Transformative Leadership in Critical Care


This reflective essay aims to reflect the experience and critically analyse the transformational leadership style and decision -making skills in a dynamic, complex Intensive Critical Care Unit (ICCU), where nursing interventions may change unpredictably, and decisions are made 'on-the-spot'. Clinical decision making and leadership skills based on personal traits rather than organisational activities will also be discussed (Azouay et al., 2019). Therefore, nurses must be competent in leadership and management of the critical situation by making the right decision at the right time to provide safe, effective and quality care (Sellgren, Ekvall and Thompson, 2008). The reflective assessment provides a scope to identify the leadership style and patient management practice in the ICCU for maximising safe and effective patient care (Balsanelli and Cunha, 2015).

This Reflection is a self-criticism (Bulman and Schutz, 2004) about self-awareness and self-challenge, leading towards new personal and professional dimensions. Reflection is the most beneficial learning tool that allows strength and limitations to gain professional knowledge (Coward, 2018). According to Ash and Clayton (2004), learning from reflection seems to be an effective way to analyse nursing practice, nurturing nurses' work and development critical thinking methods essential for providing high-quality nursing care in complex environments. Nursing and Midwifery Code of Professional Conduct (NMC, 2018) states that, nurses should be responsible for their own suitable learning experiences within a team or organisation, enabling them to clarify roles and promote advance, safe, and endure the practice (Garrouste-Orgeas et al., 2015).


In this essay, the Driscoll model (2007) as a reflective writing tool will be used for comprehensive analysis, focusing on the importance of leadership and critical decision making to enhance nursing competencies for future practice. As compared to other reflective models such as – Kolb (1984), Gibbs (1998), John's (2013), Driscoll (2007) model is highly relevant to the nursing field, to acquire quality outcomes based on three phases - 'What', 'So What' and 'Now What'. Even though this model is uncomplicated, however, it facilitates analysis of experience with a guideline for inclusion points at each point of the model to determine validity, inappropriateness and to recognise strategies for avoidance, repetition (Brewer et al., 2016).

Following the principle of confidentiality and privacy, all the subject's identifiable information remains confidential (Data Protection Act, 2018, Section 1.11, Section 2.5), NMC, (2018), the subject refers to John (Pseudonym). John was treated with compassion, respect, privacy, dignity and decency, to promote person-centred care, which are mainly the code of conduct of the nursing care and management where the nursing professionals try to provide the best treatment and continuous care to the patient (NMC, 2018).


This reflection based on caring for John, 65 years old male admitted to the Intensive Critical Care Unit (ICCU) due to acute respiratory failure, previous medical history (PMH), Abdominal Aortic Aneurysm (AAA), and ex-smoker.

John was sedated and paralysed as he was intubated and placed on mechanical ventilation at titration of a fraction of inspired oxygen (FiO2) 85%. His Glasgow Coma Scale (GCS) was 3. John’s was on spontaneous breathing. His blood pressure controlled with noradrenaline IV infusion and fluctuates during oral suctioning. He had clear secretion and very sensitive that little movements could dramatically alter his blood pressure and heart rate. According to his last arterial blood gas (ABG), his partial oxygen (PaO2) - 6.7 kPa, partial carbon dioxide (PaO2)- 6.0 kPa, pH- 7.0, bicarbonate – 17 mmol/l. He had a central venous catheter (CVC) at his right Internal Jugular vein (IJV) and arterial line on his right artery, two peripheral venous catheters (PVCs) on his right brachial and left radial, respectively. The nasogastric tube (NGT) and the catheter was in situ.

Despite 85% of FiO2, John's oxygen saturation was continuously dropping, and the newly qualified nurse was fixing his pulse oximeter probe on his finger when oxygen saturation dropped (Brilli et al., 2018). It was essential to check the ETT patency by suctioning if secretion obstructing airways, and thus, it was required to apply suction (Bambra et al., 2020). Despite experience in the ICCU, I could not take blood samples or do any clinical interventions due to limitations as a student nurse. Therefore, the health care team requests the newly qualified nurse to do suctioning and take a blood sample from John's arterial line for ABG analysis to check his PaO2 and PaCo2 level in PA's absence. When PA arrived, he consulted with the doctor before increasing FiO2 to 90%, based on ABG analysis and if John needed a prone position (Bass, 2008). However, John's SpO2 improved to its baseline without any need for a prone position. PA appreciated the decision to check ABG at the right time and also, for giving support to newly qualified nurses for taking blood samples and suctioning as she was anxious and unsure about the decision (Bassett and Westmore, 2012).

Despite the complexity of John's condition, empathy and compassion have been shown to him and to his family, who was in distress (Howell and Davis, 2018). Also, it helped and encouraged newly qualified nurses to become oriented to the dynamic environment of the ICCU, daily routine, hourly documentation, information regarding setting alarms and fluids input-output calculation (Jasper and Rosser, 2013).

Primary Issue- Management of Oxygen Saturation (SpO2)

So what

Mechanical ventilation is integral in the patient's critical care with acute respiratory failure in the Intensive Critical Care Unit (ICCU), where they receive efficient care with advanced respiratory support (Faculty of Intensive Care Medicine, 2019). The World Federation of Critical Care Nurse (WFCCN, 2019) defines critical care as comprehensive, unique, complex patient-centred care with complex interventions in a highly technical environment with a unique blend of knowledge and multi-disciplinary team (MDT). Therefore, the ICCU nurse is highly skilled in making decisions on the spot, proactively observing any physiological changes, and acting upon accordingly by assessing and raising concerns (Bloomer et al., 2019).

Spiers et al., 2015; Healthcare Safety Investigation Branch 2019, emphasised that, healthcare professionals should be proficient in acknowledging patient worsening signs to act appropriately to evade catastrophic results (Beaucham and Childress, 2009). Despite mechanical ventilation with FiO2 85%, John's SpO2 dropped to 89% that triggered deterioration in his condition due to lack of oxygen (Babiker et al., 2014). Additionally, before making any decision, knowledge of the patient's pre-medical history, domain-specific knowledge, and other conditions are essential to consider for making appropriate decisions (Benner et al. 1996). As John did not have PMH of COPD (SpO2 range 88%-92%), therefore, it was essential to maintain his baseline Sp02 >94% through efficacy clinical intervention and decision of providing ICCU treatment (Johnsen and O'Brian, 2016).

Thus, ABG's analysis decision was justified to check the degree of hypoxemia and imbalance of gases, electrolytes level that may cause supraphysiological changes in John’s condition that may lead to acute respiratory distress (Bas, 2018; Howell and Davies, 2018). British Thoracic Society (BTS) (2015) stated that, acute respiratory distress as a life-threatening condition in which there is an imbalance of gas exchanges (PaO2 and PaCo2) in the lungs to maintain the balance of metabolic demands, bilateral lung infiltration, hypoxaemia (i.e. PaO2 is <8.0 kPa or <60mmHg and hypercapnia, i.e. PaCo2 >6.0 kPa or 45 mmHg) that lead to alveoli damage (Han and Mallampalli, 2015; Johnsen and O'Brian, 2016). As a result, it may cause mismatched ventilation-perfusion, diffused impairment, alveolar hypoventilation, hypoxia, pulmonary oedema and reduce lung compliance (Bateman and Leach, 1998; BTS, 2015).

John’s condition was deteriorating due to low SpO2 subsequently, needed immediate clinical interventions, i.e. resetting ventilator settings, i.e. FiO2 level, Tidal volume (Tv), Minute Volume (Mv), PEAK flow, Positive End Expiration Pressure (PEEP) flow accordingly (BTS, 2015). This is a life-saving strategy, if not executed effectively, consequently, cause unnecessary mortality (BTS, 2015). Thus, in John's case, ABGs analysis's decision was accurate to assess his level of PaO2, PaCo2, and electrolytes to manage safe SpO2 level through adjustment in ventilator settings. Thus, this helped in increasing John’s PaO2 to >7.85kPa and avoided the risk of hypoxemia and lung injury (BTS, 2015). Therefore, it was significant to recognise John's low SpO2 and accurate oxygen management accordingly to ensure his safety and promote health and well-being.

Johnsen and O'Brian (2016) argued that, decision-making and leadership are the most challenging factors in ICCU, which has potential effects on patient care's positive outcomes. To support this, Moghaddam et al. (2018) described decision-making as consisting of interventions and effective strategies for improvement in patient life-sustaining condition to a more favourable, using professional knowledge, experience and complex clinical decision-making and leadership skills (Chreim et al., 2010). On contrary, inappropriate decision-making in nursing interventions leads to a negative impact on physiological responses in patient’s respiratory condition, i.e. increased metabolism that leads to increase oxygen requirements and immunocompromised (Azouley et al. 2018), and increases in mayo-cardiac workload (BTS, 2015). For example, it is necessary to develop intervention planning and make effective decision for the treatment of John, through collaboration among the doctors, nursing professionals, general physicians and therapist so that the health condition of the individual can be improved. Hence, all the health care professionals must be cooperative and work as partnership working practice for rationale decision making behaviour to deliver safe and effective care to the patient.

Similarly, Schwartz (2017); Garrouste et al., (2015) believed decision making as challenging in a fast-paced, complex ICCU environment where medical evidence is highly uncertain, incomplete, and decision errors may cause significant detriment. Therefore, Megan (2019) suggests, making a decision, it is critical to comprehend the potential continuum of respiratory decompensation and other comorbidities to safe and effective management of FiO2 in patients with respiratory distress.

Although, the decision regarding John's ABG analysis and management of his SpO2 based on empirical (professional/technical) knowledge, ethical, personal experience and aesthetic (intuitive) factors. However, there are different theories regarding decision-making based on intuitive and analytical thinking (Chen- yaoKao, 2014). However, it is straightforward but complex, built on intensive knowledge, uses innovative ways in nursing practice and a sense of patient interaction that allows trust in decision-making (Gobet and Clarkson, 2004). In contrast, beginners, trainee nurses use an analytic approach based on sound, conscious rationales when taking decisions (Sque et al., 2009). Patient diagnosis and analysing the health needs are necessary to make rational decision and develop good care plan for the patient.

Hence, the decision to maintain SpO2 and administration FiO2 was based on empirical and ethical principles of beneficence (to maintain SpO2) and non- beneficence (do not harm by excessive/ low administration of FiO2), (Bauchamp and Childress, 2019). Additionally, safe oxygen management (FiO2) is crucial as they are at high risk of getting excessive mechanical ventilator, ventilator-induced pneumonia, and thus, increase recovery time and more extended hospital stay (BTS, 2015), it was essential to administer safe FiO2 to sustain John's SpO2 to circumvent such complications, hence it is necessary to take immediate decision to treat the individual.

Bucknall et al. (2019) stated that, the nurse focus on creating proficient acquaintance, clinical decision-making and developing leadership skills for safe and effective patient care management. In John's case, inappropriate administration of FiO2 may cause adverse physiological sequelae toxic effects. Therefore, careful evaluation should be made according to the condition, aetiology and medical standards (Muthiah, 2009; Briel et al., 2010; Wozniak, 2014). If John did not receive adequate FiO2, this could alter arterial oxygen level, pH, cell hypoxia, and hypercapnia are affected (Higgins et al., 2018). Hence, it is crucial to consider sensible factors for the patient's safety during decision-making in assessment and safe oxygen management for acutely unwell patients with respiratory distress (Rossi et al.1995; Amato et al., 1998; Esan et al. 2010).

Henceforth, effective heuristics strategy needed for a quick assessment, recognition of pattern or rules, cues such as low SpO2, high respiratory rate, alteration in blood pressure that needs to amalgamated, previous experiences of equivalent context, help to generate hypotheses and consequently, proceed to judgement for decision making (Bulman and Shutz, 2013). On the other hand, whilst heuristic considered helping reduce uncertainty, it can negatively impact decision-making if not accurate (Gilovich et al. 2002; Elstein et al., 2005; Graber and Berner, 2008). Furthermore, as the attitudes like ignoring base rates, over-confidence, fatigue, hindsight, nurses' attributes, negative body language, and beliefs influence the decision-making process (Graberr and Berner, 2008).

Nevertheless, among decision-making theories, leadership is the centre of all decision-making process, to manage and impose appropriate strategies for safe, effective and compassionate person-centred care (NHS, 2018; West, 2020). Porter-O'Grady (2003); Bass (2008); NHS Leadership Academy (2011) described leadership as a multi-dimensional approach to achieve a well-defined aim and induce team members to act mutually to attain the common goal (Chen- yaoKao, 2014).

Further, the Department of Health (DOH, 2007) emphasises clinical leadership as promoting safe, effective, compassionate care values of the NHS to motivate others. Patrick et al. (2011) explain clinical leadership as combination of clinical capability, collaboration, mutual understanding, coordination, effective communication skills.

There are different leadership styles, e.g. autocratic, transactional, transformational, Laissez-faire, task-oriented leadership (Lamb et al., 2018). Despite personal limitations as a student nurse, transformational leadership style used to coax the newly qualified nurse to take John's ABG and apply suction to clear the obstruction in ETT, to check PaO2 and PaCo2 levels to manage John's SpO2 (Ash and Clayton, 2004).

However, autocratic leadership style includes closed-minded, power-oriented, and stringent to the rules (Bass, 2008). Burke & McLaughlin, (2013) believe transformational leadership as a democratic approach to motivate others and find autonomous opportunities to work for patient care and organisational goals. Similarly, Smith (2011) advocated that, transformational leadership in all organisational areas improved nurses' satisfaction, limited burnout with emotional intelligence, and created a desirable working environment. In contrast, Whitehead et al. (2009) argue that democratic leaders fail to control their team by providing leadership skills opportunities than issuing orders (Bulmar Smith et al., 2009).

Doody (2012) and Enwereuzor et al., (2016) argued that, transformational leaders motivates the followers to appeal to higher concepts, spiritual principles, and an in-depth collection of inner values and concepts that lead them to have a shared work ethic towards achieving the ultimate institutional goals. Similarly, Hunziker et al. (2013) agreed that, effective leadership is responsible for enhancing team performance, while Lamb et al. (2018) agreed that, clinical nurse professionals are responsible for offering advanced specialised clinical advice and leadership to support the staff with the management of complex patients. Sample for ABG analysis, she agreed to take John's arterial blood sample. Cousee and Sikula (2011) explained that, nursing leadership's main essence is to improve the practice environment and implement critical decisions for the patient's best interest and enhance patient safety and promote compassion (Fischer, 2017). Thus, leadership means influencing others to improve a patient's care provision (Cook, 1999; Weihrich and Koonz, 2005; Sullivan and Garland, 2010).

As an illustration, Michael (et al., 2020) argues that, nurses required leadership style, clinical judgement skills, appropriate management and a systematic approach. On the other hand, according to Curtis et al. (2011), merely taking on a nursing leadership role ensures quality and effective leadership is not adequate; however, leaders must equip with the right skills and knowledge for safe and efficient practice (Rowold and Rehmann, 2008). The immediate intervention was to monitor his PaO2 and PaCo2 level to manage his FiO2 to maintain his SpO2 through ventilator settings (Raghubir, 2018). John's low SpO2 indicates lack of oxygen, as he was at risk of becoming hypoxic (Raghubir, 2018). Therefore, nursing leadership's essence lies in implementing necessary clinical interventions and emphasis on the responsibilities of nursing professionals to enhance patient outcomes through knowledge, effective communication and clinical practice (Lee et al., 2011; Chreim et al., 2010; NMC, 2018).

As a matter of fact, to guide thinking and performance emotional intelligence (EI) also plays a vital role in leadership (Goleman, 1998). Colman, (2008) describes EI, which is more close to ‘empathy’, as a skill to govern our emotions as well as others. As John's family was in distress, showing empathy and compassion, it was essential to ease their distress through EI (Leary, Reilly and Brown, 2011). There are different models of leadership such as ‘The trait model’, ‘The ability model’ focus on self-awareness of nurses’ ‘behavioural disposition’ (Petrides and Furnham, 2001) regarding EI, to improve the health and mental well-being of the patients and families as they receive hope for wellness from the positive gestures of the nurses (Ranaud et al., 2012). Thus, consequently, enables nurses to make better decisions and promote compassion (Smith et al., 2011; Renaud et al., 2012). In such situation, transformational leadership is beneficial to ensure emotional intelligence through individualised skill enhancement and continuous creative decision making behaviour. The transformational leader focuses on empowering the staff in nursing care and management, motivate them and encourage their creativity to develop good decision (Leary, Reilly and Brown, 2011).

Additionally, a study by Nabiha et al. (2016) showed that, compassion and EI positively impacts one's leadership skills leading to teamwork (Sergul et al., 2011; Raghubir, 2018). West (2016) argues 'compassionate leadership' as reimbursing attentiveness towards staff to share an understanding of the clear vision (Lee and Stinson, 2014). On the contrary, Hougaard et al., (2020) argued that, compassion is essential; however, it is not sufficient. Lack of compassion and EI may negatively impact patient care outcomes. However, studies have shown that compassion and EI, constructive behaviour of nurses (Joseph and Newman, 2010; O,Boyle et al., 2011;) patient and family satisfaction positively correlated with decreased adverse effects (Balsanelli and Cunha, 2015).

Although, in John’s case, there were no conflicts regarding decision making and adopting leadership approach. However, there is role ambiguity; differences in hierarchy exited in the team due to diverse professional roles, experience, training level and education, which had a potential impact on leadership style (Johansen and O’Brien, 2016). During decision-making regarding ABG analysis, the newly qualified nurse was unsure of taking ABGs analysis (Nabiha, Metwally and Nawar, 2016). PA had consulted with the doctor for further direction to increase Fi02 and considered whether John needs a prone position or not; as a result, it was evident that professional qualifications contribute to the hierarchy differences, impacting nurse’s role, confidence and patient care quality (Grossman and Valiga, 2009).

Nevertheless, due to the patient's unpredictable physiological conditions and situations in the ICCU, no particular leadership style can be adopted. However, a flexible approach in leadership is needed. According to Hawkins and Thornton (2002), there is limited evidence available on leadership style within ICCU; however, the prominent fundamental nature of leadership is to impose the effective management of strategies competently to promote safety, improve patient outcomes and collective team performance with effective communication (Institute of Medicine, 2004; West et al., 2015). Similarly, the Royal College of Nursing (RCN) (2021), accentuated personnel, regardless of their status, acts as role models to achieve organisational aims and optimal patient care (Fischer, 2017).


On reflection, I realised working in the ICCU is challenging. Although, the quick decision of ABG was able to bring John's condition back to stability, however, there is much to learn in the ICCU and need extensive knowledge regarding the complexity of the patient's condition and high-tech equipment (Doyle and McCutcheon, 2015). It is essential to stay attentive and be quick in making decisions as the patients in ICCU require accurate, practical, and quick on-the-spot procedures.

In decision-making process, some actions need to be revalidated to improve decision-making skills and future practice by using other tools, i.e. cognitive and societal judgement analysis. Accurate assessment and judgement to gather quality information prior to decision making, need to be reconsidered (Curtis and O’Connell, 2011). Further, I learnt how heuristics approach, biases or unwise decision have the potential risk to alter patients' positive outcomes and may risk to patient safety. Thus, reflecting on personal biases, values, beliefs are essential to be dealt with for improvement in future practice.

Throughout the procedure, compassion, empathy has shown and develops communication skills as well as emotional intelligence, confidently (Enwereuzor, Ugwu and Eze, 2016). I have learnt that, co-operation and transparency are essential to make any decision by developing transformational leadership styles. However, there is no particular leadership style that works in ICCU (Fan et al., 2017). Therefore, it is crucial to be confident, competent and flexible to develop transformational leadership style with continuous motivation and support to other colleagues (Coward, 2018). Also, I need to be attentive, accountable for actions in order to safe, effective patients care (Babikar et al., 2014).

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Further, I need to learn a multi-disciplinary perspective regarding clinical decision-making, leadership skills, nursing issues, and developing an organisational culture to promote compassion, safe, effective high-quality person-centred care (Huston, 2008; NMC, 2015).

Finally, this reflection is beneficial, enabling me towards self-awareness of my strengths and limitations as a student of nursing. I will continue to develop decision-making and leadership skills in future for my professional development in delivery of safe and effective care to achieve organisational goals.

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