In 2005, a nurse-led CCOS was introduced in South Africa at a private hospital in Pretoria, which was the context in which the activity was performed. This private hospital emergency department is endorsed as a level 2 trauma unit and has six critical care units, 18 theatres (for cardiothoracic, nephrology, orthopaedic, neurology and general surgery) and 11 low-acuity wards (for oncology, medical, surgical, orthopaedic obstetrics and paediatric care) that total to approximately 500 beds.

The CCOS is essential for assisting bedside nurses (all nurse categories) in providing individualised nursing care for patients. Wood et al. (2017) indicated that CCOS enhances nurses’ skills and competence, which leads to an increase in their confidence.

In this private hospital, the CCOT was predominantly nurse-led and involved a team of nurses, namely the critical care outreach nurse expert and bedside nurses working in low-acuity wards. The patient medical practitioner also forms part of the CCOT. Patients at risk of deteriorating are recognised by nurses who measure the patients’ vital data and determine the patients’ MEWS. The MEWS is a set of criteria to identify early deterioration in patients. If a patient is identified as a patient whose health is at risk of declining, the outreach nurse expert is called to assess the patient. The outreach nurse expert will assist the bedside nurse with nursing interventions needed and monitor the patient. The patient medical practitioner is also informed of interventions implemented and that the CCOS has been activated to monitor the patient. The medical practitioner may request additional interventions to be implemented, and the outreach expert nurse has the competency to evaluate the outcome of the interventions implemented. The outreach nurse expert enhances the bedside nursing skills by explaining to the bedside nurse to monitor for specific outcomes that are expected from interventions implemented, for example, to monitor if a patient’s breathing improves after pain medication is given to a patient who is in pain and displays signs of hyperventilation. Critical care outreach service patients are monitored more frequently than patients not identified as at-risk patients. Better nursing and patient outcomes are associated with work milieus that are supportive of professional practice (Stein-Parbury 2017). Empowerment of nurses increases feelings of competence, and being responsible for monitoring patients whose health is at risk of declining provides a sense of self-control and purpose which is naturally rewarding to nurses (Ryan & Deci 2017).

The agent is the critical care nurse expert, that is, a critical nurse specialist with competencies for advanced practice nurses developed by SANC (2014), registered at the SANC. These nurses are self-directed critical care specialised nurses with the goal of promoting the health of patients (secondary recipients) in assisting bedside nurses (primary recipients) with nursing activities for patients whose condition is at risk of declining or declining. Hansen-Turton, Sherman and King (2015) defined nursing expertise as the use of all features of practising evidence-based nursing in solving health care problems. Critical care outreach expert clinical expertise enables nurses to holistically assess patients, and they have the skills and knowledge to assist bedside nurses with timeous nursing care interventions for a patient whose health is at risk of declining or declining at the moment.

The critical care nurse expert as a mentor empowers the bedside nurse and is in a position of authority when practising self-direction when they take the lead and provide assistance and support to bedside nurses with nursing care interventions to promote patients’ health. The American Association of Colleges of Nursing defines mentoring as:

The critical care nurse experts as agents need to reflect on their practice, displaying self-awareness (Bang & Reio Jr 2017), and should indicate to bedside nurses that they want to support and guide them with nursing care activities to improve patients’ health whose health is at risk of declining.

The agent as a team leader is a critical care nurse expert who leads and directs the functionality of the CCOT. As a team leader, the critical care outreach nurse expert is competent in making decisions on which activities are needed to improve a patients’ health status. Dupree (2018) stated that the role of team leaders is to guide team members and provide them with direction and support so that they can complete the assigned goal successfully. The self-motivated critical care outreach nurse experts empower bedside nurses by employing self-direction when they guide and support these nurses with the nursing care interventions for patients whose health is at risk of declining or declining at the moment. In self-direction, the critical care nurse expert as the agent directs their own thoughts, approaches and behaviours to modify their behaviour in order to gain the desirable outcomes (Watson & Tharp 2014). The support that bedside nurses receive from the critical care outreach nurseexpert transforms the nursing care provided to patients into a more positive experience (Cherry 2018), which makes nursing care more naturally rewarding.

Neck et al. (2020) indicated that self-leadership stems from intrinsic motivation theory and more specifically self-determination theory. The critical care outreach nurse experts render self-leadership by being confident about their skills and knowledge when attending to a patient whose condition is at risk of declining or declining at that moment. Self-efficacy is the belief that one has the essential resources, namely skills and knowledge, to meet the needs of one’s specific goal (behaviour-focused action) (Ayub, Kokkalis, & Hassan 2017).

Two recipients were identified; namely, the bedside nurse who works in low-acuity wards and who is part of the CCOS is the primary recipient, and the secondary recipient is the patient in a low-acuity ward whose health is at risk of declining or declining at the moment. The bedside nurses include all nurse categories (professional, staff and auxiliary nurses) as stipulated in the South African Nursing Act 33 (South Africa 2005) and are thoughtful therapeutic practitioners, who exhibit competencies, principles, attitudes, clinical skills and expertise in the endorsement of patients’ health, for example, by observing the patients’ vital data. The bedside nurse (primary recipient) as a team member of the CCOS must demonstrate self-leadership through these practices: self-motivation, self-direction, being a role model, recognition of their own role in the CCOS as a vital service in nursing, concerning patient outcomes, team assistance and challenges and self-affirmation.

The bedside nurses need self-motivation to support and lead their self-leadership in the CCOS. Messineo, Allegra and Seta (2019) stated that self-motivation occurs when nurses follow a pupose, which creates emotions of satisfaction in the activity. Nurses are self-motivated to act when they have to chance to independently decide on meaningful interventions that allow them to use their competencies. The bedside nurses should exhibit their awareness of their responsibility through behaviour-focused strategies when attending to the patient, utilising appropriate behaviour which will contribute to delivering of quality nursing care to the patient as the secondary recipient. Setting goals for themselves, bedside nurses motivate themselves to grow to be the best at what they do or at least progress in their performance. To achieve this, the bedside nurses need a proactive approach and self-control to care for patients whose health might decline or is declining. Bedside nurses practice self-leadership cognitively through self-talk (constructive thought process) on what nursing care activities are needed for the patient whose health is declining. The bedside nurse applies natural reward strategies by implementing self-control (autonomy) when the bedside nurse becomes aware that the patient’s health is declining, reports it to a more senior nurse and demonstrates their ownership of the situation by following the CCOS guidelines when a patient’s health is declining. Bedside nurses should be competent to provide standard nursing care and to show a positive feeling of self-efficacy (Ayub et al. 2017).

The bedside nurse must be mindful of their own self-leadership and need to be a role model for their colleagues to encourage each other in the CCOS. Being role models, nurses set goals and perform their duties excellently and persistently by setting high standards when providing nursing care to patients. Nurses should develop realistic expectations of their own capabilities whilst theyprovide nursing care to a patient whose health is declining. This can be performed through self-assessment of a behaviour-focused activity where they need to determine their need to improve their knowledge about some aspects of nursing patients whose health is declining. They demonstrate self-control and self-direction when the bedside nurse reports a patient’s declining health to a more senior nurse. As role models, nurses need to develop their knowledge and skills and show their commitment to improving their patients’ (secondary recipient) health by attending training. They should be hands-on and exhibit their competence when attending to patients whose health is declining. Being competent in attending to patients creates feelings that are naturally rewarding. Neck et al. (2020) indicated that natural reward strategies are self-motivating when a task is enjoyable, and that leads to increased feelings of competence. They should share their expertise, involving their colleagues through communicating to them the expected nursing interventions needed to provide nursing care to the patient. Nurses also use constructive thought patterns when they visualise the successful completion of nursing interventions. This involves substituting dysfunctional beliefs or assumptions that could hamper the treatment of thepatient with visualising and performing the nursing interventions under the guidance of the outreach nurse expert and replacing the assumptions that they are not competent to perform these interventions. Passi and Johnson (2016) stated that role modelling is a forceful process where onlookers, namely bedside nurses, intentionally and subconsciously decide if the observed behaviour will be applied to their own behaviour. Furthermore Jochemsen-Van der Leeuw, Wieringa-De Waard and Van Dijk (2015) mentioned that when a person is aware that he or she is a role model, it improves role model behaviour.

Nurses acknowledge their own role through self-awareness as vital concerning patient outcomes and activating the outreach nurse expert. Nurses should acknowledge their role as team members of the CCOS and need to motivate themselves to provide the appropriate care for a patient, which can be seen as the goal for a patient whose health is declining. They ought to exercise their understanding of the MEWS, which can be a cue to act correctlyto make sure that the patient receives the correct nursing care to remain stable. Zuckerman, Friedman and Castro (2018:17) are of the view that self-awareness refers to self-examination: understanding of one’s own choices, motivation and behaviour. When nurses have the knowledge to attend to patient nursing care needs, they display their confidence, which is a natural reward and demonstrates their self-control when they attend to these nursing care needs such as calling the outreach nurse expert if needed. The availability of the CCOS and the awareness that they (primary recipient) can call the outreach nurse expert (agent) to assist in caring for a declining patient (secondary recipient) contributes to providing quality nursing care to the patient and is naturally rewarding for nurses.

Through self-observation, nurses should be aware of the skills and knowledge that need to be improved, and their self-leadership will be demonstrated when they empower themselves by improving their skills and knowledge. Empowering themselves influences their behaviour and affirms nurses that they contribute to providing quality nursing care to patients. According to Armitage and Rowe (2017:490), self-affirmation increases motivation and changes behaviour. A nurse might adjust his or her behaviour to comply with professional standards when she or he is confident that his or her effort to change his or her behaviour will result in positive patient outcomes. Patients who express their gratitude to nurses for the nursing care they received contribute to nurses’ self-affirmation, creating feelings of competence and self-confidence which are self-rewarding.

The data analysis revealed that mindfulness is an underlying energy source for self-leadership. In addition, Tutzer and Sachse (2018:353) defined mindfulness as the intentional and non-judgemental self-observation of incidents involving self-regulation of perception and orientation towards incidents in the current moment. Mindfulness enables nurses to focus on what is necessary to do at that instant and focus their behaviour towards their self-leadership. The goal of self-assessment amongst nurses is to develop self-awareness that guides themto perform basic professional actions, namely providing nursing care to patients whose health is declining. Yu and Zellmer-Bruhn (2018:340) stated that team members (such as in the CCOS) require mindfulness to form mutual insights on their interactions and increase those which are valuable for the team. Nurses need to focus on listening mindfully to their patients and the CCOT, which is needed when providing nursing care for a patient whose health is declining. Mindful listening is beneficial for positive communication and can create an internal calm in team members, releasing them from presumptions and biases, which will to a great extent support the team leader (such as the outreach nurse expert) (Ackerman 2017).

Another underlying energy source that was revealed through the data analysis is training. Training focuses on building knowledge, skills that are directly related to work and are planned to increase the efficiency of employees (Warren et al. 2018:117). Health care organisations can empower nurses through training programmes to increase their knowledge and competence. Through self-awareness, nurses are aware of skills and knowledge that need to be improved and will attend these training programmes. Patients whose health is declining in general wards provide challenges for the bedside nurse; therefore, training is needed to improve nurses’ competence. The outreach nurse expert empowers (informal training) bedside nurses when they assist bedside nurses with guidance and advice on the nursing care needed for their patients. Bedside nurses’ (recipient) knowledge increases, and they develop skills that increase their confidence and competency. Van Vianen et al. (2018:594) stated that mentoring is an important part of training and preparing bedside nurses to deal with challenging job demands. The mentor (outreach nurse expert) is at the core of such training, and mentoring bedside nurses provides them with the prospect to grow, which creates job satisfaction and enhances bedside nurses’ competencies (Goodyear & Goodyear 2018). Further, Bang and Reio Jr (2017:150) reported that mentoring contributes to self-efficacy. Mentoring bedside nurses as a training method in the CCOS increases nurses’ competency and self-efficacy and encourages job satisfaction. The underlying dynamics of mindfulness and training will encourage self-leadership amongst bedside nurses in the CCOS.

Dickoff et al. (1968:423) stated that the guiding procedures are the blueprint for the execution of an activity. In the CCOS, the mobilisation of self-leadership is needed to provide appropriate nursing care for patients whose health is declining. Bedside nurses utilising self-leadership in a CCOS should apply the following activities to lead and guide themselves in providing nursing care to patients, namely self-motivation, role modelling, teamwork and self-affirmation.

Neck et al. (2020) stated that the self-determination theory suggests that enhancing self-motivation, competence and self-determination are needed. The ability to motivate yourself to provide quality nursing care is crucial in self-leadership. Self-motivation is the spontaneous feeling of attraction and delight in an activity that supplies rewards (Deci, Olafsen & Ryan 2017:21). Duckworth et al. (2019) defined self-control as the self-initiated management of conceptions, outlooks and actions when enduringly valued goals conflict with briefly more rewarding goals. Self-motivation allows a person through personal self-control (mindfulness) to take action to render the needed effort to carry out a task such as providing nursing care to patients. Nurses motivate themselves through self-control to measure patients’ vital data and follow the MEWS guidelines to call the outreach nurse expert if needed. Cherry (2018) stated that self-determination theory suggests that people are motivated to develop and transform through psychological needs such as the need to be competent in what they do. Self-directed behaviour increases feelings of competence when nurses motivate themselves to learn more.

According to Price-Mitchell (2017), a role model functions as an example of motivating people with integrity, determination and compassion. In the health care organisation, nurses (recipients) act as role models when they demonstrate an interest in their patients’ health and accept responsibility for their patients’ nursing care. They exercise self-control and change their behaviour if needed to be proactive in providing quality nursing care to their patients. Nurses are proactive when they act without delay to ensure patients receive the appropriate nursing care when they focus on visualising what to do to assist a patient whose health is declining. Nurses also employ constructive thought patterns through planning and visualising the successful completion of tasks to address the needs of patients. Nurses as role models for their peers increase the likelihood that peers (other nurses) could change their behaviour to meet task demands and face new challenges positively (Kranabetter & Niessen 2017). Nurses as role models should through self-assessment know the boundaries of their knowledge and skills, have realistic expectations of their competencies and should call for outreach expert nurses when needed.

Heathfield (2018) stated that to create teamwork, a work culture that values collaboration between employees need to be created and that employees understand and believe that reasoning, creating plans, making decisions and activities have better outcomes when performed together. Jooste (2017) stated successful teams and team members should have an understanding of the team goal. Behaviour-focused self-leadership involves the setting of goals (Neck et al. 2020) and forms an important part of successful self-leadership. Bedside nurses working as a team set goals such as calling the outreach nurse expert for assistance when a patient’s health is declining. Being a member of a team is an important aspect of bedside nurses’ work, which helps to enhance the effectiveness of quality nursing care (ed. Peteva 2017). Team members provide support and empower other team members, which create feelings of competence and unity amongst the team members. Feelings of competence are naturally rewarding, which is an approach applied in self-leadership (Neck et al. 2020).

Bedside nurses’ positive attitudes are imperative in employing self-leadership approaches. Nurses feel proud when they have provided quality nursing care, and patients express their appreciation to nurses, which is an opportunity for self-affirmation. White (2015) emphasised the importance of employees needing to know what they do matters. This creates feelings of self-affirmation for nurses.

The final activity of the framework is the accomplishment of activities and procedures bedside nurses use in applying their self-leadership in the CCOS, which is the core outcome. The CCOS offers the critical care skills and knowledge of the outreach nurse expert to patients whose health is declining in low-acuity wards.