Leadership Competencies in Nursing and Healthcare Essay

Using the Quality Improvement model you described in Week 3, provide a detailed explanation of the evidence-based practice plan that you will use to address the practice problem (6-10). Be sure to include the sources you found in the analysis of the evidence to support your EBP plan. Use appropriate and persuasive language that communicates meaning with clarity and fluency to readers, and is virtually error-free (see AWE Capstone Checklist). Leadership Competencies in Nursing and Healthcare Essay

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For this Assignment, write 4-5 paragraphs that address the following: does not need headings or title page

Evidence-Based Practice Performance Improvement Plan Explanation
Using the Quality Improvement model you described in Week 3 (attached) , provide a detailed explanation of the quality improvement plan that you will use to address the practice problem.
Use the sources you found in the analysis of the evidence (attached) to support the plan.-you can add more if needed-must be in last 5 years..peer reviewed if articles
This is a specific plan….must all flow with the previous paper(attached) and information attached because it will all go into one project. If you need other resources to support plan that is fine….make sure they are credible sources and last 5 years. Please cite in information. Leadership Competencies in Nursing and Healthcare Essay

To prepare for this Assignment:

Review the Capstone Paper Assignment Guide
Locate the most current version of your Week 3 Assignment. You will add this section to that document.
Review the Academic Writing Expectations Checklist Capstone Level
Note the new expectations for Use of evidence and Credit to Source
Use a Scholarly Voice
http://academicguides.waldenu.edu/writingcenter/scholarlyvoice
http://academicguides.waldenu.edu/writingcenter/webinars/scholarlywriting#s-lg-box-2773859
Review the Walden University Writing Center webpage: Using Evidence: Synthesis
Review the Week 5 Assignment Rubric
Remember: Each section of the Capstone Paper must meet the Academic Writing Expectations for the Capstone Level. Leadership Competencies in Nursing and Healthcare Essay

Use of Edmonton Symptom Assessment Scale to Determine Decline in the Hospice Patient
Leslie Hill
BSN, Walden University
NURS 4220: Leadership Competencies in Nursing and Healthcare
Dr. Debra Hairr
11/07/2020

Use of Edmonton Symptom Assessment Scale to Determine Decline in the Hospice Patient
Practice Problem
The Edmonton Symptom Assessment Scale (ESAS) is an effective way of determining a decline in the hospice patient. The scale is utilized in my practice and required at each visit. The practice problem evident by measurement terms was not having a skilled nursing visit 0-6 days before death. The misinterpretation of ESAS and not rating the symptoms correctly explains why the number of visits was not increased in the days leading to death, based on the information derived from tracking the ESAS. Leadership Competencies in Nursing and Healthcare Essay
The data used is from the QAPI tracker, which indicates we did not meet the goal of increasing skilled nurse visits as the patient declines in two of the last three quarters. The purpose statement of this project is to determine the root cause of the ESAS system and determine the possible solution to the problems.

Analysis of the Existing Evidence
The findings indicated a misinterpretation of the ESAS, resulting in errors in differentiating between symptoms such as tiredness and drowsiness (Leclair, 2016). Also, difficulties in translating the severity of the symptoms into numbers suggested misinterpretation of the ESAS. The hospice team confused the score with the symptoms, which is vital in determining the decline before the patient’s death (Venkat, 2016). In some cases, the patients died even when there was no increase in the severity of the symptoms; therefore, there was no increase in the number of visits (Lundh, 2018). The third item indicating a misinterpretation of the ESAS system is reverse scoring. Some of the recorded ESAS scores noted an increase in appetite, for example, and concluded positive results on the overall well-being of the patient rather than specifically indicating temporary improvement of appetite. This contributed to the conclusion that the patient did not decline; hence, the visits were not increased (Tanaka, 2017). Leadership Competencies in Nursing and Healthcare Essay
Difficulty in rating the ESAS symptom level is the second main problem suggested by Leman (2016). Lack of proper training and not asking for guidance from supervisors resulted in reports which indicated errors in interpretation, which suggested that interpreting symptom level was a challenge to a significant number of the hospice team (Leman, 2016).
In supporting the practice problem, Venkat (2016) attributes misinterpretation of the ESAS to difficulty in the ability to scale the symptom level of the patient. A research study by Leman (2016) on the impact of difficulty in differentiating symptoms on the patient’s outcome expounds on the correlation between misinterpretation of ESAS and reverse scoring of symptoms for example eating well for 1 day can be interpreted as symptoms improving.
Quality Improvement Process
Plan-Do-Study-Act is the quality improvement selected for testing a change by planning it, trying, observing the outcomes, and address problems according to the results obtained (Spath, 2018). The main reason for selecting this model is because it helps in developing specific improvement ideas. In achieving this, the model involves four steps: plan, do, study and act (Christoff, 2018). Leadership Competencies in Nursing and Healthcare Essay
Based on some of the findings concerning the patient’s decline and the use of the ESAS, the model can be used to develop a plan for the practice experience project with the first step being to identify an opportunity to improve and plan a change. In this case, the opportunity addresses the proper use of ESAS system to determine decline in the hospice patient and increasing nursing visits accordingly. Also, communication between the nurse and the patient /caregiver is a contributing factor that can be addressed as an opportunity. The plan for improvement in respect to this will involve educating the nursing staff on the proper use of the scale and the importance of asking the patient/caregiver each visit to properly scale the symptoms. If a decline is noted, skilled nursing visits would be increased accordingly..
The next step would be implementing the improvement plan and examine if there is improvement after the enhancement of the changes (Jiao, 2017). After the test, the results will be examined to determine if the goals were achieved such as skilled nursing visits 3 to 6 days before the patient expires. This includes using QAPI tracker to track the death of the patient and nursing visits. The QAPI tracker can also determine if skilled nursing visits increased as symptoms worsened according to the ESAS scores. Leadership Competencies in Nursing and Healthcare Essay

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Conclusion
The goal of hospice care is to provide every patient with the best quality of life through the dying process by offering support and symptom management. It is imperative to be aware of any decline in the patient and increase visits as the patient declines. Proper use of the ESAS is a valuable tool to determine the decline of hospice patients. The data from our QAPI tracker indicates that nursing visits were not made 1-6 days prior to death, indicating there is a potential problem with the proper use of ESAS. Research indicates that the problem lies in understanding the scale, misinterpreting the scale, or poor communication with the patient or caregiver. Using the plan-do-study-act quality improvement process will effectively improve the outcome of our QAPI scores by providing good education to staff and ensuring good communication with the patient and caregivers at each visit. Leadership Competencies in Nursing and Healthcare Essay

Literature Review
Hui, D., & Bruera, E. (2017). The Edmonton Symptom Assessment System 25 Years Later: Past, Present and Future Developments. J Pain Symptom Manage, 53 (3): 630-643.
The article discusses that the symptoms of hospice patients often fluctuate with time. This makes it essential to track patients longitudinally and record their symptom decline or progress. Accordingly, Edmonton Symptom Assessment System (ESAS) is to be administered at each clinic visit to record any symptom fluctuations. The article suggests further refinements to ESAS including integrating ESAS in electronic health records, coupling ESAS with individualized symptom goals to optimize symptom response assessment, and utilizing ESAS as a trigger for palliative care referral.
Richardson, L.A; Jones, G.W. (2009). A review of the reliability and validity of the Edmonton Symptom Assessment System. Curr Oncol, 16 (1): 55-70.  Leadership Competencies in Nursing and Healthcare Essay
This article discusses that ESAS is consistent but its validity is limited, and its utilization needs a logic clinical procedure to assist in interpreting the scores and provide a suitable level of attention. The authors establish that emotional symptoms are normally poorly captured using the depression and anxiety items. This is because the emotional components in ESAS are underdeveloped and need general adjustment. The authors suggests a separate tool to be developed that is similar to ESAS, which addresses more than ten emotional symptoms using nonpsychiatric labels and include symptoms representing additional disorders than just depression and anxiety.
Pereira, J.L., Chasen, M.R., Molloy, S., Amernic, H., & Brundage, M.D. et al. (2016). Cancer Care Professionals’ Attitudes Toward Systematic Standardized Symptom Assessment and the Edmonton Symptom Assessment System After Large-Scale Population-Based Implementation in Ontario, Canada: Systematic Standardized Symptom Assessment, Journal of Pain and Symptom Management, 51 (4): 1-19.  Leadership Competencies in Nursing and Healthcare Essay
The article states that some hospice patients do not understand aspects of the ESAS, hence can find difficulty completing it. This necessitates healthcare professionals and patients to be coached on the way to use the instrument properly. The authors claim that a person centered approach to care focuses on the call for for care providers to recognize and take into consideration the needs, preference, and illness experience of the patient. The article therefore suggests that the use of ESAS should be aligned with person centered approach to care, and acknowledge and address patient needs.
Rauenzahn, S.L., Schmidt, S., Aduba, I.O., Jones, J.T, Ali, N., & Tenner, L.L. (2017). Intehrating Paliative Care Services in Ambulatory Oncology: An Application of the Edmonton Symptom Assessment System. Journal of Oncology Practice 13 (4): 621-710.
The authors affirm that symptom burden still remains equally high from initial to follow-up encounters. Misunderstanding of the advantages of palliative care services is the greatest barrier to proper use of ESAS. This requires potential criteria to construct and apply a trigger that is supported on patient-rated symptom scores to assist patents and care providers manage symptoms. The article suggests the utilization of ESAS instrument with an electronic medical record-based provider alert that documents a predefined percentage of patients towards improving palliative care, symptom improvement as well as patient outcomes.  Leadership Competencies in Nursing and Healthcare Essay
Garyali, M.D., Palmer, L., Sriram, Y., Zhang, T., Pace, E.A., & Bruera, E. (2006). Errors in Symptom Intensity Self-Assessment by Patients Receiving Outpatient Palliative Care. Journal of Palliative Medicine, 9 (5): 1059-1065.
The article discusses that there is a possibility of error if nurses do not monitor routinely the way patients have completed ESAS form. It is necessary to be cautious regarding the ESAS scores that are performed by the patients especially for symptoms of appetite, sleep, and pain. The authors suggest that nurses need to carry the ESAS symptom score into rooms of patients and review symptom outcomes to make sure there is consistency. Symptom intensity assessment is very important in minimizing measurement errors among hospice patients since it assists to guide patient care. Leadership Competencies in Nursing and Healthcare Essay

Brandyn, D.Q; Aslakson, RA; Wilson, RF; Fawole, OA, et al. (2013). Methods of Improving the Quality of Palliative Care Delivery: A Systematic Review. The American Journal of Hospice & Palliative Care, 31 (2): 202-210.
The article discusses what patients experience with aggressive treatment in the last weeks of life. Palliative care is delayed until the last days of a patient’s life, and this results in palliative care used to manage death instead of treating the symptoms. The delay is caused by decreased access to palliative care, and fewer skilled nurse follow-ups on patients with complex and severe illness. The authors propose that timely care is necessary along with clinical information, caregiver and patient education, and individual-management.Leadership Competencies in Nursing and Healthcare Essay
Stilos, K; Wynnychuk, L; DasGupta, T; Lilien, T. (2016). Improving end-of-life care through quality Improvement. International Palliative Nursing, 22 (9): 430-434.
The article discusses that gaps exist in the quality of care given to imminently dying patients. This requires a high quality of care for dying patients and their families. Also, the care of imminently dying patients is ordinarily complex and requires skilled nurses. The author proposes that quality improvement interventions include; staff education and patient and family education.
Rawlings, D; Devery, K; Poole, N. (2019). Improving quality in hospital end-of-life-care: honest communication, compassion and empathy. BMJ Open Quality, 8 (2).
The authors propose that quality end-of-life care is hard to achieve if hospitals lack a workforce not trained to care for over half of the expected deaths that occur in their facilities. The authors claim that education is essential but cannot bring change by itself. It needs to be offered in combination with a practice toolkit that provides nurses with feasible ways to transform their practice continually. This can be through interventions such as communication, professional mind-set, professional practice, and patient-centered care.  Leadership Competencies in Nursing and Healthcare Essay
Sinuff, T; Dodek, P; You, J.J; Barwich, D; Tayler, C; Downar, J. (2015). Improving End-of-Life Communication and Decision Making: The Development of a Conceptual Framework and Quality Indicators. Journal of Pain and Symptom Management 49 86): 1070-1080.  Leadership Competencies in Nursing and Healthcare Essay
The authors affirm that there are still significant gaps in end-of-life communication for decision making for expected deaths. Communication and decision-making in the end-of-life aim to develop a shared understanding concerning a person’s values and treatment preferences. This leads to a plan of care that is consistent with the outlined values and preferences. Quality indicators connected to end-of-life communication and decision making include advanced care planning, proper documentation, proper organizational structures, and proper goals of care discussions.
Dobson, J. (2017). Providing high-quality care at the end of life; the role of education and guidance. British Journal of Nursing, 26 (20), 1116-1120.
The article discusses that Palliative care has been deteriorating as staff lack the needed knowledge of caring for dying patients. Those approaching the end of life deserve optimal care, attention, consideration, and compassion, yet this is not often the case. The article suggests that care of the dying must be based on individualized care planning for the patient approaching end-of-life. Additionally, nurses need to be trained further on how to care for dying patients.  Leadership Competencies in Nursing and Healthcare Essay

Leadership is essential to the successful management in the field of nursing. However, nursing leaders and employees have different views on the type of leadership style to be adapted for best results. Owing to the challenges in the nursing leadership, re-evaluation of current managerial tactics is necessary. A nurse leader must master delegation because it constitutes a critical portion of the effective leadership and success in the patient care. Since we live in a multi-cultural nation; good leaders should consider all aspects of a person including cultural diversity. Time management skills, self-efficacy and assertive communication are the other significant qualities of nurse leaders. All the attributes of a nurse leader influence the quality of care provided to the patients.
One of the nursing leadership approaches is transformational style. A transformational leader is the one who employs good and qualitative styles associated with improvement in patient care. This style inspires the others to develop and implement leadership qualities. It comprises charisma, self-confidence, inspiration, intellectual stimulation and individual consideration. The transformational leader motivates the other nurses; he is sensitive to the needs of his subordinates and communicates effectively. This style of leadership increases the staff satisfaction leading to an overall reduction of nurse turnover and an increase in patient satisfaction (Smith, 2011). Though transformational leadership promotes nursing excellence, the difference in the interpretation of the nursing styles between the nurse leader and the staff is often associated with decreased satisfaction with the leadership (Andrews, 2012). Leadership Competencies in Nursing and Healthcare Essay
Several studies have been done to establish a relationship between managerial competencies, personal characteristics and leadership style of the nursing leaders. Managerial competencies refer to the ability of the nursing leaders to manage the other nurses well. The managerial competencies of nurse leaders consist of characteristics like visionary leadership, conflict resolution, effective communication, problem solving abilities and teamwork. The issues requiring apt management by nursing leaders include conflict resolution and addressing the laziness of employees. A leader must, therefore, have qualities or competencies that help in problem solving and conflict resolution. A leader who is a great manager is the one who is long-sighted. A leader must be a person who considers the future and not just the present. The leader must know that future healthcare depends on the present health care. Another important attribute of a nurse leader is delegation. Delegation of work by the leaders increases the satisfaction amongst the employees and nurses working under them. All these characteristics and attributes positively correlate with the patient care both in the short- and the long-terms (Lorber & Savic, 2000). Leadership Competencies in Nursing and Healthcare Essay
There is no dearth of knowledge regarding the appropriate leadership styles for nursing fields. However, inappropriate leadership styles are used by the nursing leaders in many healthcare set-ups. Therefore, a uniform and unique healthcare model for all institutions must be formed so that the country can properly facilitate the reforms needed in the healthcare system or sector. The country must also facilitate the competency evaluation and consistent monitoring of the leader’s work so that the results can be seen and appreciated. The leaders that do not furnish appropriate results may be denied their leadership roles (Lorber & Savic, 2000).
The definition of leadership is multi-faceted. All sectors in the society, from the business to the financial sector and even the nursing or the healthcare sector require good leadership for greater productivity. According to Giltinane (2013), leadership in the working environment is of utmost significance. Direct involvement of the leadership is advised because leaders motivate the employees to go beyond the call of duty. The leader’s role is to ‘elicit effective performance from others.’ The leader influences and guides others towards positive results and productivity. They empower the employees and, therefore, increase organizational loyalty, job satisfaction and reduce sickness levels. The direct involvement of nursing leaders in the actual work of taking care of patients encourages the other nurses to work and to take care of the patients in a better way. Hence, the nursing leader must have personality traits, emotional intelligence and apt cognitive responses that are able to inspire others to work harder and better in their work stations. Thus, a positive productivity is associated with good leadership styles. Effective leadership also requires trust between the leader and the staff. Therefore, the leader should treat them fairly and acknowledge individual achievements. A good leader shows interest in the working of the staff, listens to their problems and helps them in decision making (Giltinane, 2013). Leadership Competencies in Nursing and Healthcare Essay
The leader is a person who can inspire those behind him. This means that the followers should be able to agree with their leader, and the leader should be able to make them see the things the way he sees them. Overall, there should be an agreement between the leader and the followers regarding the goal(s). A respectful leader is the one who inspires the subordinate(s) to achieve the positive and effective results of the laid plans (Boyle & Kochinda, 2004). The registered nurses are trained to use techniques of the goal-oriented path to delegate more effectively to the patient care tasks. Delegation is an entry level skill and is the ability to be able to assign duties well to the respective people. Lack of delegation skills is a potential cause for negative and adverse outcome(s) resulting from ineffective supervision (Boyle & Kochinda, 2004).
A good nursing leader must learn the skill of delegation through educational and practical experience. Thus, a nursing leader can’t live without the delegation power, and every success of a registered nurse will depend on their power to effectively delegate duties well. Delegation has the major role in leadership and has the determination of how the leaders perform their duties. The results in positive or negative outcomes in patients measure the level of delegation in nurses. Therefore, a successful leader is the one who possesses the qualities to delegate duties well to the subordinate staff (Dunham-Taylor, 2000). Leadership Competencies in Nursing and Healthcare Essay
Confidence is the value of self-belief that a nurse should possess to be able to delegate patient care tasks. Research shows that demographic variables, registered nurses leadership skills and confidence in delegation are related to the outcomes of patient care in a community teaching hospital. The level of confidence is vital in the process of delegating duties among the registered nurses. The low level of confidence affects the delegation of tasks by the nurses adversely and may result in poor patient outcomes. Therefore, the level of confidence in the nurse leaders directly influences to the productivity in the health centers (Saccomano & Pinto-Zipp, 2011).
In a recent study, it was hypothesized that registered nurses who demonstrated a supportive leadership style will report more confidence in delegating patient care tasks than the ones with either directive or participative styles. The hypothesis failed to hold from the research conducted and thus, the level of confidence was not justified as a measure to alter the delegating process. The level of confidence was then correlated to the delegation of duties by the nurses. In a healthcare setting, some departments help to develop the delegating skills while others do not. Therefore, the skill may or may not develop in the leader. Also, the level of confidence in the nurses will help in increasing the productivity level as they are aware of what they are doing and are not undertaking a trial process. If the nurses undertake their duty with confidence, their productivity levels are bound to increase (Saccomano & Pinto-Zipp, 2011). Leadership Competencies in Nursing and Healthcare Essay
The nurses serve the patients with very distinct cultural beliefs. Some of the issues that face the nurses due to such occurrences include the language barrier in cases where the nurse is serving a patient from a different ethnicity or with communication problems. Secondly, there can be the cases of prejudice. They may serve the patients with their belief about the patient or what they think rather than taking keen interest in the problem faced by the patient. Thirdly, they could be ethnocentric. The issue is more problematic where a nurse is serving patients from a country that has different ethnicities, religion and/or cultural beliefs. The nurse may serve in favor of some ethnic groups, religions or communities. In the case, a hospital is not in the position of solving the issue of biasness, the simple acts of favoring one group of patients and not-favoring the other group(s) may settle an institutional trend. This type of trends may lead to the loss of nurses as well as the healthcare organization(s). Therefore, much needs to be done about the issue of cultural competence in nursing students and faculty.  Leadership Competencies in Nursing and Healthcare Essay Psychological empowerment is considered as the best option to enhance the cultural competence. Nurses should be trained on how to give equal treatment to the patients of different backgrounds. They should have the capacity of understanding that every patient is as important as the others and the services and resources should be allocated equitably and not by bias of issues such as ethnicity, religion or race. A perception is very powerful and can lead to justice in any service. The decisions of nurses should be autonomous with a professional basis in the decision making process. This can be installed by bringing in such study fields in nursing schools as well as seminars in places of work. The nurses should be empowered by the knowledge and not pressure (Dreher, & MacNaughton, 2002; Lipson & Desantis, 2007). A nursing leader has several roles in a culturally diverse healthcare system. In any hospital setting with culturally diverse nursing workforce, the nurse leader should be fair and unbiased towards all the staff members irrespective of their background. Leadership directly affects the staff retention, level of motivation and quality of the care provided. Therefore, a good leader should be able to generate and maintain a diverse workforce for the provision of culturally relevant care.
According to Skim and Miller’s theoretical framework (1999),(I could not find this reference??) there is a given process of achieving a sensitive process of changing the perception of a nurse or healthcare provider. The process involves the steps mentioned below: Leadership Competencies in Nursing and Healthcare Essay

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• Understanding cultural diversity: Learning different cultural practices from other countries from where the practitioner might get clients.
• Increasing cultural awareness: It involves teaching the nurses to be mild on cultural decisions and not acting in the favor of some patients at the expense of others.
• Minimizing cultural sensitivity by uniting the community: This means that the patients work together with the medical practitioners in improving health standards. They communicate well and try to understand each other.
• Eradicate cultural competence behavior in the individual(s): In cases of cultural differences, the different cultures may be competing on usage of health resources. Nurses are not supposed to be a part of this fight. Therefore, they should remain neutral.

Such a process has the capacity of making a nurse act more professionally and avoiding being biased (Dreher, & MacNaughton, 2002). Leadership Competencies in Nursing and Healthcare Essay
In a study conducted in Australia, there was much effect of diversity on medical practices as well as medical practitioners and patients. Biases were noted in the nursing practice, and the patients with chronic diseases were very much affected in terms of the provided healthcare. Therefore, medical professionals need training on how to be of higher importance to such patients. The patients include diabetics, cardiovascular patients and others chronic disease patients. These patients need medical training on how to manage the illnesses and conditions when the medical practitioners are not around. The healthcare of these patients may be adversely affected if they are subjected to bias. Hence, the medical practitioners are needed to ensure a diverse cultural understanding of the community they are dealing with (Pardue & Morgan, 2008). Leadership Competencies in Nursing and Healthcare Essay
Another study was done in three different first world countries viz. the USA, Canada, and Switzerland. In all the three countries, the research gave a positive report about the diversifying services in the medical sector. Such diversities included overcoming language barriers. One of the best examples of the study was in the USA, in a clinic where physicians were facing a little challenge with language problems with some of their patients. They were not in a position to communicate perfectly with other patients other than the ENL speakers (ENL- English Native Language). The researchers brought interpreters of other languages and communication flow was improved. The result was evident from the customer satisfaction analysis. It proven that the services were appreciated 140% of the previous level of appreciation, an implication that diversifying cultural practices, such as teaching nurses different languages is of utmost significance to service improvement process in hospitals as well as clinics and also medical practices at homes (Pardue & Morgan, 2008). Leadership Competencies in Nursing and Healthcare Essay
Cultural diversity has been discussed as a way of improving the services of nurses and medical practitioners. It is of high importance to consider communication. To get better services, a nurse or any other practitioner must be in a position of understanding the language of the patient quite vividly, implying that the practitioner will be able to know the problem faced by his or her patient. For example, if a French speaking patient who does not communicate in fluent English is assigned to an American nurse, a communication breakdown is expected since most American health workers are trained in English (Flores, 2006).
In order to come up with a better understanding, medical practitioners should have cultural diversities. They should understand several languages and, therefore, be able to serve patients better. There is also a possibility of working with interpreters. It is, however, not only a matter of spoken language; the dumb might also need to be served in a hospital. They communicate using sign language. Interpreters of such signs should be available to ensure communication between the patient and the nurse (Gerrish, Chau, Sobowale & Briks, 2004). Leadership Competencies in Nursing and Healthcare Essay
Patients and medical practitioners need to work together interactively. Hence, there should be a clear understanding of communication from both sides. The nurses need psychological preparations that are of importance to them during the process of providing medical services to patients. Language barrier and other issues due to culture should be dealt with; they are a barrier to communication as well as efficient medical services. Patients with chronic diseases need attention and well stated instructions, since in the absence of doctors and medical practitioners they are supposed to nurse themselves. The process of treating them, therefore, needs to be communicated well to them, to avoid misunderstanding due to cultural differences including the language barrier (Flores, 2006).Leadership Competencies in Nursing and Healthcare Essay