Nurse 243: Exam #1 Leadership and Management; Career Planning and Development in Nursing; Creating a Motivating Climate; Scope of Practice and Delegation

Staffing

- Consists of recruiting, interviewing, hiring, and orienting staff. Scheduling, staff development, employee socialization, and team building are also often included as staffing functions.

Over-delegating

-Poor managers of time may over-delegate -Feel insecure in ability to do a task Improper Delegation -Wrong time, wrong person, wrong reason -Delegating beyond capability of person being delegated to -Level of supervision available (micromanaging or no supervision)

MOTIVATION THEORIES

1. MASLOW: HIERARCHY OF NEEDS 2. SKINNER: OPERANT CONDITIONING AND BEHAVIOR MODIFICATION 3. HERZBERG: MOTIVATION-HYGIENE THEORY 4. MCCLELLAND: NEEDS CATEGORY 5. MCGREGOR: THEORY X AND THEORY Y 6. VROOM: EXPECTANCY MODEL

Reasons for Delegation

Delegate routine tasks so that you can handle more complex issues Delegate if someone else is better prepared or has greater expertise or knowledge on how to solve a problem Provide learning opportunities for subordinates -Subordinates may be come bored, nonproductive, or ineffective without more challenging tasks to perform; delegation contributes to personal and professional development of both the RN and UAP.

Kouzes and Posner's Five Practices for Exemplary LeadershipFive Practices for Exemplary Leadership

Modeling the way Inspiring a shared vision Challenging the process Enabling others to act Encouraging the heart Copyright © 2021 Wolters Kluwer • All Rights Reserved 19

FIVE RIGHTS OF DELEGATION 1. Right Task

One that is delegable for a specific patient FACTORS TO BE AWARE OF: Policies & Procedures Scope of Practice Knowledge required Standards of practice Potential for harm Predictability of outcome

PROFESSIONAL CERTIFICATION

One way an employee can demonstrate advanced achievement of competencies. BENEFITS OF SPECIALTY CERTIFICATION: Sense of accomplishment and achievement Validation of knowledge and skills (RN licensure only measures "ENTRY-LEVEL" competence) Promotes greater autonomy of practice Increased chance for rapid promotion on career ladders Earn more than their NON-certified counterparts ADVANCED TRAINING (CONTINUING EDUCATION) EXAMPLES BLS (Basic Life Support) ACLS (Advanced Cardiac Life Support) PALS (Pediatric Advanced Life Support) TNCC (Trauma Nursing Core Course) ENPC (Emergency Nursing Pediatric Course) NRP (Neonatal Resuscitation Program) CARN (Certified Addictions Registered Nurse)

The Hawthorne Studies—Elton MayoElton Mayo

Paying attention to your employees can affect productivity via the Hawthorne effect. - When being watched you behave better

Nurse Delegation: Washington Administrative Code (WAC)

The delegating nurse shall... • determine the competency of the individual • evaluate the appropriateness of the delegation based on the nursing process • supervise the actions of the person performing the task • delegate only within the scope of the RNs practice

HOW DO I SIGN MY NAME?

1. Highest earned degree 2. Licensure 3. State designations or requirements 4. National certifications 5. Awards and honors 6. Other recognitions The highest degree is listed soonest after your name A higher degree in the same field eclipses a lower degree For example, once I got my MSN, I didn't put BSN after my name Having a master's degree in nursing implies that I also have the baccalaureate nursing education which comes before it Carley Borgen, MSN - not Carley Borgen, MSN, BSN If you have degrees from different fields, you may want to list them For example, Susie Sunshine has her MBA, then gets her MSN: Susie Sunshine, MBA, MSN Do not list ADN after your name An associate degree is the minimum required for RN licensure, so if you have your RN license, the ADN is implied If Susie Sunshine had no other degrees, but graduated from the Shoreline program and passed the NCLEX, she would write it as: Susie Sunshine, RN - not Susie Sunshine, ADN, RN Degrees are always listed first because they cannot be taken from you, and they cannot lapse - licensure may be revoked, and may lapse If you pursue an advanced practice nursing degree, the state you are practicing in may have requirements or designations that you are required to list in a certain fashion after your name National certifications come after degrees and licenses For example, if Susie Sunshine gets her BSN and her certification in critical care, she would sign: Susie Sunshine, BSN, RN, CCRN

FIVE RIGHTS OF DELEGATION 5. Right Level of Supervision

Appropriate monitoring, evaluation, intervention as needed, and feedback FACTORS TO BE AWARE OF: Patient response to the delegated task Performance of activity HOW TO SUPERVISE PROPERLY: 1. Provide supervision expectations 2. Release control - allow the person to complete the task 3. Monitor and give guidance as needed 4. Provide corrective instructions if necessary 5. Ensure proper documentation is completed

FIVE RIGHTS OF DELEGATION 2. Right Circumstance

Appropriate patient setting, available resources, and other relevant factors considered FACTORS TO BE AWARE OF: Health status of the patient Complexity of the task or activity Supervision available

Great Man Trait Theories: Are Leaders Born or Are They Made?Are Leaders Born or Are They Made?

Behavioral Theories (Lewin, White & Lippit - p.46-47)(Lewin, White & Lippit -) Autocratic or authoritarian Democratic or participative * Take longer to get done but people feel more empowered Laissez-faire, permissive, or free rein * No oversite from management

SCOPE OF PRACTICE: NAC/NAR

COMPLETE CHAPTER for NURSING ASSISTANTS IMPORTANT SECTIONS 246-841-400: Standards of practice and competencies for nursing assistants 246-841-405: Nursing assistant delegation NURSING ASSISTANT COMPETENCIES CPR Vital Signs Height & Weight Intake & Output Eating and Hydration Activities of Daily Living *Recognize normal body functions & deviations* And timely reporting of the changes to the RN NURSING ASSISTANT COMPETENCIES: Personal care skills Mental health and social service needs Care of cognitively impaired residents Basic restorative services Client or resident rights and promotion of independence Communication and interpersonal skills Infection control Safety and emergency procedures Rules and regulations knowledge

FIVE RIGHTS OF DELEGATION 4. Right Direction/Communication

Clear, concise description of the task, including its objective, limits, and expectations FACTORS TO BE AWARE OF: Oral or written clarity Clarity of direction and supervision Reporting requirement Time constraints Re-check for understanding Don't ignore nonverbal communication

Supervising a Diverse Team

Cultural considerations o Self-awareness of biases o Enhancing awareness in the team o Legal / Title VII / Civil Rights Act o Staff consistent with clients Generational considerations

Nursing Scope of Practice Defined Boundaries

Defined boundaries • Federal laws • RCWs & WACs • Interpretive Statements Educational Qualifications • Formal nursing training • Knowledge • Experience • Training • Competency Standards of Practice • Professional organizations • Accrediting organizations • Evidence-based nursing Facility Boundaries • Policies & Procedures • Protocols

Definitions

Delegation • Directing the performance of one or more people to accomplish organizational goals (ANA and NCSBN). Supervision • Provision of guidance, oversight, evaluation, and follow-up by the Licensed Nurse for accomplishment of a delegated nursing task by assistive personnel. ACCOUNTABILITY -Responsible and answerable for actions or inactions of self and others in the context of delegation. RESPONSIBILITY -Reliability, dependability, and the obligation to accomplish work when an assignment or delegation is accepted.

Delegation in the Community-Based Setting

Delegation of nursing care tasks in community-based care settings and in-home care settings is ONLY allowed for individuals who have a stable and predictable condition. EXAMPLE: • "Stable and predictable condition" means a situation in which the individual's clinical and behavioral status is known and does not require the frequent presence and evaluation of a registered nurse. A home health or hospice registered nurse may delegate the application, instillation, or insertion of medications to a certified nursing assistant under a plan of care. FACTORS TO CONSIDER: • Resident is in a stable, predictable condition • Task will be performed by NAC who has completed state course in delegation (COMPETENCIES) • Proper documentation that NAC has received training and clear and concise instructions • RN evaluates outcome of delegation

SKINNER'S OPERANT CONDITIONING AND BEHAVIOR MODIFICATION

Developed by B.F. Skinner in the 1940s. • Contributed towards the understanding of motivation, dissatisfaction and productivity. • His research demonstrated that "people could be conditioned to behave in a certain way based on a consistent reward or punishment system" • Behavior that is rewarded will be repeated and behavior that is punished or goes unrewarded is extinguished. • REINFORCERS: elements that encourage good behavior • PUNISHERS: elements that decrease likelihood of good behavior • NEUTRAL OPERANTS: environmental influences that neither encourage nor discourage • What are some nursing considerations you can derive from Skinner's Theory?

MCCLELLAND'S THREE NEEDS CATEGORIES

Developed by David McClelland in the 1970s. He wanted to examine what motives guide a person to action. • He believes that people are motivated by three basic needs: achievement, affiliation, and power. • ACHIEVEMENT-ORIENTED: quantity over quality; focus on improving task, transforming ideas into action, taking risks when necessary • AFFILIATION-ORIENTED: quality over quantity; overt productivity is less, focus their energies on families, friends, relationships • POWER-ORIENTED: motivated by power, they want to command attention, get recognition, and control others

Situational & Contingency Leadership Styles

Differences between situational and contingency.

Planning

Encompasses determining philosophy, goals, objectives, policies, procedures, and rules; carrying out long- and short-range projections; determining a fiscal course of action; and managing planned change

MOTIVATION STRATEGIES

Establishing credibility Being a role model Taking a genuine interest in others Shared-decision making Offer constructive criticism CREATING A MOTIVATING CLIMATE Worker Empowerment Incentives & Rewards Supervisor & Employee Relationship

Leader Transactional

Focuses on management tasks Is directive and results oriented Uses trade-offs to meet goals Does not identify shared values Examines causes Uses contingency reward

Common Pitfalls in Delegation

Following routines blindly without rationale • Geographic assignments • Numerical assignments • Popularity assignments Failure to clarify staff roles, expectations, and job descriptions Failure to clarify individual abilities and experience Failure to define parameters for reporting or taking action Failure to be accountable for scope of practice

Generational Diversity in Nursing

Generation Year of Birth Silent generation 1925 to 1942 * Baby Boomer 1943 to early 1960s * workaholics * Work to live Generation X Early 1960s to 1980 * Both parents working outside of the home * Work life balance Generation Y 1980 to mid-1990s * Millennials * Change jobs frequently for better opportunities * Grew up with technology * Working in groups and using social media Generation Z 1996 to 2015

ANA & NCSBN Joint Statement on Delegation

Goal: To facilitate & standardize the nursing delegation process Delegation process is multifaceted Starts at administration level of the organization Extends to the staff responsible for delegating, overseeing the process, and performing the responsibilities As you can see, delegation is multifaceted. In the center, you see public protection. That is the overarching goal of delegation - to keep the patient safe. That is why delegation is so important. Nurse Leader or Employer responsibilities Determine what tasks can be delegated, to whom, and under what circumstances Develop delegation policies and procedures Promote positive culture/work environment Communicate information about delegation process and delegatee competence level to licensed nurses Provide training and education on potential tasks to delegatees Licensed Nurse Responsibilities (RN) Determine patient needs and when to delegate Ensure availability to delegatee Evaluate outcomes of and maintain accountability for delegated responsibility Two-way communication with delegatee Delegatee Responsibilities Accept activities based on own competence level Maintain competence for delegated responsibility Maintain accountability for delegated activity

Good Leaders and Managers

Good Leaders o Envision the future o Communicate their visions o Motivate followers o Lead the way o Influence others to accomplish goals o Inspire confidence o Take risks o Empower followers o Master change Good Managers o Coordinate resources o Optimize resource use o Meet organizational goals and objectives o Follow rules o Plan, organize, control, and direct o Use reward and punishment effectively to achieve organizational goals Copyright © 2021 Wolters Kluwer • All Rights Reserved 6

Transformational Leader

Identifies common values Is a caretaker Inspires others with vision Has long-term vision Looks at effects Empowers others Copyright © 2021 Wolters Kluwer • All Rights Reserved 20

Strategies for Successful Delegation

Identify necessary skills and education levels Plan ahead Select and empower capable personnel Communicate goals clearly Monitor the role and provide guidance Set deadline and monitor progress Evaluate performance

EDUCATION LEVELS

In 2010, IOM (now NAM) recommended "increasing proportion of nurses with a baccalaureate degree to 80% of nurses by 2020." Why is the NAM making recommendations for US nurses? Because nurses: Are the largest segment of the nation's healthcare workforce. Work front line. Play a VITAL role in helping actualize healthcare. Are vital in the implementation of new healthcare acts. What are the different types of nursing degrees available? LPN/LVN (1-2 years vocational) LPN to ADN or LPN to BSN (1-2 years) ADN-RN (pre-req + 1.5-2 years) ADN to BSN (1-2 years) BSN (traditional 2 years pre-req + 2 years) Accelerated BSN (2 years pre-req + 1 year) BSN to MSN is the traditional route but RN (ADN) to MSN is available MSN (Master of Science in Nursing) Different pathways: Leadership (rewards MSN, RN) Informatics (rewards MSN, RN) Advanced Practice (rewards MSN, ARNP) Nurse Midwifery (rewards MSN, CNM) Nurse Anesthetist (rewards MSN, CRNA) Education (rewards MSN-Ed) Clinical Specialty: Clinical Nurse Leader (rewards MSN, RN, CNL) Clinical Nurse Specialist (rewards MSN, RN, CNS) Doctorate (DNP or PhD) What is the difference? DNP stands for Doctor of Nursing Practice (CLINICAL) 2-4 years full time depending on specialty, and at least 2,000 clinical practice hours Focus can be in executive leadership, population health, advanced clinical practice, health policy, health technology, education leadership Rewards (DNP, potentially ARNP) PhD stands for Doctor of Philosophy in Nursing (RESEARCH) 3-4 years full time, and original research and evidence (THESIS) Rewards (PhD)

Organizing

Includes establishing the structure to carry out plans, determining the most appropriate type of patient care delivery, and grouping activities to meet unit goals Other functions involve working within the structure of the organization and understanding and using power and authority appropriately.

Controlling

Includes performance appraisals, fiscal accountability, quality control, legal and ethical control, and professional and collegial control

What RNs May Not Delegate

Initial nursing assessment and subsequent assessments if nursing judgment is needed Decisions/judgments about nursing diagnoses Decisions/judgments about outcomes Determination/approval of plan of care Interventions that require professional nursing knowledge, decisions, or skill Administration of meds (except within specific provisions) Piercing of tissues (except insulin) Evaluation of the plan of care

Critical Aspects of Effective Delegation

Knowing when not to delegate • Identifying to whom to delegate • Determining what to delegate • Supervising delegated tasks • Matching the task to the person to whom it is delegated

Scope of Practice: LPN

LICENSED PRACTICAL NURSES: Function in an INTERDEPENDENT role to deliver care as directed and assist in the revision of care plans in collaboration with the registered nurse. Function in a DEPENDENT role when executing a medical regimen under the direction and supervision of MD, ARNP, etc. Never has an INDEPENDENT role The LPN Is responsible for providing nursing care to clients in stable and predictable situations. May delegate to NACs. Has a dependent role in the nursing process. Requires supervision by law. "Under the supervision of a RN, may administer drugs, medications, treatments, tests, injections, and inoculations, whether or not the piercing of tissues is involved and whether or not a degree of independent judgment and skill is required..." LICENSED PRACTICAL NURSES: Recognize and can meet the basic needs of the client and give care under the direction and supervision of the RN, to clients in nursing situations that are ROUTINE: Relatively free of complexity Clinical and behavioral state of client is relatively stable Requires care based upon a relatively fixed and limited body of knowledge Functions as an assistant to RN in complex situations. May NOT accept delegation of acts that are not within their scope of practice.

Commonly Delegated Tasks for LPNs and NACs

LPN Medication pass Non-invasive procedures: EKG, venipuncture, IV start Basic nursing skill for a stable, predictable patient NAC Non-invasive and non-sterile treatment Vital signs, height and weight Intake and output Capillary blood check Urine test Ambulation, positioning, turning Transporting patient within a facility Personal care skills Activities of Daily Living Assistance with eating

Leadership versus Management

Leadership o Empower others; maximize workforce effectiveness o Needed to implement the planned change that is part of system improvement Management o Guide, direct, and motivate others o Intervene when goals are threatened o Emphasize control

Leadership

Leadership is the art of getting work done through others willingly. Leaders are in the front, moving forward, taking risks and challenging the status quo. A job title alone does not make a person a leader. Only a person's behavior determines if he or she occupies a leadership position.

Scope of Practice: RN

REGISTERED NURSES: Perform acts that require SUBSTANTIAL knowledge, judgment, and skill based on the principles of biological, behavioral, health, and nursing sciences. The registered nurse, using specialized knowledge, can perform the activities of administration, supervision, delegation, and evaluation of nursing practice Independent role When using the nursing process for complex patients May revise nursing plan of care independently Interdependent role Coordinating/evaluating care of client Executing medical regimen under direction of MD, ARNP, etc. May not accept delegation of acts outside RN Scope of Practice

Under- delegating

RN afraid if the task is delegated, then this may be interpreted as a lack of ability Desire of delegator to complete all pieces of the job RN might be afraid to delegate a task for which they are ultimately responsible Not enough time to delegate because it takes time to explain task RN fails to anticipate the help they will need

Accountability & Responsibility

RN ultimately responsible for ensuring patients receive appropriate, high-quality care RN accountable for delegated tasks Only RNs have formal authority to practice nursing Any activities relying on nursing process or requiring specialized skill, expert knowledge, or professional judgment should never be delegated

FIVE RIGHTS OF DELEGATION

Right Task Right Circumstances Right Person Right Direction/ Communication Right Level of Supervision One that is delegable for a specific patient Appropriate patient setting, available resources, and other relevant factors considered Right person is delegating the right task to the right person to be performed on the right person Clear, concise description of the task, including its objective, limits, and expectations Appropriate monitoring, evaluation, intervention as needed, and feedback

FIVE RIGHTS OF DELEGATION 3. Right Person

Right person (RN) is delegating the right task to the right person (UAP) to be performed on the right patient. FACTORS TO BE AWARE OF: Job descriptions Scope of Practice Skills and abilities of delegated person Special competencies *GENERAL RULE* Do not delegate a task to a person that has never performed the task before. INSTEAD, you can teach them the task and appropriate documentation so that they can perform it independently next time.

BENNER'S STAGES OF CLINICAL COMPETENCE

STAGE 1: Novice No experience in that which they are expected to perform. STAGE 2: Advanced Beginner Demonstrates marginally acceptable performance due to prior experience in actual situations. STAGE 3: Competent Develops a plan that is conscious, abstract, and efficient. STAGE 4: Proficient Perceives situation as a whole and understands its meaning in terms of long- term effect. STAGE 5: Expert Has intuitive grasp of each situation.

Subordinate Resistance to Delegation

Subordinates may respond to delegation with resistance. Common causes: Failure of the delegator to see the subordinate's perspective Increased workload for UAP Inherent resistance to authority Testing the water, pushing boundaries Over-delegation RN should try to mix routine and boring tasks with more challenging and rewarding assignments

Management Theory Development

Taylor—scientific management Weber—bureaucratic functions Fayol—management organizations Gulick—activities of management Follett—participative management Mayo—Hawthorne effect McGregor—theory X and theory Y Argyris—employee participation Copyright © 2021 Wolters Kluwer • All Rights Reserved 13

SCOPE OF PRACTICE: LPN & IV THERAPY

The LPN may administer fluids, medication, Total Parenteral Nutrition (TPN), blood or blood products via central venous catheters and central lines, access these lines for blood draws and administration of emergency cardiac medications via IV push if the following occurs: (1) Strict guidelines and protocols are in place. (2) The guidelines clearly state all policies and procedures. (3) Annual review and assessment of the LPN's knowledge, skills and abilities is conducted. (4) Emergency cardiac medications given "IV push" shall be administered by the LPN only if: a. The LPN has direct supervision per WAC 246-840-010(22) (a) or b. The LPN has a current ACLS certification. (5) Blood or blood products shall only be given with direct supervision as per WAC 246-840- 010(22)(a). (6) It is within the scope of LPN practice to perform peripheral venipuncture (to start IV or draw blood), flush peripheral, PICC and central lines for the purpose of ensuring patency if the following occurs: a. The LPN completes an annual instructional program on the initiation of peripheral IV. b. Documentation of satisfactory completion of the instructional program and supervised practice is on file with the employer. c. Written policies and procedures are maintained by the employer.

What is the RN's role in delegation

The RN: • is responsible and accountable for the provision of nursing care • is responsible for assessment, diagnosis, care planning, and evaluation • is responsible for the patient outcome related to delegation • is aware of strengths and limitations of other team members • does not require supervision

Diversity

The new role of leaders/managers as a cultural bridge has become a requirement as our society becomes more diverse. Many foreign nurses must be supported through a period of cultural, professional, and psychological dissonance that is associated with anxiety, homesickness, and isolation. Generational diversity is occurring in all health care organizations.

Assignments

The nurse must consider: • Complexity of patient's condition • Dynamics of the patient's status • Complexity of required assessment • Type of technology used • Degree of supervision needed • Availability of supervision needed • Relevant infection control and safety issues Assignments: Considerations Capability of staff member Scope of Practice Experience Special skills Care needs of patients Physical environment Infection control Anticipated changes in assignment Special staff needs Standards of practice

FOOD FOR THOUGHT

The nursing profession is the largest medical profession in the world... and we have the "POTENTIAL" to profoundly influence policies and make a big change in the healthcare field... but why aren't we doing enough of that? REASONS: -Lack of awareness -Little opportunity for involvement -Limited formal healthcare policy education -Segmented associations (ANA, NLN, Board of Nursing, etc.)

Delegation

Transferring authority to perform a selected nursing task in a selected situation to a competent individual The delegating nurse retains accountability for the delegation Important patient management tool Necessary for efficiency in healthcare The RN transfers the authority to perform a specific activity from their own practice to an individual qualified to perform that task but retains ACCOUNTABILITY for the delegated task.

Directing

Usually entails human resource management responsibilities, such as motivating, managing conflict, delegating, communicating, and facilitating collaboration

The Management Process (Functions)

planning, organizing, directing, leading, controlling

WHAT IS MOTIVATION?

• A stimulus that causes people to do certain things • Motivation is the stimulation which is internal or external and influences behavior Can be internal - intrinsic, from self; or external - extrinsic, from other EXAMPLES: Internal = need for recognition, self-esteem, self-actualization; developed through life experiences influenced by culture, family, age External = financial, promotional, or reward MOTIVATION • Basic Concept: • Different things will motivate different people at different times! You must learn what the motivators are for the people you work with .• Does a person's age influence motivation? • How do rewards and incentives create a motivating environment? • "All behavior has a purpose..." • Behavior that is rewarded increases. • Behavior not rewarded decreases. • Does the value or size of the reward matter?

MASLOW'S HIERARCHY OF NEEDS

• Developed by Abraham Maslow in the 1950s; part of the modern positive psychology movement. • Maslow believed that people are motivated to satisfy certain needs, ranging from basic survival to complex psychological needs, and that people seek to meet a higher need only when the lower needs have been predominantly met. Maslow - people are born with the desire to self-actualize, which occurs when an individual maximizes their potential, doing the best that they can do Self-actualized people: Embrace the unknown and ambiguous Accept themselves, with all their flaws Prioritize and enjoy the journey, not just the destination While inherently unconventional, do not seek to shock or disturb Are motivated by growth, not by the satisfaction of needs Have purpose Are not troubled by the small things Are grateful Share deep relationships with a few, but also feel identification and affection towards the entire human race Are humble Resist enculturation (the gradual acquisition of the characteristics and norms of a culture or group by a person, another culture, etc.) Are not perfect • What are some nursing considerations you can derive from Maslow's Hierarchy of Needs?

HERZBERG'S MOTIVATION-HYGIENE THEORY

• Developed by Frederick Herzberg in the 1980s. • He believed that employees can be motivated by the work itself and that there is an internal or personal need to meet organizational goals. • He believed that separating personal motivators from job dissatisfiers was possible. What are some nursing considerations regarding Herzberg's Theory? MOTIVATORS -Achievement -Recognition -Work -Responsibility -Advancement -Possibility of Growth HYGIENE FACTORS -Salary -Supervision -Job Security -Positive Working Conditions -Personal life -Interpersonal relationship and peers -Company policies -Status What are some nursing considerations regarding Herzberg's Theory?

VROOM'S EXPECTANCY MODEL

• Developed by Victor Vroom in the 1960s. This theory looks at motivation in terms of the person's valence or preferences based on social values. • What that means is that people look at all actions as having CAUSE & EFFECT. • People make conscious decisions in anticipation of reward. - Valence is the value an individual places on the rewards of an outcome, which is based on their needs, goals, values, preferences, and sources that strengthen their motivation for a particular outcome. NURSING CONSIDERATION: Managers using the expectancy model must become personally involved with their employees to understand better the employee's values, reward systems, strengths, and willingness to take risks.