable of giving free, full, or informed consent to these behaviors (OAC, 2015).

In other words, the rules of the OBN clearly make the nurse responsible for assuring that sexual misconduct does not occur even with a seemingly willing patient. If the client consents, even if the client initiated the sexual contact, it is still considered sexual misconduct because it is an exploitation of the nurse/patient relationship (NCSBN, 2018).

The impact of sexual misconduct varies and can be complicated by the trauma of a failed personal relationship.  Should sexual involvement cease, a patient’s response may range from a sense of exploitation to embarrassment, humiliation, and ultimately severe depression. None of these reactions is conducive to the health and well-being of the patient, which ought to be the underlying goal of all nursing interventions (NCSBN, 2018). Patients are not the only ones affected by sexual misconduct and/or harassment in the workplace. Evans (2018) states, “sexual harassment in healthcare can adversely affect employee health and, by extension, patient safety” (Evans, 2018, para. 5). Additionally, he states, “We have empirical data that shows a direct link between disruptive behaviors and sexual harassment to adverse patient outcomes, medication errors, and so on,” (Evans, 2018, para. 7).

What about dating a “former” patient?

Personal relationships that begin after the nurse is no longer caring for the patient pose significant questions. The NCSBN (2009) published guidelines for use by the various state boards of nursing that state, “A health care provider shall not engage, or attempt to engage, in the activities … with a former patient, client or key party within two years after the provider-patient/client relationship ends” (p. 6).  The American Nurses Association (ANA) (2015) Code of Ethics does not specifically address post-termination relationships but clearly states any relationship with a current patient is prohibited. The rules of the OBN are also silent on this matter. In the absence of clear standards regarding post-termination relationships, in dealing with a case involving a post-termination situation, the Board of Nursing members would likely look to standards developed by other entities, such as the NCSBN to determine if the nurse’s conduct violated the laws and rules regulating professional practice. They would consider the type of nursing care provided and the length and nature of that care to determine whether sexual misconduct occurred. Regardless of when a personal relationship is established with a former patient, the nurse/patient role must not be resumed should future ongoing health care needs arise (NCSBN, 2009).

What are professional boundaries and why are they important?

Simply put, “professional boundaries are the spaces between the nurse’s power and the patient’s vulnerability” (NCSBN, 2018, p. 4). Valente (2017) defines boundaries as, “… the mutually understood physical, emotional, sexual, and social limits of a relationship”(Valente, 2017, para. 1). These boundaries are not visible. Nonetheless they define the types of behaviors that are most likely to enable nurses to effectively meet the health care needs of their patients and their patients’ families. The concept that there are “limits” to acceptable nursing behaviors within the nurse/patient relationship and the reason for those limits form the framework for an understanding of the intricacies of professional boundaries. Once the boundary is crossed, it may ruin the professional nurse-patient relationship completely (Petosa, 2018).

The NCSBN emphasizes that professional boundaries are necessary for an effective nurse-patient relationship. The NSCBN states, “the therapeutic nurse–patient relationship protects the patient’s dignity, autonomy and privacy” (NCSBN, 2018, p. 4). Nurses must keep patient’s dignity, autonomy and privacy in mind at all times in order to ensure boundaries are not crossed and trust is not violated.

Certain actions are not acceptable when a nurse is caring for a patient. Limits exist to help assure that a vulnerable patient is not exploited in any way even by a well-meaning nurse. “The power of the nurse comes from the nurse’s professional position and access to sensitive personal information” (NCSBN, 2018, p. 4). Nurses’ professional position affords them control over life-sustaining therapies and complex equipment through which they exert subtle but tremendous influence over their patients’ behaviors. This power, which is an essential element in the nurse/patient relationship, enables the nurse to positively influence the patient’s health status. However, “if the extent of that power is not limited through the establishment of appropriate professional boundaries, the patient is subjected to unacceptable risks that could ultimately affect the patient’s physical and emotional health” (OBN, 2002).

The difficulty in defining and maintaining professional boundaries has long been recognized within the nursing profession. The lines can easily be blurred, especially in long-term home care settings (Petosa, 2018). It can be even more difficult to maintain professional boundaries in pediatric home care settings, as “parents of pediatric patients and the children themselves can grow to view the nurse as a friend rather than a professional care provider” (Petosa, 2018, para. 2).

Case Study:

Nurse Anne has been Patient Tom’s home health nurse for 6 weeks following his surgery. Throughout this time, Anne and Tom have formed a trusting relationship. On the last day of Tom’s home health care, he takes a photo of himself standing to post on his Facebook, celebrating that he is officially “up and about” and near the end of his recovery. Tom posts some details about his surgery in this post.

Anne and Tom’s nurse-patient relationship ends at the termination of his care. Anne happens to be neighbors with someone who knows Tom, so she notices Tom appear in her “suggested friends” on Facebook. She clicks on Tom’s profile, and sees his proud post and feels good about her role in his recovery. Anne sees that Tom’s profile is “Public”, so she decides to “share” his post on her Facebook page. She adds to the post that Tom was unable to even stand up the first few weeks after surgery and has had a long battle with his disease. Because Tom posted these details about his own personal life and healthcare, Anne believes it is safe to continue sharing.

What are your thoughts? Is Anne correct in her thinking?

No. Green (2017) states, “patients are able to disclose their own information online; however a duty of confidentiality arises when a patient/client discloses information to a health professional in circumstances where it is reasonable to expect that the information will be held in confidence” (Green, 2017, para. 10).

Even if Anne had not added any details to her post, it would still not be considered appropriate and a violation of the nurse-patient relationship.

One study notes the lack of research on terminating the nurse-patient relationship (Ashton, 2016). Because of the intimacy of the nurse-patient relationship, especially over a long period of time, severing these relationships can prove to be difficult for both parties. This can become even more complicated with the addition of social media (Ashton, 2016). Severing ties with a former patient and their family does not mean you no longer care about them, but it is maintaining the professional and ethical boundaries of nursing practice. The nurse-patient relationship was still “real” and deeply meaningful (Ashton, 2016).

Boundary Crossings v. Boundary Violations

Boundary crossings:

“…are brief excursions across professional lines of behavior that may be inadvertent, thoughtless or even purposeful, while attempting to meet a special therapeutic need of the patient. Boundary crossings can result in a return to established boundaries, but should be evaluated by the nurse for potential patient consequences and implications. Repeated boundary crossings should be avoided” (NCSBN, 2018, p. 4).

Boundary violations:

“…can result when there is confusion between the needs of the nurse and those of the patient. Such violations are characterized by excessive personal disclosure by the nurse, secrecy or even a reversal of roles. Boundary violations can cause distress for the patient, which may not be recognized or felt by the patient until harmful consequences occur” (NCSBN, 2018, p.4)

 What does the law say about maintaining professional boundaries?

Ohio law authorizes the Board of Nursing to take disciplinary action when a nurse fails to establish and maintain professional boundaries with a patient (ORC, 2015b). Nurses also risk disciplinary action if they obtain or attempt to obtain money or anything of value by intentional misrepresentation or material deception in the course of practice (ORC, 2015a). Rules of the OBN further define expectations with respect to boundary violations.

*    Nurses are not to misappropriate a patient’s property or engage in behavior to seek or obtain personal gain at the patient’s expense.

*    Nurses are not to engage in behavior that constitutes inappropriate involvement in a patient’s personal relationships or financial matters.

*    Nurses are not to engage in any behavior that could reasonably be interpreted as inappropriate involvement (OAC, 2015).

Identifying Boundary Infringement

Excessive Self-Disclosure: The nurse discusses personal problems, feelings of sexual attraction or aspects of his or her intimate life with the patient.

Secretive Behavior:  The nurse keeps secrets with the patient and/or becomes guarded or defensive when someone questions their interaction.

“Super Nurse” Behavior: The nurse believes that he or she is immune from fostering a nontherapeutic relationship and that only he or she understands and can meet the patient’s needs.

Singled-Out Patient Treatment or Patient Attention to the Nurse: The nurse spends inappropriate amounts of time with a particular patient, visits the patient when off-duty or trades assignments to be with the patient.

This form of treatment may also be reversed, with the patient paying special attention to the nurse, e.g., giving gifts to the nurse. If a nurse is receiving this type of attention from a patient, it is advisable for the nurse to seek the guidance of his or her supervisor.

Selective Communication: The nurse fails to explain actions and aspects of care, reports only some aspects of the patient’s behavior or gives double messages. In the reverse, the patient returns repeatedly to the nurse because other staff members are too busy.

Flirtations: The nurse communicates in a flirtatious manner, perhaps employing sexual innuendo, off-color jokes or offensive language.

“You and Me Against the World” Behavior: The nurse views the patient in a protective manner, tends not to accept the patient as merely a patient or sides with the patient’s position regardless of the situation.

Failure to Protect Patient: If the nurse fails to recognize feelings of sexual attraction to the patient, consult with a supervisor or colleague, or transfer care of the patient when needed to support boundaries (NCSBN, 2018).

Summary

Nurses often need help understanding how to effectively balance professionalism with effective care-giving. In other words: how to stay within the “zone of patient-centered care.” Administrators and managers as well as nursing colleagues can help nurses with this difficult matter by being sensitive to the challenges and alert to signs of boundary crossings.

Nurses must be aware of the reporting requirements and grounds for discipline on their license by the OBN. Nurses must be aware of and practice within the law and rules, but also the standards of care for the patient in whatever setting the nurse is working. “Nurses also need to be cognizant of the boundary violations that occur when using social media to discuss patients, their family or their treatment” (NCSBN, 2018, p. 10). Awareness is the key to avoiding crossing the professional boundary.  Being cognizant of one’s own feelings and behaviors and observant of the behaviors of other nurses are important steps in finding the middle ground on the professional continuum. Nurses must also be clear about their own needs and the needs of their patients. They need to separate the personal from the professional. Patients need professional health care from a nurse, not personal friendship.

References

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Retrieved September 18, 2018 https://www.nursingworld.org/coe-view-only

Ashton, K. (2016). Teaching nursing students about terminating professional relationships, boundaries, and social media. Nurse Education Today, 37, 170-172. https://doi.org/https://doi.org/10.1016/j.nedt.2015.11.007

Evans, G. (2018). #MeToo in medicine? Sexual harassment in healthcare. Hospital Employee Health, 37(3). Retrieved from https://search-proquest-com.library.capella.edu/docview/2000994175?pq-origsite=summon

Green, J. (2017). Nurses’ online behaviour: lessons for the nursing profession. Contemporary Nurse: a Journal for the Australian Nursing Profession, 53(3). https://doi.org/10.1080/10376178.2017.1281749

National Council of State Boards of Nursing. (2018). A nurse’s guide to professional boundaries. Retrieved from https://www.ncsbn.org/ProfessionalBoundaries_Complete.pdf

National Council of State Boards of Nursing [NCSBN] Discipline Resources Committee. (2009). Practical guidelines for boards of nursing on sexual misconduct cases. Chicago, Illinois, USA: National Council of State Boards of Nursing. Retrieved September 18, 2018, from https://ncsbn.org/Sexual_Misconduct_Book_web.pdf.

Ohio Administrative Code (OAC). (2015). OAC 4723-4-06 Standards of nursing practice promoting patient safety. Retrieved September 18, 2018, from http://codes.ohio.gov/oac/4723-4-06v1.

Ohio Revised Code (ORC). (2015a). ORC 4723.28 Disciplinary actions (B)13. Retrieved September 18, 2018. from http://codes.ohio.gov/orc/4723.

Ohio Revised Code (ORC). (2015b). ORC 4723.28 Disciplinary actions (B)31. Retrieved September 18, 2018. from http://codes.ohio.gov/orc/4723.

Ohio State Board of Nursing (OBN). (2014). Ohio board of nursing annual report: SFY 2014. Retrieved from http://www.nursing.ohio.gov/PDFS/AnnualReport/FY14_Annual_Report_Final.pdf.

Ohio State Board of Nursing (OBN). (2015). Ohio board of nursing annual report: SFY 2015. Retrieved from http://www.nursing.ohio.gov/PDFS/AnnualReport/FY15_Annual_Report_Final.pdf.

Ohio State Board of Nursing (OBN). (2016). Ohio board of nursing annual report: SFY 2016. Retrieved from http://www.nursing.ohio.gov/PDFS/AnnualReport/AnnualReport2016.pdf.

Ohio State Board of Nursing (OBN). (2002). Disciplinary action. Nursing Momentum, 1(1).

Petosa, S. D. (2018). Maintaining professional nursing boundaries in the pediatric home care setting. Home Healthcare Now, 36(3), 154-158. https://doi.org/10.1097/NHH.0000000000000649

Valente, S. (2017). Managing professional and nurse-patient relationship boundaries in mental health. Journal of Psychosocial Nursing & Mental Health Services, 55(1), 45-51. https://doi.org/10.3928/02793695-20170119-09

DIRECTIONS

1.   Please read the below independent study carefully.

2.   Complete the post-test, evaluation, and the registration and payment (if applicable).

The post-test will be reviewed. If a score of 70 percent or better is achieved, a certificate will be sent to you. If a score of 70 percent is not achieved, a letter of notification of the final score and a instructions on how to take the second post-test will be sent to you. We recommend that this independent study be reviewed prior to taking the second post-test. If a score of 70 percent is achieved on the second post-test, a certificate will be issued.

If you have any questions, please contact the Ohio Nurses Association’s CE department at info@ce4nurses.org or call 1-800-735-0056.

The Theory of Successful Intelligence:

It’s not all about IQ. 

Dr. Robert Sternberg, a psychologist, proposes that IQ tests, SAT’s and ACT’s measure only a portion of our total intelligence. As a matter of fact, he states that IQ tests, SAT’s and the like measure for the most part, our inert intelligence. Inert intelligence is defined as intelligence that is unable to move or act; it is not reactive with other elements and is not goal-directed. Many IQ tests call for the regurgitation of information learned from books such as solve a math problem, define a word, etc. Even when given a problem to solve, one may rely on an algorithm, again learned from a book, to solve this particular problem. The problem is a structured one that conveniently can be solved using the learned algorithm.

However, inert intelligence is not real world. Algorithms learned from a book seldom fit the everyday real world problems we encounter. While the inert intelligence we acquire during the course of our academic education certainly gives us a basis to enter into the real world, it doesn’t give us all we need in order to function. We have to be able to recognize when to apply learned information as well as we have to apply that knowledge to a given real world situation.

Sternberg also contends that IQ test scores can actually harm a person. If a person scores poorly on an IQ test, he or she may be labeled as being “dumb”. Because of the “dumb” label, expectations are also set at a lower level for that individual. No one expects much from the “dumb” person, and this becomes a self-fulfilling prophecy. The individual then, being labeled “dumb,” often has very low or no expectations for him or herself. It becomes a vicious cycle and the individual lives up to expectations that are far below what he or she could accomplish.

Furthermore, when a “dumb” person does happen to perform well, perhaps in a subject he or she really enjoys, the good work is viewed with suspicion and an assumption that he or she “cheated” may be made. Yet we have all encountered “dumb” individuals who go on to become very successful in life, i.e., Thomas Edison, and Albert Einstein.

Ironically there are ramifications for the individual who achieves high scores on IQ tests. The individual is labeled as being “smart” and the expectation bar is set very high for that person. In some cases, there may be so many high expectations, it is difficult for the individual to meet all those expectations. Because the individual is labeled “smart,” s/he is expected to be “smart” in all aspects of his/her lives. When a “smart” individual encounters a situation he or she doesn’t know how to handle, or is less than stellar, he or she doesn’t know how to handle the situation. He doesn’t know how to be second best or the B student, when he has always been the best or the straight A student. The smart individual then begins to think of himself as a failure. In the face of failure, the smart individual may choose to withdraw from the situation.

Sam, for example, had been a stellar student, becoming valedictorian of his high school class and maintaining an A+ average in advanced college placement courses. He was in all sorts of extracurricular activities that included a variety of sports, band, debate club, and the theater group in high school. He excelled at everything he did. With high expectations for continuing excellence, Sam went on to college. However, in college many of his courses were graded on a curve and there were individuals in Sam’s classes who scored higher on tests than Sam did. While Sam was at the front of the curve at his high school, he found he was struggling in some classes to fall in the middle of the curve in college. Sam came home with a 2.7 (B-/C+) grade point average in college. His parents, who always expected him to excel, were very disappointed and accused Sam of “partying” too much and told him he better “buckle down” and study harder. Sam felt like a total failure!

During the next semester, Sam studied every moment he could, even seeking out tutoring. His next report card showed his grade point average to be 2.8! He became despondent. He was working so hard, but there were other students who were more academically gifted than he was. Sam decided he was just wasting his time and since in his eyes he was failing, he withdrew from college. He came home and got a job working at a fast food restaurant earning minimum wage. He simply did not know how to cope with the fact he was not the “smartest” person in college; thus he withdrew from the situation. In essence, he committed academic suicide.

In some instances, one may see others commit professional suicide, meaning that when these individuals cannot cut it in the real world; they will withdraw to a “safe” place. While Sam wasn’t the smartest person in college, perhaps he chose to work at the fast food restaurant because that was an environment where he could appear to be the “smartest” person. It was a safe environment for him, but far below his abilities and capabilities.

IQ tests, while they measure our inert intelligence, should perhaps be viewed with a bit of skepticism. IQ test results are not predictors for future performance. There certainly must be an explanation for why we see “dumb” people exceeding in life, while “smart” people simply are not living up to their potential. This is what led Dr. Sternberg to his theory of Successful Intelligence. He simply states IQ is a measure of knowledge achievement (inert knowledge) while Successful Intelligence is a measure of those who excel. Low IQ scores do not preclude high yields of Successful Intelligence and high IQ scores do not guarantee high yields of Successful Intelligence either. IQ and Successful Intelligence are not dependent on one another. There must be something more to our intelligence than what is measured in an IQ test.

Dr. Sternberg proposes there are three areas of intelligence and that people who use and balance all three intelligences are those who are successfully intelligent and go on in life to excel. The three intelligences are analytical intelligence, creative intelligence and practical intelligence.

Analytical, Creative and Practical Intelligence Defined

Sternberg identifies three areas of intelligence that, when used in balance with one another, yield successful intelligence. The intelligences are:

Analytical intelligence has to do with learning things and analyzing things. Inert intelligence is a small part of analytical intelligence. Critical thinking, in its narrowest of definitions, and nursing process are examples of analytical intelligence. (Critical thinking in a broader definition would include creative and practical intelligence as well as analytical intelligence). Solving a structured problem from a book is another example of analytical intelligence.  However, most problems encountered in everyday life are not well structured. Many times we have to figure out just what the problem is before we can begin to solve it. Evaluation is a form of analytical intelligence. Consider patients you encounter. Many times they will report a problem, only you discover the problem is something entirely different.

Mrs. Sweet came into her physician’s office repeatedly with high blood sugars and elevated hemoglobin A₁C levels. She persisted in saying she was taking her insulin and was avoiding sugars. She maintained there was something wrong with her insulin because it didn’t seem to be working. A new prescription was given to her; she filled it at the pharmacy, but returned to the physician’s office with the same elevated blood sugar levels. This was repeated a number of times with no correction of the blood sugars. The nurse analyzed there was still a problem and evaluated that the solutions they were offering were not working.  The nurse knew they had to do something else.

Creative intelligence was primarily the focus of Part 4 of this series and deals with synthesis of ideas. Creatively intelligent individuals connect ideas to formulate new ideas that others have missed. A big part of creative intelligence is making connections with what one knows in order to define problems. To continue our story about Mrs. Sweet, the nurse asked Mrs. Sweet to show her how she was injecting her insulin. Mrs. Sweet had excellent technique and was accurate with the dose of insulin. When she finished, Mrs. Sweet commented that she always administered the insulin in one particular spot on her thigh because “it didn’t hurt to give the shot there.” The nurse picked up on this comment and found Mrs. Sweet had been administering her insulin in the same spot and not rotating her injection sites. The particular “spot” was now a thickened almost callous like area of skin. No wonder the insulin “wasn’t working” anymore! It wasn’t that the insulin wasn’t working; the problem was it was being incorrectly administered which is a completely different problem. The nurse had synthesized the problem.

Here’s another example of creative intelligence. Many years ago when continuous tube feedings were just beginning to be the up and coming mode of nutritional support, nurses struggled with how to maintain and administer these feedings. Accurate feeding pumps were not yet developed and available. Regina was a nurse who frequently had to administer continuous feedings to her patients. The old feeding pumps that were in use at the time didn’t administer the feedings with the accuracy that was now demanded. Regina had the idea to take a douche bag, cut the tubing off leaving approximately four inches of tubing. Next she spiked mini-drip IV tubing into the remaining douche bag tubing. Miraculously it fit. She then put the tube feeding solution into the douche bag and ran the IV tubing, now connected to the douche bag through an IV pump. Voila! She had synthesized a way to accurately deliver continuous tube feedings to patients.

She had the idea to take readily available equipment and she literally connected these together to devise her system. For a number of years on her nursing unit, that was how nurses delivered continuous feedings to patients.

Practical intelligence has to do with putting our ideas into use. Some people refer to practical intelligence as common sense, or to paraphrase an old Nike athletic shoe advertisement, “just do it”.  Individuals who possess practical intelligence are able to translate their ideas into action. Practically intelligent individuals have a knack for taking information they have gained and making use of it.

Consider Mrs. Sweet again. The nurse, using her creative intelligence, had identified she was dealing with an insulin administration problem. Now she needed to develop a plan and put that plan into work.  The nurse reminded Mrs. Sweet of the importance of rotating injection sites and Mrs. Sweet said she had remembered hearing this information previously, but had forgotten. The nurse also consulted with the physician who revised the dosage of insulin upon hearing the problem was an administration problem.  The nurse had utilized her practical intelligence. She formulated ideas, devised a plan and executed her plan; she is successfully intelligent.

Consider Regina the nurse who created the method to deliver continuous tube feedings. Not only did she recognize and define the problem and formulate a solution (creative intelligence), she acted on her ideas (practical intelligence). She actually tinkered with the equipment, and made her ideas come to life when she began using her IV tubing/douche bag tube feeding system. There are many individuals who have great ideas, but they never put their ideas into play. The difference between someone with great ideas and Regina is the can-do attitude Regina possesses. She follows through, while others never execute their ideas. The world is full of individuals who are “someday” going to do this and such, but it is the practically intelligent who actually “just do it.”

How we come by practical intelligence: tacit knowledge, experience, and reflection: 

Practical intelligence is a display of our tacit knowledge. Tacit knowledge is that action-oriented common sense practical know how type of intelligence. Tacit knowledge does not necessarily correlate with IQ. In other words, a person can have high IQ, but a low level of tacit knowledge.

Sometimes these individuals are described as being “book smart” but have no common sense. On the other hand, there are those who have less than great IQ scores, but have high levels of tacit knowledge. Often these individuals are described as being “down to earth and practical” or as possessing “a lot of street smarts”. Think about this for a moment. Let’s say you encounter a unique clinical situation you have never encountered previously. You decide to consult a nurse colleague. You are working with two nurses. One is book smart; the other colleague is that down to earth, practical person. Which one do you choose to consult regarding the problem? Why? What might each nurse contribute to solving your patient problem?

Very often, the nurse who is the down to earth, practical nurse will be the one consulted. The book smart nurse, while he or she may be able to recite a theory, he or she has no idea how to make use of that theory. But the “street smart” nurse, while he or she may not be able to recite theory, will more often than not have a solution for you to try. Tacit knowledge is a predictor for future performance and success. When an individual possesses both high levels of IQ and tacit knowledge, that combination makes for an extremely successful individual.

There are three parts to tacit knowledge.

1.)    Tacit knowledge is about knowing how and about doing.

2.)    Tacit knowledge is relevant to the attainment of goals people value.

3.)    Tacit knowledge is typically acquired without help from others.

Consider Regina again. She devised a system, using IV tubing and a douche bag, to administer continuous tube feedings to her patients (knowing and doing). She did this in an independent manner. No one assisted Regina. The solution she devised was relevant to attaining her goal of accurately administering continuous tube feedings. This is an excellent example of practical intelligence. When asked why and how she came up with this idea, Regina simply replied it seemed like common sense to her and she thought she’d give it a try. Regina is successfully intelligent. She uses all three intelligences: analyzes the problem (analytical intelligence), creates a solution (creative intelligence) and gives life to her ideas (practical intelligence). She exhibits self-efficacy or a “can-do” attitude. Successfully intelligent individuals display self-efficacy and get the job done.

Tacit knowledge comes from our experiences. Our IQ does not increase with experience, but our tacit knowledge does. It is our experiences that give us practical intelligence. It is important to note that it is not necessarily the amount of experience you have, but it is how much you profit or benefit from your experiences that is key.  This is why one may know colleagues who have been practicing nursing for many years, yet they still seem to be functioning at an advanced beginner level of practice.

It also explains why another nurse, with perhaps only a few years of practice is functioning at a proficient or even expert level of practice. The difference between these nurses is that the second nurse has profited or benefited from her experiences. How do we benefit from our experiences? Utilizing the critical thinking strategy of reflection is key. When one reflects about experiences, one learns and increases tacit knowledge. I like to say it’s not the experiences that make the nurse, but it’s what the nurse makes of the experiences.

How does one reflect?  Think back on your day and ask yourself what you learned. What new experiences did you encounter? Give thought not only to clinical situations, but interpersonal situations as well. Perhaps you encountered a difficult patient or colleague. Ponder how you could have handled communications in a better manner with that individual. Many individuals write in diaries or journals chronicling their thoughts. Often seeing your thoughts on paper and having an opportunity to re-read your ideas has the added benefit of re-enforcing what you have gained. Give consideration to observing co-workers. How do they handle situations? How do they handle clinical situations?

One can learn from observing a situation that was not handled very proficiently as well.  In observing the mistakes of others, one can learn not to repeat the mistakes made by the other person. Often at meal breaks, colleagues discuss patients or tell “war stories” about clinical situations either present or past.  Listen to these stories, they are reflections of clinical practice and clinical decision making. Much can be learned from listening to a nurse recount a clinical situation. Not only does the nurse who is recounting the story learn, but the listeners learn as well. When the person has finished recounting his or her story, ask what was learned from that situation. Share your own observations about the story you heard. Engage in a conversation about the scenario.

Case studies are also a form of reflection. Whether the case study is one presented in an independent study or one presented at a conference, it offers reflection. Along with the case study presentation a discussion follows. The discussion is reflection.  It is an excellent way for advanced beginners to experts to learn and gain practical intelligence.

Developing and Nurturing Practical Intelligence: Moving toward Successful Intelligence

Self-activation versus Self-sabotage: Helping yourself and others develop practical intelligence. 

Besides reflection, how else might one develop and nurture one’s practical intelligence? Many individuals sabotage themselves with obstacles that are often self-created. Charlotte is a nurse with three years of experience. She has had three different jobs in as many years. By now, one would expect Charlotte to be able to function independently and able to complete her patient care assignments. However, Charlotte continues to ask for assistance from her co-workers on a routine basis. When she doesn’t finish her patient care assignments, she often blames her co-workers because they “didn’t come and help her.” Her co-workers, who have their own busy assignments, have come to resent helping Charlotte, especially when they observe her sitting at the nurses’ station drinking coffee.

When they have asked her for assistance, she says she is too busy and they should ask someone else. Some of her colleagues have even tried to assist Charlotte with time management skills, but Charlotte doesn’t seem to learn these skills. Some charge nurses, in making daily patient assignments, have felt sorry for poor Charlotte and given her a lighter assignment than the other nurses. This has only fostered more resentment towards Charlotte.

Charlotte is not a stupid person. She did well in school and often contributes good ideas at staff meetings exhibiting some creative intelligence. But she does not execute her ideas and she clearly isn’t putting her education into action. Charlotte is sabotaging herself and her co-workers with this dependent attitude. She clearly lacks practical intelligence.

In the remainder of this independent study, we will explore twenty items that contribute to the evolution of one’s practical intelligence. As one learns to balance analytical, creative and practical intelligences, one achieves successful intelligence. We can use these items to nurture our own practical intelligence or to assist another person in nurturing their practical intelligence.

1. The successfully intelligent individual motivates himself or herself. It doesn’t matter how much or what talents one has if one doesn’t use them. Motivation accounts for at least as much as intellectual skills. Motivation is often the main difference that accounts for success in one individual versus another. Motivation can come from an internal or external source.

External motivators would include things like pay, awards, recognition from a superior or peers, or a promotion. Internal motivation is our own self-satisfaction. Because external motivators are transient, for a person to be able to sustain his or her motivation, internal motivation is preferable. Internal motivation gives one a need to master a skill or project. Internal motivation provides a sheer desire to work hard and see a job well done and distinguishes genius. Yes, individuals who are talented and skilled put those talents and skills to use to the best of their abilities, and take self-satisfaction are individuals who are labeled as geniuses.

Geniuses are not just the Albert Einsteins or Thomas Edisons of the world. Look around you at those productive talented people you know. They are geniuses even when it comes to completing some of the most mundane work. Thinking back to Charlotte, do you think she is motivated? She possesses knowledge and skill, but is she utilizing it to her full potential? Perhaps Charlotte does not want to succeed.  With success often comes more responsibility that perhaps Charlotte does not desire. One has to want to succeed. Just wanting to succeed is a motivator. Ask the individual what motivates him or her. Give the person a list of internal and external motivators and ask him or her to identify or rank his or her motivators.

What motivates you? If you are working with a motivated individual, it is best to stay out of his or her way. Allow that individual to pursue his or her goals and interests. With enough motivation, the person will achieve the goal, gain more successful intelligence in the process, and everyone benefits.

2. Successfully intelligent individuals learn to control their impulses. Impulsive behaviors tend to hinder intellectual work and do not allow for reflection. If one acts on the first idea one has and gets carried away with that idea, one may be missing out on a better idea. There may be better solutions than the first idea. Let ideas incubate for awhile; kick the idea around for awhile. Then, if you determine it’s the best idea, go with it. There are successfully intelligent individuals who act very quickly. Those successfully intelligent individuals who do act quickly and decisively are acting based upon past experiences.

Help nurture practical intelligence by learning to review one’s work and ideas. Utilize incubation. Use analytical intelligence to critique ideas, creativity to adjust the idea, and practical intelligence to put the idea into action.  Reflect on results. However, endless reflection is not desirable either. One who reflects and “thinks about” things endlessly also does not accomplish anything.

3. Successfully intelligent individuals know when to persevere. Many individuals, upon not achieving success the first time around, give up. They do not persevere. Perhaps they are not willing to re-evaluate their ideas, fine tune them and try again. Successfully intelligent individuals know how to rework problems and possible solutions and often, in spite of a lack of support, will achieve success. Also important, successfully intelligent individuals know when to quit. They recognize when a problem cannot be solved and move on. Successfully intelligent people do not keep solving the same problem over and over again.

Mary is one of Charlotte’s colleagues. Mary has tried a number of times to assist Charlotte with time management and work organizational skills to no avail. She has come to the conclusion Charlotte is being lazy and feels Charlotte is simply taking advantage of her co-workers by getting them to do a lot of the work she should be doing. Knowing she has not been successful in changing Charlotte’s behaviors, Mary gives up. She recognizes that Charlotte is the only one who can change her own behaviors. Mary also refuses to play into the scenario by always helping Charlotte, unless it is a situation whereby Mary realizes Charlotte’s request for assistance is reasonable.

4. Successfully intelligent individuals know how to make the most of their abilities. Successfully intelligent individuals know what they are good at doing as well as what they are not good at doing. Successfully intelligent tend to love what they do because they choose to undertake work for which they have ability to do.

Jane is a nurse who has wonderful teaching skills. She has always gravitated towards teaching roles being a preceptor, patient educator and now enjoys a role in continuing education.  However, at one point in Jane’s career she had been a manager. While she competently did the job, she hated every minute of it and struggled to complete many of her managerial duties, especially when she had to fire an individual from her staff.

She began to have health problems while serving as a manager. She developed high blood pressure, sleeping difficulty and severe heartburn problems. She realized that in this particular job she was not utilizing her strengths.  She decided to leave this position and return to teaching where she has created her own business in continuing education. She recognized her strengths were in teaching, not managing. Rather than stay in a position where she was not able to use her talents and the fact she was miserable, she changed positions. And that high blood pressure, insomnia and heartburn, they all resolved spontaneously when she left management!

Too often individuals stay in jobs where they do not use their talents. The sad thing is when they don’t use their talents, they are not happy. Often when they are unhappy, like Jane, it may translate into health problems or take a toll on personal relationships. They turn into someone no one likes or respects. It’s interesting to ask a tyrant why they stay in the particular position they hold. Often they will tell you it is because of the money, job title or power, all external motivators. If you asked them what their ideal job would be, you will often get a very different answer compared to the job they currently hold.

What about you?  Are you doing what you love to do?  What are your talents and abilities? Make a list of things you love to do and are good at versus those you do not like and struggle to do. (Or have the person you are nurturing do this.) Review this list. Are you able to do the things you like frequently enough? Is there too much in your job or your life that you do not like doing? Are you having health or interpersonal problems because of it?  What can you do to change this situation?

5. Successfully intelligent individuals translate thought into action. People can become buried in thoughts. They have all kinds of great ideas, but don’t know what to do with them. How many times have you heard someone say “Some day I’m going to….”, only they never seem to do anything. But how does one get started? Putting together an action plan is a good place to begin. Break the idea or project down into smaller increments or a “To Do List”. Next, you will want to prioritize the items. You may want to develop a time line or set deadlines to accomplish milestones of the project. This is especially important if you need time management assistance. Then start! You can assist others in this same manner.

Individuals who are less successful often have regrets about things they have done, i.e., if only I had done thus and so.  Successfully intelligent individuals, if they have regrets at all, have regrets about the things they have not done.  Successfully intelligent individuals realize the only way to benefit from an idea is to put it into action.

6. 6. Successfully intelligent individuals have a product orientation and focus on the end result. Many people aren’t as successful as they might be because they get caught up in the process of doing versus producing. Bob is a nurse who gets caught up in process. He is a home care nurse assigned to Mr. Hoover and he fills Mr. Hoover’s pillboxes every two weeks. What would take any other nurse 45 minutes to complete takes Bob three hours. He fills the pillboxes, then goes back and double and triple checks the medications. Often he removes pills and then starts anew on the project.

Unfortunately, in spite of Bob’s diligence, when other nurses have visited, they have found errors in Mr. Hoover’s medications. Bob is certainly busy the entire time he is working to fill the pillboxes; he just isn’t productive. Besides taking a long time to complete, he doesn’t complete the task accurately and leaves Mr. Hoover at risk. Successfully intelligent individuals don’t get bogged down in minutia. There is more than one way to complete just about any given task. Rather than waste or spend time getting bogged down in the multiple ways of “how” to do something successfully intelligent individuals keep looking forward to the “what” they are completing.

Successfully intelligent individuals are concerned with process, but the ultimate goal is the end product. Successfully intelligent individuals want results. In our society, we have increasingly become a consumer society. We purchase disposable products, download music, watch television, communicate via computers, and purchase the latest gizmo and gadget. But what do we create? What do we make?  Successfully intelligent individuals have a producer mentality versus a consumer mentality.

7. Successfully intelligent individuals complete tasks and follow through. Some individuals have problems completing tasks for a variety of reasons. These non-completers may be afraid of failure or they may be afraid of success. With success come new responsibilities or people now expecting more from that individual. Some people may not complete tasks because they don’t know what they will do next.

Successfully intelligent individuals know what they will do next. They generally are not at a loss for things to do. Some individuals fall prey to Zeno’s Paradox.  Zeno’s Paradox states that a body in motion wishing to reach a given point must first traverse half the distance, then half the remaining distance, then half the distance again, ad infinitum. If one always goes half the distance, he or she will never reach the final destination. Successfully intelligent individuals get to where they are going. They follow through. They recognize the difference between lifelong learning and being a perpetual student!

8. Successfully intelligent individuals are initiators. Many individuals have to wait to be told what to do.  Or others spend time mulling things over for such a long time, they never make up their minds and pursue their goals.  An inability to initiate often results from a fear of commitment.  Successfully intelligent individuals usually do not have to be told what to do.  Successfully intelligent individuals see things that need to be done and they do them!
9. Successfully intelligent individuals are not afraid to risk failure. A fear of failure seems to begin early in life. If a person is a low achiever, because she or he has experienced so much failure, he or she takes an attitude of “why try again, I’ll only fail again”. They undervalue their skills and abilities because of all the failure they have experienced, and thus decide not to risk more failure. At the other end of the spectrum, those that are high achievers may also develop a fear of failure. Because they have been high achievers, they have not experienced failure and do not know how to handle it; thus they avoid situations in which they may risk failure for that reason. They will “play it safe” rather than appear foolish by a failure. A fear of failure results in a lack of motivation to achieve (whether a low achiever or a high achiever). Do you have a fear of failure? What holds you back from getting started towards reaching a goal?

Successfully intelligent individuals tend to have a need to achieve, and often take on tasks that have no guarantee of success. They are not afraid to risk failure. Think back to Regina, who put together a douche bag and IV tubing to create a system to deliver continuous tube feedings to patients. There was no guaranteed success to her contraption. But she did it anyway and it worked and solved a problem in her nursing unit. Even if they do fail, a successfully intelligent individual does not view it as a failure. They look at it as a gain of experience. They now know what not to do, correct their mistake and move on.

There is an old saying “Nothing ventured, nothing gained” that describes the risk taking of successfully intelligent individual. In other words, they are willing to try in order to gain a solution. And if in the course of trying they make a mistake or fail, they persevere.

10. Successfully intelligent individuals do not procrastinate. Let’s face it, we all procrastinate at times. But when we procrastinate, we don’t achieve. Less successful individuals can become expert procrastinators, getting so immersed in daily trivia it gobbles up their time. They never get started on long term goals. With many of these individuals it may take forever just to get everyday work done and they never get started on projects that could make a difference in their lives.

Another interesting item of note about procrastinators is that they are always pressed for time. It’s because they are always putting things off, then when a deadline is upon them, they have to rush to complete the task. Often in their rush to complete a task, they do not do a very good job either! Procrastinators are very often late for appointments and social functions-often to the irritation of their hosts. To help this person, help them set goals, both long term and short term. Often procrastinators underestimate the amount of time it takes to complete a task, which adds to them feeling pressed for time. Help them set reasonable time expectations to complete the various parts of a task. If you are having difficulties with procrastination and time management, find someone who you deem to be good at these things and seek their advice. Look for someone who amazes you in regard to how much they accomplish in a day.

Mary Ann is a nurse who is a great time manager.  She gets an enormous amount accomplished in one day. Besides working full time, she has three children, who are active in a variety of activities and Mary Ann herself is involved in some community and church activities. Yet she handles each day with a mastery of her time, accomplishing much and never seems to appear rushed. When asked about her productive life, she states she hates to waste time and it’s all in the planning and having a plan B to fall back on, just in case plan A fails! Successfully intelligent individuals are aware of the penalties of procrastination. They tend to schedule their time wisely. They schedule their time in order to get things done and done well. There is much to be learned about time management from a successfully intelligent person.

11. Successfully intelligent individuals accept fair blame. Some individuals accept no blame. They have an “I can do no wrong” attitude which only results in alienating others as they are perceived as being arrogant. On the other hand, there are others who accept blame for everything and are always apologizing, even for things over which they have control or accountability.

Misattribution of blame can be seriously debilitating.  If a person always accepts blame, it can result in low to no motivation to attempt anything. Successfully intelligent individuals accept blame for their own mistakes. They only accept blame if it is their fault.  Successfully intelligent individuals don’t make excuses or blame someone else. They may say something like: “I’m sorry; I made a mistake, let me correct that right now.” Furthermore, successfully intelligent individuals expect others to do the same.  Peggy is a nurse who works on a medical-surgical unit where a lot of post-operative abdominal surgery patients are admitted. Time and again, the wrong diets arrived from the dietary department for many of Peggy’s patients. Time and again, Peggy phones the dietary department to re-order meals for her patients.  Often the replacement meals do not arrive for an hour or more, leaving patients hungry and angry.

On Mr. Vittles’ third post-operative day and third day of incorrect meals, Mr. and Mrs. Vittles launched into an attack on Peggy. They were both irate that something as simple as the correct meal couldn’t seem to be delivered to Mr. Vittles. They even began to question whether he was receiving correct medications, since correct meals were not materializing. Peggy, tired of apologizing for this problem, over which she had no control, decided to take another approach. Peggy found the dietary director and asked her to pay a visit to Mr. Vittles.  Peggy escorted the dietary director into Mr. Vittles’ room and introduced them. Peggy explained to Mr. Vittles that the dietary director was the person who supervised the staff who prepared the patients’ trays, and that it was the director who could fix the problem.

Mr. Vittles then proceeded to air all his concerns about the meal problems to the dietary director.  Guess what happened after that? Right, the meal problem was fixed. Peggy had stopped accepting the blame for a problem over which she had no control.  But when the appropriate person was face to face with the problem, and accepted accountability, the problem got resolved.

As nurses, how many problems do we accept the blame for, on a daily basis, over which we have no control? If this is happening to you, you may be contributing to prolonging the problem by apologizing for it when you have no control over the problem. Be successfully intelligent and customer focused. It’s fine to say, “I’m sorry this has happened, but let me get the person who can fix this to talk with you.” Then follow through. Successfully intelligent individuals do not accept accountability for those things they cannot fix.

12. Successfully intelligent individuals reject self-pity. There are individuals who seem to wallow in self-pity. The self-pity seems to never end for some individuals. Everyone and everything in their life is wrong! Even if it a beautiful sunny day, the person sitting on the pity pot will find a reason why the beautiful sunny day is a problem. The self-pitying person reminds me of Eeyore who is always down about something. One wonders if some of these individuals even know how to smile or laugh. You say “good morning” to them and they respond with “What’s so good about it?” Excessive self-pity is both maladaptive and is off-putting to others. While the person is wallowing in self-pity, they are accomplishing nothing or if they do manage to accomplish something, it is usually poor quality work. After all, it won’t be right anyway, so why should they even try?

And while you started out as a pretty happy person, after being around this Eeyore, you are now feeling down, and you don’t know why!  Who wants to be around a person who wallows in self-pity?  Successfully intelligent individuals have little to no time for self-pity or poor quality work.  Be mindful of your own level of self-pity.  While you cannot change the behaviors of others, you can limit your exposure to these individuals, or at least recognize them for what they are and not allow yourself to be dragged down with them.

13. Successfully intelligent individuals are independent. Successfully intelligent individuals rely primarily on themselves. Successfully intelligent individuals do not expect others to take on their responsibilities. It is important to role model independence, self-initiation and motivation so that others may learn to do so as well. If one always tells and shows another how to do, they will never learn to be independent. Instead the person will learn to wait and be told and shown what to do and how to do it.

While some guidance needs to be offered in the beginning as someone is learning, it is then important for the individual to develop his or her tacit knowledge (learning without the assistance of others) in order to achieve independence. In precepting advanced beginner nurses, Sue often simply observes their actions, only intervening if she thinks the new nurse is going to do something dangerous or harmful to the patient. Sue is allowing her new orientees opportunities to develop their independence.

14. Successfully intelligent individuals seek to surmount personal difficulties. Everyone has sorrows or tragedies in their lives at times. The successfully intelligent keep their personal lives separate from their professional lives. They attempt to not allow personal problems to influence performance in a professional arena. However, one may be so devastated by a personal problem, that in spite of the best efforts, it may take a toll on one’s work. If one is distracted by a bitter divorce, physical abuse or an unexpected death, one may make mistakes at work. This can happen even to the best person.

However, it is the successfully intelligent person who recognizes the source of distraction and deals with it.  They may make an extra effort to be diligent or perhaps they take some time off until the sorrow passes, then they return to work without the distraction. However, some individuals may choose to wallow in their problems excessively.  This results in gross interference in their work and personal life.

15. Successfully intelligent individuals focus and concentrate to achieve their goals. Many individuals find they are easily distracted or have a short attention span. We see many individuals that have been labeled as having an attention deficit, and perhaps some of these individuals do indeed benefit from current medications. The problem with high levels of distractibility is that these individuals don’t get much done. But how many people simply never learned to focus and concentrate? Perhaps teaching these individuals how to create structure for themselves would be helpful.

Again, helping them create a to-do list and prioritizing it may be of assistance. Recognize when you do your best work. Some individuals are morning people, while others peak in the afternoon or evening hours.  If you are a morning person, you may want to tackle projects during the morning versus the afternoon when you experience the ‘slumps’.

What kind of environment does one need in order to remain focused? Some individuals seem to be able to be productive with music blaring, while others require quiet. Is there a time of day when you can be left alone with minimal or no interruptions?  Could someone else answer the phone? Could you close an office door to assure some peace and quiet?

At St. Good Sam’s Hospital, a Joint Commission inspection found nursing documentation to be woefully inadequate. Even the nurses were not satisfied with their own documentation. In arriving at solutions to fix this problem, the nurses recognized that the great number of interruptions and the fact they did not even have a desk to sit at were contributing to their documentation woes. One nurse hit upon the idea to use an empty janitor’s closet as an office. The nurses found two desks in the basement of the hospital and asked maintenance to move the desks into the closet that now had a hand written “Nurses’ Office” sign posted on the door.

Next the nurses procured (pirated from another office) two chairs and stocked the desks with their forms, pens and paper. They then implemented “office time” where the nurse who covered you for lunch would also cover your patients for you while you went into the office to complete your documentation. What the nurses found was that within twenty to thirty minutes tops, they were able to complete all their documentation, update care plans and patient teaching records. They also found they gave a better change of shift report.

When Joint Commission returned for a re-inspection, they gave accolades to the nurses for the vast improvements made in a short period of time. What these nurses did was create an environment where they could stay focused and concentrate on the task (documentation) at hand and gave it structure in the form of “office time”. What’s even more interesting is that this solution of a “Nurses’ Office” did not cost the hospital a penny! This illustrates quite a use of analytical, creative and practical intelligence on the part of these nurses. These nurses are successfully intelligent in that they became aware of the circumstances that would allow them to function at their best and they created and used that environment.

16. Successfully intelligent individuals spread themselves neither too thin nor too thick. When we spread ourselves too thin, we over commit and end up completing only small amounts on many projects, or do not complete projects at all. For those who over commit, learning to say no may be helpful. At the other extreme, there are those who spread themselves too thick and don’t commit to enough. Perhaps these individuals say “no thank you” too often.

In under committing, one misses opportunities and this may result in a decreased level of accomplishment. In fact, if one always declines invitations to take part in opportunities, eventually one will stop being invited at all.  Successfully intelligent individuals do not take on every opportunity that passes their way. But they do have a sense for knowing what is too little or too much for them to handle at any given time. Successfully intelligent individuals allot their time to achieve maximum performance, but they recognize when it is unrealistic for them to take on another project and decline respectfully. You might hear these individuals saying something like: “I’d love to participate on your committee, but right now I have other commitments that would preclude me from giving your project the attention it requires. I appreciate you asking me, but I’m going to decline this time.  If another project presents itself in the future, please consider me again.”

17. Successfully intelligent individuals have the ability to delay gratification. Many individuals seek rewards for accomplishing small projects. Perhaps the person is an author and writes only short articles and seeks to have them published, when he or she could have written a book and garnered even more success. Successfully intelligent individuals recognize success does not come overnight, thus it requires a delay in gratification. However, for those who are not willing or able to delay gratification, they often give up and abandon their goals.

Kelly graduated from college and had the goal of becoming a nurse. While at a community college taking her prerequisite courses, she became certified as a phlebotomist. She wanted a job in a clinic, offering Monday through Friday, 9 AM to 5 PM hours as did everyone else. Since the only jobs available were on the midnight shift with rotating weekends and holidays at the hospital, she abandoned the idea of being a phlebotomist to help her pay for school. Next Kelly became a certified nurses’ assistant and she desired work on a pediatric unit in the hospital, but only on the day shift.

Again, the only jobs available were on the afternoon and midnight shifts and there were no positions for CNA’s on the pediatric unit.  The only place she could find a day shift position was working as a CNA in a nursing home. Kelly, not wanting to work any shift but days and not wanting to work with the geriatric population, abandoned her goal of being a CNA. Kelly is not willing to delay gratification for working when and where she wants for a job in the meantime to help pay for nursing school. Plus, she has spent time and money on obtaining these two certifications and is now not using them. What will happen if she is successful in completing her nursing education, but isn’t able to obtain the “job of her dreams”?

Will she abandon nursing all together?  Successfully intelligent individuals recognize they may have to “pay their dues” first delaying gratification before they achieve their ultimate goal. Successfully intelligent individuals are willing to “pay their dues”.

18. Successfully intelligent individuals have the ability to see the forest for the trees. For some individuals, taking on a big project or task is too overwhelming for them. They choose to get bogged down in minutia and trivial details and are either unwilling or unable to deal with the bigger task at hand. And yes, small details can be very important at times. It is important to give the correct medication to the correct patient. It is important to deflate that urinary catheter balloon before one removes it. But some individuals obsess over these details checking, rechecking and triple checking and consulting with everyone, but in the meantime, the urinary catheter is still in the patient and has not been removed!

Successfully intelligent individuals, while paying attention to details, are able to sort out the consequential details from those that are inconsequential. Does it really matter if one deflates the urinary catheter balloon before one offers the patient a urinal?

Or is it more important to deflate the balloon fully with a syringe before one attempts to remove the catheter? Successfully intelligent individuals recognize there is more than one way to complete a given procedure, and they are able to maintain the integrity of a procedure, while entertaining various ways to complete the procedure. Successfully intelligent individuals know the answers to these questions: Why am I doing this?  What do I hope to achieve?  They see the forest for the trees.

19. Successfully intelligent individuals have a reasonable level of self-confidence and a belief in their ability to accomplish their goals. Self-confidence is essential for success. Too little self-confidence gnaws away at our ability to get things done due to self-doubts. If we constantly doubt ourselves, it results in a self-fulfilling prophecy or ineptitude and in action. If we don’t have confidence in ourselves, how can we expect others to have confidence in us? Being a nurse, it is essential to maintain a level of confidence in our actions as it provides a level of comfort to our patients.

If you were the patient, would you want a nurse who is exhibiting self-doubt about to undertake a procedure on you? Most people want someone who is confident that she knows what she is doing. At the other extreme are individuals who have too much self-confidence. These individuals often come across as being arrogant or won’t admit when they do not know all there is to know. Overly confident individuals often have difficulty admitting when they have made a mistake and perhaps need to make improvements. Often they are reluctant to ask for help when they need it. They may take on tasks or projects for which they are not or are ill prepared, resulting in calamitous errors.

Mark is a nurse who works in the ICU.  He was taking care of Mrs. Blupuffer when she began to experience difficulty breathing.  Mark had seen a number of patients intubated and since he knew where the endotracheal tubes were stored, he decided to intubate Mrs. Blupuffer. Mark had never intubated any other patient previously, nor was he granted that privilege as a practicing staff nurse. Needless to say, since he did not know how to perform the procedure, he botched it. Anesthesia was paged when another nurse saw what Mark had done and was able to successfully intubate Mrs. Blupuffer without further incident.

When discussing this incident with his nurse manager, Mark stated he thought it was entirely appropriate for him to attempt the procedure, since he had seen it done previously.  Because of the arrogance that often exudes from these individuals it may cause resentment from others.  Arrogance also blocks the free exchange of ideas, because the overly confident individual always has to be right.  Successfully intelligent individuals know how to strike the right balance of self-confidence and belief in their abilities.

20. Successfully intelligent individuals balance analytical, creative and practical intelligences. This is the definition of successful intelligence.  It knows when and how to use our analytical intelligence (critical thinking strategies), formulate new ideas with our creative intelligence, then put those plans into action by employing our practical intelligence.  Successfully intelligent individuals recognize there are times to be analytical while other situations call for creativity.  There are times to be creative, but there are situations that do not call for creativity.  One may not want a real creative accountant because one could find him or herself in trouble with the Internal Revenue Service!  Successfully intelligent individuals use a continuum of all three intelligences.  This allows for fluid thinking that yields problem resolution, productive individuals and a further gain in tacit knowledge.

In today’s world of healthcare with financial considerations, the rapid influx of new technologies, more patients, sicker patients, and ever more new procedures to learn, just to name a few of the things we deal with everyday, we need successfully intelligent nurses.  Healthcare is crying out for nurses who can move beyond inert knowledge and excel through the use of successful intelligence.  We need nurses who can analyze problems, create solutions, evaluate the best options, and put their plans into action.  It is hoped this series of independent studies has inspired the reader to think about one’s thinking (metacognition) and work towards honing one’s successful intelligence.

References

Benner, Patricia A, Tanner, Christine A, Chesla Catherine A. (2009) Expertise in Nursing Practice: Caring, Clinical Judgement and Ethics. 2^nd ed. New York, Springer Publishing Co.

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