Medicine

10

10 ORGANIZATIONAL POWER AND POLITICS

Understanding Organizational Structures

Organizational mergers and health-care changes are rampant in the 21st century. In health care today, organizational structures are affected by the economic, political, social, and technological pressures in society (Marriner Tomey, 2000, p. 231). The structure identiﬁes the authority, the responsibility, and the decision-making processes. Today’s structures are no longer simple and hierarchical; they are complex systems with cross-functional teams and communications and interactions occurring at many levels. The structure of the organization is representative of its mission, vision, and values and how it functions. Nursing is an integral and major component of the health-care organization, with nursing being the largest group of employees within the health-care setting. As a result, it is essential that nurses know their organization, the structures within which they function, and be able to relate this to their individual clinical unit. As health-care delivery expands, organizations will continuously take on a new look and approach to structure. By studying and learning the organizational structure, nurses will better understand their role within it. The nurse is the key person at the bedside, coordinating the care for the patient. Registered nurses work within a matrix of systems within the health-care organization, being a gatekeeper of information that can improve outcomes for the organization. In this chapter, the reader will learn about organizational theory and its role; review the characteristics and the different types of health-care organizations; and understand how the corporate vision, mission, values, and philosophy guide the organization. The chapter also presents information on governance models, the different types of health-care delivery settings, and the importance of continuity of care for the health of the organization. The chapter concludes with predictive future trends related to organizations.

Organizational Theory

Organizations consist of groups of people coming together for a common purpose. An organization can be deﬁned as “a group of persons with speciﬁc responsibilities who are acting together for the achievement of a speciﬁc purpose determined by the organization” (Huber, 2000, p. 454). It is “the structure that supports the organizational processes,” according to Yoder-Wise (2003). Organizations comprise people who are given speciﬁc tasks to complete within their deﬁned job role. Organizational “theory,” technically, dates back to biblical times, when thought was given to how groups were organized. Pharaoh utilized theories to build the pyramids of Egypt. Workers were organized into speciﬁc groups with speciﬁc tasks to be completed for the success of the structure. Modern organizational theory began during the Industrial Revolution. Many theories have been reviewed to demonstrate the how and the what of organizational structure. Today’s view of the structure emphasizes the relationships of the groups within the organization, the people, and how work is accomplished in a self-organized system (Crowell, 1998). It is important to understand the different theories of how organizations have come to be because the theory serves as the foundational component and the driving force for how groups are formed and function in today’s health-care arena. As we discuss the theories, it will reveal the transitions and variations that shape organizational functions today. By studying organizational theories, the reader will understand the functionality of organizational structures.

CLASSICAL THEORY

The Classical Theory, dating to the 1890s, is one of the oldest theories regarding organizational structure. The focus of this theory was on the struc ture of the formal organization: it examined the efficiency of the organization as a by-product of the design of the system. The concept was that the people of an organization will be productive if they are given a well-deﬁned task to complete. By dividing work into tasks and requesting employees to complete the same task every day, the theory proposed that productivity would increase because of the repetition of the task. This worked from an industrial perspective.

Results of this theory have come to be known as the classical principles of organizational design. These principles examine how members are divided into work teams, who reports to whom, the number of people for whom the managers are responsible, and the shape of the structure. From classical principles, Max Weber, called the Father ofOrganizational Theory, created the bureaucratic model of organizational structure. Weber’s model consists of the following components:

■ Organizational structure

■ Division and specialization of labor

■ Chain of command

■ Span of control

The organizational structure concerns the arrangement of the work groups within the organization and is intended to support the organization’s survival and success. The structure determines accountability and responsibility. It dictates who makes the decisions and who has authority and oversight of workers. The structure shows who reports to whom and gives a pictorial view of the organization. In the Classical Theory, workers were placed into departments in relation to the work they were assigned to complete.

Specialization of labor dictates that the work of the organization be divided into tasks and employees be assigned a speciﬁc task to complete. Limiting the number of tasks assigned to each individual increases the efficiency and improves the organization’s product. Just as in an assembly line, the worker who puts steering wheels on a car every day will become very proﬁcient at the task. The risk of error is reduced, and efficiency is increased.

Chain of command refers to the formal line of authority and responsibility within the organization. Authority is the power to guide and direct workers within their speciﬁc area. This authority is usually depicted by vertical lines on an organization chart. This linkage is from the key position on top to the positions directly below. Responsibility refers to the obligation to produce or to complete the task. Each worker is responsible to ﬁnish the task assigned by a superior. Span of control refers to the number of employ ees who report to a manager or a supervisor. A wide span of control indicates that many employees report to a supervisor; a narrow span means that few employees report to one. The number of people reporting determines the organizational structure (Altaffer, 1998). A narrow span of control is indicative of a tall structure because each manager has only a few people in the reporting structure. There are many managers responsible for a limited number of people, which results in many layers to get to the top of the organizational structure. There are often many layers for the change of command, and the span of control is narrow. A wide span of control is indicative of fewer managers and more reporting workers, resulting in a ﬂat organizational structure.

Many organizations still base their structure on the Classical Theory principles, utilizing some of the components to make up their structure. As organizations begin to function leaner with limited resources, other approaches and options to organize the employees are being implemented. The Classical

Theory is based on the concept that the employee does one job and will learn it well. In health-care organizations today, multiple tasks are being managed and completed by fewer employees.

NEOCLASSICAL THEORY (HUMANISTIC THEORY)

The Neoclassical Theory became popular in the 1930s. It placed emphasis on cooperation and participation in the workplace (Sullivan & Decker, 2001). The key factor in this theory is motivation. A motivated employee will produce better output in the job setting (see Chapter 3 on motivation in this book). If employees are given satisfactory working conditions and have opportunities to socialize with other employees, job satisfaction will improve, and the employee will be more motivated.

The Neoclassical Theory links with a democratic style of leadership because the employees are encouraged and allowed to participate in the functions of the organization and the decision-making process. For example, employees may participate on committees related to patient education and care outcomes. Nurses and other members of the healthcare team have a voice in the decision-making process. The Neoclassical Theory relates to a ﬂat organizational structure. Processes are decentralized, and member involvement is encouraged.

SYSTEMS THEORY

Systems Theory is based on the work of Von Bertalanffy (1968). This theory asserts that systems are a whole and that organizations should be viewed as a whole, considering the relationships within the structure of the organization. A system is a complex mix of intertwined elements, including inputs, throughputs, and outputs. Inputs are the

items being put into the organization to create the product. The throughputs are the processes put intoplace to assist with the creation of the outputs. These elements work together to accomplish speciﬁc goals within the organization. Changes in one part of the system affect the other parts of the system, creating a ripple effect. The resources are inputs, such as the employees, patients, materials, money, and equipment imported from the environment. The work is considered the throughput. This is the work within the organization, transforming energy and resources to yield a product. The product (the output) is then exported to the environment. The organization is a constant recurring cycle of inputs, throughputs, and outputs.

CHAOS THEORY

The Chaos Theory stresses the importance of change within organizations. Change is the stimulation of the organization, and it is constant in health care today. Change can create stress or relief for organizations, depending on how it is perceived and interpreted (see Chapter 11 on leading change). Leaders must constantly assess the organizational environment and determine whether there is consistency within the structure. Organizational leaders working under the Chaos Theory will excel with change and creativity (McGuire, 1999). Management is ﬂexible and will reward those organizational members who thrive on adaptive behaviors and innovation. The overall goal of the organization is to be successful in an environment of constant change. This theory works well with healthcare organizations today. Change is inevitable, and employees must learn to adapt and excel to remain employable in health care.

CONTINGENCY THEORY

The concept within the Contingency Theory is that the organization’s structure must match the working of the environment. The most common aspect of the Contingency Theory recognizes the style of the leader and how this inﬂuences the situation. How the leader leads will determine how the organizational structure is established. There is variation in leadership style to gain expected outcomes. There is no one leadership style that ﬁts every situation; a good leader will learn how to adapt to each situation to support the desired outcomes. The organizational structure based on this theory is ﬂexible and varies based on the needs of the organization and the leader.

LEARNING ORGANIZATIONS

In a learning organization, the people and the systems respond and expand their capabilities to obtain the results that are desired. The basic concept is that in situations of change, the organization that is adaptive to the change will thrive. Learning organizations are becoming more popular in businesses today. Members of organizations have the ability to create and manage the changes (Senge, 1999). Particular people are employed becauseof their commitment to the organization, and this commitment serves as a resource for the success of the organization. Peter Senge (1990) identiﬁes ﬁve disciplines for a learning organization to be successful: systems thinking, personal mastery, mental models, building a shared vision, and team learning.

Systems thinking is the ability to examine an organization as a whole entity, not separate units, and to see the interrelationships between the units. Successful organizations explore systems as a whole and as very dynamic processes. Personal mastery refers to a continuous learning process by each individual. It is based on self-discipline and the idea that individuals never stop learning. Mental models refer to an individual’s ability to see things differently and work with pictures within the mind to inﬂuence how a given situation is seen and interpreted. This means taking a situation and being able to view all sides of it to discover the objectivity of it. Building a shared vision is the ability of the organization to create a shared idea of the future goals and dreams. This vision creates energy for the members of the organization to work together as a team and meet the goals of the organization. The ﬁnal component, team learning, refers to the organizational members’ ability to unite as a whole for the betterment of the organization. This will improve organizational results. When members work together, processes improve, and outcomes are enhanced.

Organizational theory plays an important role in the productivity and success of the organization. The theory helps determine the type of organizational structure and how the organization will function. It is important for managers and leaders to understand the theories, how they relate to their organizations, and how they can inﬂuence the members of their organization.

Organizational Components and Planning

Health-care organizations have been transformed by the many changes in social, structural, political, and human resource allocations (Bolman & Deal, 2003). Some speciﬁc factors that have contributed to these changes include quality care issues, increasing health-care costs, and the focus on patient satisfaction. These factors affect how the organization is run and contribute to changes within the structure. Organizations with a strong value set, mission, vision, and philosophy will be more prepared to successfully meet these ever-changing events. Goals and objectives, policies and procedures, and strategic planning are also key components of facile organizational operation.

ORGANIZATIONAL VALUES

The stated values of an organization give meaning to its existence and help its members act in concert with its motives. The values clarify what is important to the organization in regard to its customers, products, and/or services. Values set the standards for behavior within the organization and supportthe mission and the strategic plan. Organizational leaders determine a set of values that align with the mission and the vision of the organization.

The values for the organization serve as the foundational cornerstone for the events and activities of the facility. Organizational values are related to the success of the organization and determine how it will function when working with its customers. For example, if a hospital as an organization values service, the members will work hard on methods to improve their patient satisfaction surveys. A client who returns for future care at the hospital is usually one who is pleased with the type of service given. Leaders of the organization express these values on a daily basis within their work and responsibilities to the system. Values can be an implicit or explicit part of the mission statement and are incorporated implicitly into the organization’s culture. See Box 4-1 for some examples of organizational values.

MISSION STATEMENTS

The purpose or the mission statement encapsulates the intent and goal of the organization. It explains, in a short statement, the core reasons behind the organization’s existence and a primary focus on a single strategic thrust for the organization. The purpose of each area of the organization is to pursue the stated mission of the organization. The mission statement sets standards for the organization’s philosophy and its goals and objectives; it is the baseline for decisions of the organization. The mission statement drives the organization’s existence and is

a reﬂection of the culture. See Box 4-2 for an example of a mission statement.

VISION STATEMENTS

The vision statement incorporates an organization’s mission and values. It serves as the future-oriented plan for the organization, the wish list of future development ideas, and the plan to set this wish list into motion. The vision statement serves as the dream of the organization and provides guidance on where an organization wants to be 10–15 years into the future. See Box 4-3 for an example of a vision statement.

ORGANIZATIONAL PHILOSOPHY

The philosophy of an organization is derived from its mission and incorporates the organizational values that direct the behavior of the organization. The information provided in the philosophy—the values and principles of the organization—provides the framework for the decision-making process of the organization and shapes the social and professional development of the organization. The philosophy serves to allow employees to achieve common goals (Wendenhof & Strahley, 1995). The philosophy underlies the goals and objectives of the organization, so it is imperative that nurses understand and know their organization’s philosophy. See Box 4-4 for a sample philosophy

ORGANIZATIONAL GOALS AND OBJECTIVES

The speciﬁc goals and objectives of the organization provide more concrete information on what and how the organization plans to provide/act, under the guiding hands of its established mission and philosophy. The organizational goals are the broad statements of intent, and the objectives are the speciﬁc ways to accomplish the goals. Goals are a part of the planning process, which is one of the functions of management. Generally, the goals and the objectives explain the services offered, the resource allocation, the future plans, and the responsibility to the customer (Box 4-5).

ORGANIZATIONAL POLICIES AND PROCEDURES

Each organization also has established policies and procedures. A policy is a written plan stating how the organization will function and work together. Policies help the organization to accomplish the established goals and directives and provide cohesive guidance for the members of the organization. The procedures are the methods and direction on how the policy will be implemented. Procedures

offer step-by-step guidance as to how to implement and carry out the policy. Policies and procedures are used during employee orientation, daily routines, and decision making. Both establish interdepartmental consistency within the organization. The policies and procedures familiarize employees with the rules and also serve to provide guidance and organizational direction.

ORGANIZATIONAL STRATEGIC PLANNING

Many organizations do strategic planning 3–5 years (see Chapter 14) out for the purpose of preparing to reach future goals. Strategic planning begins with analysis of where the organization stands currently and where it wants to be in the future. The strategic plan has to have value for the members of the organization, and it needs to ﬁt with the vision and mission of the organization. The strategic plan may include new services for patients, building opportunities, and other growth for the organization. It serves as the blueprint for the future. The strategic plan maps out ideas from the vision while focusing on the mission of the organization.Implementation of the strategic plan requires strong leadership and managerial skills, support from the board of directors, administrative acceptance, and an understanding by all employees. It is critical that members of the organization understand what the strategic plan contains and where it will guide them for the future. Many organizations hold informational sessions to obtain employee input and feedback. Informed employees are happy employees, and there will be greater acceptance when all understand and participate in creating the goals for the organization’s future.

The chart displays the decision-making authority within the organization, illustrating who has the power to make and enforce decisions for the organization. Organizational leadership has the unique ability to implement and follow the values, mission, vision, philosophy, and strategic plan in order to ensure the organization’s future. The leadership of the organization is identiﬁed and described in the organization chart.

The formal channels of communication are identiﬁed as well as how members ﬁt within the given structure. The chart demonstrates the formal relationships within the organization but does not demonstrate the informal communication and relationships that often develop as a result of working within the organization. The chart shows how the organization is supposed to run and how departments support one another in this process. Charts change frequently and require updating at least annually so that they represent what is really happening within the organization. Organization charts generally reﬂect the components displayed in Figure 4-1.

CHAIN OF COMMAND

Chain of command demonstrates who formally reports to whom within the organization. The vertical lines in the chart represent chain of command. It is a formal line of authority and communication within the organization and the structure. Authority and responsibility are delegated down through the chain of command. This philosophy works well, as organizations are attempting to decrease the number of layers within their structures in order to decrease the number of management positions and save money.

Organizational components.

Line Positions

Line positions are depicted by the solid vertical lines within the organization chart. These lines demonstrate who is responsible to whom within the organization. The positions with the most decisionmaking power are near the top of the organization chart. An example of a line position would be the Nurse Manager of the Pediatric unit, who has power and authority over the staff nurses on the unit. Another example would be the vice president of the organization who reports directly to the president.

Staff Positions

Staff positions are broken horizontal lines or dashes within the organization chart, showing the relationship between two people who work together to support objectives within the organization. These positions are primarily advisory in nature, with no direct authority over the people they are working with. The staff positions support each other within the organization by consultation, education, role modeling, and development. An example would be the vice presidents of the organization with respect to one another. These members advise and consult with each other but report to a person in a higher position, through the vertical line connection.

Organizations would be hard-pressed to function without staff positions. Managers usually work closely with people in staff positions to support a speciﬁc cause or opportunity for the unit. For example, the manager works closely with the nursing educator to support the educational needs of the nursing unit. The manager would ﬁnd it difficult to do this task without the educator’s assistance and expertise. The educator does not necessarily report to the manager, nor do the staff nurses directly report to the educator. This is an example of the advisory nature of the staff position.

Unity of Command

The concept of unity of command is central to the hierarchy of the organization. The overall thought is that each person on the organization chart has one manager or one boss. This is observed on the chart by the vertical solid lines that connect positions on the chart. As health-care organizations continue to grow and increase in complexity, there may be more than one person to whom an employee must report.

Span of Control

Span of control is denoted on the chart as the number of people reporting to each manager. The span of control determines how the organizational structurewill appear on paper (Altaffer, 1998). A wide span of control indicates that many people are reporting to a manager, and a narrow span of control indicates that only a few people are reporting to the manager. In the 1990s, many managers were let go, and their positions were combined to cover many different units in an effort to reduce management costs. Due to the hierarchical nature of the chart, the higher a leader resides within the organizational structure, the fewer the people who report, but the greater the overall responsibility that leader has within the organization. As health-care organizations change and consolidate, upper-level managers are taking on a greater span of control (Altaffer, 1998).

DECISION MAKING

Organization charts also depict how decisions are made within an organization. Centralized decision making occurs when a few people at the top levels of the organizational structure make decisions. Such a chart will appear tall and hierarchical on

paper. Decentralized decision making occurs when decisions are made throughout the organization, at the lowest level possible within the organization. Such an organization chart takes on a ﬂattened appearance. In decentralized decision making, authority, responsibility, and accountability are given to the person closest to the problem to resolve the issue. This method increases employee morale and job satisfaction. Employees given such authority tend to be more motivated and feel valued as members of the organization (Huber, 2000; Marquis & Huston, 2003).

The management and the leadership of the organization have to be comfortable with the type of decision making that will evolve with the organization. The method used to make decisions is inﬂuenced by the mission, the vision, the values, and the philosophy. The size of the organization may also inﬂuence what method is used.

Type of Organizational Structures

Health-care providers should be familiar with the type of structure used within their organization. The structure affects communication patterns, relationships, and authority within the health-care setting (Marquis & Huston, 2006). The structure provides stability for the mission, the vision, the values, and the goals of the organization. The structure aligns itself with the goals of the organization and provides efficiency for the organization. The structure provides stability for decision making within the organization. The structure determines how the decision will be made. The organization chart depicts the lines of authority and chain of command and identiﬁes communication patterns and relationships for the employees of the organization.

TALL/CENTRALIZED/BUREAUCRACY

The centralized structure, a tall structure, also known as the bureaucracy, is a hierarchical structure (Fig. 4-2). Decision making and power are held by a few people within the top level. Each person who has some power and authority is responsible for only a few people. There are many layers of

Bureaucracy.

departments, and communication tends to be slow as it travels through this type of a system. This type of structure is noted for its subdivision and specialization of labor. Advantages to this type of structure are that managers have a narrow span of control and can maintain close supervision of their employees. A disadvantage is that there may be a delay in decision making due to the many layers of people that the decision must pass through to get to the top administrative level. It predisposes leaders to an autocratic style of leadership because many decisions must go to the top of the organization or the higher-level supervisor for an answer.

FLAT/DECENTRALIZED STRUCTURE

The decentralized structure is ﬂat in nature, and organizational power is spread out throughout the structure (Fig. 4-3). There are few layers in the reporting structure, and managers have a broad span of control. Communication patterns are simpliﬁed, and problems tend to be addressed with ease and efficiency at the level at which they occur. Employees have autonomy and increased job satisfaction within this type of structure. A disadvantage is the broad span of control, which may make it hard for management to process information quickly and efficiently for the employees. This is especially true for decisions that need to span the whole structure. Management at all levels takes on a greater sense of responsibility within this structure, so education across teams is important. Managers may be super-

vising areas with which they are not familiar or have limited working experience.

AD HOC/ADHOCRACY STRUCTURE

The organic or adhocracy structure of organization is an open, free-form system. This system has resulted from behavioral research based on job

Decentralized structure

satisfaction and efficiency. This type of structure is used with specialized teams to complete a speciﬁc task. From an organizational perspective, the entire organization consists of specialized teams, each assigned to complete a speciﬁc task. The major disadvantage of this type of structure is the lack of a formal chain of command. The teams work together, but when problems are encountered there is no assigned person within the structure on whom they can rely for resolution.

MATRIX STRUCTURE

The matrix structure is a combination of two structures, consisting of the product (output) and the function, linked into one structure. The function consists of all of the activities and duties needed to produce an end product, and the product is the result of the function. The structure works to balance the function and service of the organization into one operational outcome. The functions are the tasks required to complete the product. The manager of the product division works with the manager of the function division, creating two lines of authority, accountability, and communication. The team approach is incorporated, and there is a decrease in the number of formal rules for this type of structure. Issues with the matrix structure include the vague chain of command and goal variation between the two structures. This type of structure implements the use of resources efficiently.

STRUCTURES SPECIFIC TO HEALTH CARE

As health-care organizations continue to change and reorganize services to meet the needs of the customer, so will the look of the structure. Many services are changing and becoming more accessible for the patient entering the complex health-care arena.

Integrated Health-Care System

Integrated health-care systems can be deﬁned as innovative, patient-centered hospital delivery systems that continuously improve quality and use resources cost-effectively (Effken & Stetler, 1997). This type of system evolved as a result of changes in reimbursement and managed care. An integrated health-care system is a network of structures combined into one to provide better continuity of care for patients in the most applicable setting. The networks share the risks associated with the cost to provide care to the patients (McCarthy, 1997). By providing services in the most appropriate setting, the costs can be contained, which allows for a better patient outcome. The push for an integrated system stems from the need to improve the quality of care within organizations, to reduce costs associated with health care, and to ensure patient/customer satisfaction (Wolf, Hayden, & Bradle, 2004). The single hospital of yesterday is now a component of a much larger system, offering a wide range of services for the consumer. Integrated health-care systems attempt to keep costs down and keep dollars for care within their own systems. This type of consolidation also assists and prepares for managed competition. One example of a cost control measure includes redesigning practice to serve the organizational and patient needs better. Management systems look collaboratively at patient care and outcomes of care. It is important for nurses to know and understand how these systems work and what can be done to enhance them.

The services offered can include a combination of any of the following: hospital, clinics, home health, community health, school nursing, longterm care, and rehabilitation services. When services vary like this, it is known as vertical integration, which provides a range of health-care services across the life span (Newhouse & Mills, 1999). When the integrated system consists of a chain of similar services, such as all hospitals or clinics, this is known as horizontal integration.

TYPES OF HEALTH-CARE SERVICES

There are three types of health-care services on the health-care continuum. Integrated systems often provide all three types. The shift to managed care has also changed the focus from secondary and tertiary care to primary health care. Primary health care prioritizes the importance of health promotion and illness prevention. This is the ﬁrst line of defense for health care. Examples of health-care services provided in primary care include physician visits, immunization clinics, mammography, and teaching and education for clients. Primary health care covers services that prevent illness. Secondary health-care services focus on treating diseasethrough intervention. The patient has a health alteration and seeks treatment to improve the current state of health. Secondary health-care settings include the acute care setting, such as inpatient hospitals, surgical centers, and birthing centers.

Tertiary health-care services focus on the restoration and rehabilitation services for patients with chronic health-care needs. The goal is to maintain the current state at the best possible level of health. Health-care settings include long-term care facilities, hospice, and rehabilitation centers. Managed care is the umbrella term that is used to address the ﬁnancing and risk management for services provided in integrated health-care systems. Managed care unites the ﬁnancing groups with the providers of care. The goal of managed care is to establish programs that beneﬁt all key participants, including the insurance companies and the physicians. The push for managed care was evident as the health-care industry continued to become more complex and difficult for patients to maneuver and understand. Intensifying these concerns was the increase in cultural diversity served by the private sector (Valanis, 2000). The managed care model is the only health-care delivery model formulated from market and customer response, as compared with government and legislative initiatives (Kelly Heidenthal, 2003; Liberman & Rotarius, 2001).

Managed care involves a prepaid mechanism, which means that a predetermined dollar amount is established to cover the cost of the health-care service. Care that is rendered is selective and requires prior authorization. There are many types of managed care products in use currently. The most common is the health maintenance organization (HMO). The HMO plan offers health care for its members for a ﬁxed prepaid amount. An enrolled group of patients participates in the plan, and the provider is considered an employee. The provider receives a ﬁxed payment for the services from the subscriber and assumes the ﬁnancial risk. The advantage of a managed care program is cost reduction. There is a gatekeeper for the patient, usually the primary care physician. The gatekeeper’s role is to oversee and coordinate services for the patient in the mix of the system. A disadvantage to managed care includes limitations to specialized care needs; some organizations are proﬁt-driven and limit their services. Patients in health care today are discharged quicker and sicker, with only limited services available outside of the acute care setting.

Professional Practice Models

In organizations where nurses are employed and valued, management has developed and implemented opportunities for professional, autonomous nursing practice. Shared governance is deﬁned as “structures… based on a set of principles about the relationship between the worker and the workplace” (Porter-O’Grady, 2003, p. 251). The push was for decentralized nursing leadership and decision making for professional nurses. Such a structure is based on the values of interdependence and accountability for nursing practice. The objective is to empower the nursing staff through involvement in decisions that affect their speciﬁc work areas (Erickson, Hamilton, Jones, & Ditomassi, 2003). The outcome from implementation of a professional practice model is that nurses have control of their nursing practice. Nursing staff participates in nursing committees that cover topics such as education, community involvement, research, quality control, and staffing, scheduling, and hiring practices.

The uniqueness of this structure is that nurses gain control and autonomy over their professionalnursing practice. Governance models are designed to link values and nursing practice beliefs to achieve quality care (Anthony, 2004). There are more opportunities to be involved in decision making and have a voice within the organizational structure. As the nursing staff members serve on the various committees, they plan and organize the care of the patients and establish standards for nursing care based on research and evidenced-based practice.

MAGNET STATUS

The American Academy of Nursing (AAN) began to review and identify as magnet hospitals those hospitals that had solid organizational structures and a decentralized, open management style. This concept became popular in the 1980s in relation to professional practice model concepts. The goal of the magnet organization was to demonstrate autonomous nursing practice through selfgovernance, appropriate staffing, clinical expertise, and clinical ladder career opportunities (Upenieks, 2003).

To obtain magnet status, hospitals demonstrate that the structure in place is exempliﬁed through a professional practice model that promotes excelence in nursing. Compliance with the identiﬁed standards must be demonstrated at all levels of nursing care within the organization (McClure, Poulin, Sovie, & Wandelt, 1983). Multiple days of onsite evaluations to assess organizational magnetism are conducted by the accrediting organization, American Nurses Credentialing Center, to determine if magnet status can be awarded. Status is awarded for 4 years. To achieve magnet status, there must organizational and nursing leadership linkages. There are 14 criteria necessary to obtain magnet status:

1. Quality of nursing leadership

2. Organizational structure

3. Management style

4. Personnel policies and programs

5. Professional models of care

6. Quality of care

7. Quality improvement

8. Consultation and resources

9. Autonomy

10. Community and the hospital

11. Nurses as teachers

12. Image of nursing

13. Interdisciplinary relationships

14. Professional development

Organizational Culture and Climate

All organizations have an informal structure that is not identiﬁed on the organization chart. It comprises the social networks and relationships that develop in the work setting. It provides a sense of belonging within the organization, also known as the culture and climate of the organization. These concepts provide insight into the organization and help inﬂuence change.

ORGANIZATIONAL CULTURE

Culture can be deﬁned as the assumptions and beliefs that organizational members have in common. It is the “shared values and beliefs within the organization” (Huber, 2000, p. 437). The culture of the organization contains the norms that characterize the environment (Sleutel, 2000). The culture gives a sense of identity to its members and their commitment to the organization, and it helps to determine the behavior of the organization. It drives the work and the quality of the care within the organization (Gershon, Stone, Bakken, & Larson, 2004).

Culture also means that there are things in the environment that are constant, unspoken, and rarely subject to change. The culture consists of things that are not written down but are known by all members. The organizational culture affects the outcomes of quality for the organization. The culture is learned through the relationship between behaviors and the consequences (Jones & Redman, 2000).

ORGANIZATIONAL CLIMATE

The climate of the organization is the “perception of how it feels to work in a particular environment” (Snow, 2002, p. 393). Components of the climate are speciﬁc and easy to measure. Some characteristics of climate include amount of involvement members can have, supervisor support given, amount of responsibility given, commitment of the members, ﬂexibility of the work setting, and standards set for improving practice. The key assessment question to ask regarding the climate of an organization is “Would I want to work here? Why or why not?” The climate comprises the social aspects of the organization that make the members feel like they are a part of the team.

All Good Things…

Health-care organizations face many changes in today’s world. Nurses are a major component of a health-care organization, and it is imperative they understand the structure in which they provide nursing care. The structure of the organization is deﬁned by the organization chart. This chart indicates who reports to whom and who is responsible and accountable for the functions of the organization. The organizational structure defines the arrangement of the work groups. Organizations today that have a strong value set, mission, vision, and philosophy are better prepared to meet everchanging events and the needs of their customers. This chapter deﬁnes organizational theories, different types of structures, lines of authority andaccountability, and the components of the organization chart. These are all elements that help members understand their work environment. Nurses need to be knowledgeable and comfortable within the culture and the climate of the organization. Many organizations are improving their work environment through shared governance and magnet status for the nurses. This provides autonomy and demonstrates the importance of a professional practice environment for the registered nurse.

NCLEX Questions

1. Which theory emphasizes the importance of cooperation and participation in the workplace?

A. Chaos Theory.

B. Systems Theory.

C. Classical Theory.

D. Neoclassical Theory.

2. When reviewing an organizational chart, what represents the formal line of authority and responsibility within the organization?

A. Specialization of labor.

B. Chain of command.

C. Span of control.

D. Organizational structure.

3. The basic concept behind a learning organization is:

A. The popularity to change.

B. The people change.

C. The adaptation to change.

D. The resources of change.

4. Which one of the following sets the standards for behavior within the organization?

A. The mission.

B. The values.

C. The philosophy.

D. The vision.

5. Line and staff positions are identiﬁed on the organization chart. What does the line position denote?

A. Who is responsible to whom within the organization.

B. Advisory relationships between employees.

C. The number of people reporting to each manager.

D. How the decisions are made by the employer.

6. Which type of structure has decision making and power being led by a few people?

A. Flat.

B. Integrated.

C. Matrix.

D. Tall.

7. What is characteristic of a ﬂat structure?

A. Narrow span of control.

B. Fewer layers in the reporting structure.

C. Combines two structures into one.

D. Is cost-effective with use of resources.

8. A patient was admitted to the hospital for an outpatient surgical procedure. Discharge was on the same day, and recovery continued at home. This is an example of what type of health care?

A. Primary.

B. Secondary.

C. Tertiary.

D. Quarterly.

9. Professional practice models allow for autonomous nursing practice. This concept is based on the relationship between the worker and the workplace. An example of a professional practice model is:

A. Matrix.

B. Integrated health care.

C. Shared governance.

D. Nursing care delivery.

10. Organizational culture and climate are important aspects of the organization. Which of the following are characteristic of the culture of the organization?

A. Supervisor support given.

B. Flexibility of the work setting.

C. Responsibility given.

D. Determines the behavior of the organization

Regulating Nursing

Nursing practice is regulated on the state and federal level. Nursing regulation “began as a simple registry process to protect the nursing title and the public” (Flook, 2003, p. 160). The primary purpose of nursing regulation today is not only protecting the public through a deﬁned nursing practice but also regulating nursing education and “overseeing the competence of nurses through licensing and disciplinary rules and regulations” (Flook, 2003, p. 160). The authority to license and discipline the nursing profession is granted to each state’s board of nursing, often called the board of nurse examiners (BNE) through state legislation creating a nursing practice act and mechanisms for licensure.

The Nursing Practice Act

At the state level, nursing is regulated by the nursing practice act, which provides for licensure as a registered nurse. A state’s act deﬁnes nursing and the standards of care. The nurse is licensed to practice under the state’s act. The act deﬁnes speciﬁcally what the reasonable nurse is licensed to do to meet the standards of patient care.

STANDARD OF CARE FOR THE REGISTERED NURSE

The standard of care (Box 6-1) is “that degree of care, expertise and judgment exercised by a reasonable and prudent nurse under the same or similar circumstances [through] use of nursing process” (O’Keefe, 2001, pp. 552–553).

Licensure is the “mechanism by which a state establishes and veriﬁes compliance with [nursing] standards” (O’Keefe, 2001, p. 542). The act regulates nursing through the BNE, which oversees the nurse’s compliance with the nursing standards and grants licensure.

Certification acknowledges nursing competence at an advanced level of practice. Gunn (1999, p. 135) believed that society and patients in general have grown skeptical of the willingness of the nursing profession to police itself. In the 1970s, skepticism coupled with a malpractice crisis forced regulators of nursing practice to move beyond “one-time testing for a lifelong credential, to other alternatives for assuring competency in nursing

practice.” Currently, the focus varies on a state-bystate basis, from voluntary to mandatory requirements for continuing education as a mechanism for either continuing certiﬁcation or recredentialing. Certiﬁcation involves “examinations developed by professional organizations which provide certiﬁcation of a claim to competence at a certain level of practice” (O’Keefe, 2001, p. 532). The graduate nurse must possess the competence to practice independently, a declaration that must be demonstrated and supported by documentation (Texas Board of Nurse Examiners, 2004). A nursing competency is the skill and behavior required to perform the role of a nurse.

STANDARDS OF CARE FOR ADVANCED NURSING PRACTICE

By deﬁnition, an advanced practice nurse (APN) is “a registered professional nurse who is prepared for advanced nursing practice by virtue of knowledge and skills obtained through a post-basic or advanced educational program of study, [and] acts independently and/or in collaboration with other health care professionals in the delivery of health care services” (O’Keefe, 2001, p. 529).

Regulating Advanced Practice

Advanced nursing practice is regulated by and built upon standards of care for the registered nurse, identiﬁed within each state’s nursing practice act. See Box 6-2 for the deﬁnition of an APN in Texas. Prior to1971, most states made it illegal for any nurse to perform diagnosis or prescribe treatment. Regulation of APNs and programs for their preparation by boards of nursing vary from state to state. Fenton and Thomas (1998) reported that boards have authority only to regulate advanced practice through: (1) the recognition of the APN and (2) the setting of standards and scope of practice. Fenton (1998, p. 78) noted the “lack of consistent APN educational program standards and experiences and criteria for recognition of APNs was problematic at the levels of accreditation, certiﬁcation, and regulation.” As a consequence, the Texas Board of Nurse

Examiners developed a model designed to ensure the education and recognition of the APN, emphasizing both professionalism and public safety (Fenton & Thomas, 1998).

For example, APNs practice via protocols or other written authorizations. See Box 6-3 for a definition of these protocols and other written authorizations under the Texas Nursing Practice Act. Roemer (1977) reported that states have been increasingly liberalizing the scope of nursing functions, making it possible for the APN to assume functions formerly not within the nurse’s scope of clinical practice. In some states, some of these advanced practice functions are allowed under doctor’s supervision. In other states, especially in rural areas, the APN may function independently. The independent action, however, such as dispensing medications, may be limited to a single course of treatment.

Midwives tend to function independently. According to Roemer (1977), nurse-midwives have been accepted as extensions of scarce medical facilities, generally authorized to provide prenatal and postpartum care, handle normal deliveries, and do family planning work, including ﬁtting diaphragms and inserting and removing IUDs. Moreover, courses for family planning nurse practitioners have been set up across the United States. Graduates may, with medical direction: (1) perform bimanual pelvic examinations and breast examinations; (2) prescribe contraception; (3) ﬁt diaphragms, insert IUDs, and examine vaginal secretions microscopically; and (4) refer patients with problems to physicians. Roemer (1977) also reported a California program of both registered and nonregistered nurses trained as women’s health specialists, who make routine examinations in both pregnant and nonpregnant women, to give family planning advice. Non-RN family planning specialists being trained included (1) licensed vocational nurses, (2) baccalaureate degree holders in non-nursing ﬁelds, and (3) qualiﬁed persons with less formal education. This 24-week course was authorized under the California State Department of Health. According to Roemer, the use of the APN would (1) help make family planning and well-baby services more generally available and (2) conserve valuable physician time for those cases that need greater skill and training.

As standards of nursing care vary from state to state, so does the regulation of the APN. Ponto,

Sabo, Fitzgerald, and Wilson (2002) report that many other state boards of nursing are examining advanced nursing practice to determine a process to recognize and regulate such practice for the purpose of eventual uniformity of the nursing law. For example, in 1999, Minnesota state law was redesigned to deﬁne and provide protection for advanced practice registered nurses. The Minnesota Board of Nursing convened to develop (1) recommendations regarding issues of certiﬁcation, (2) criteria for determining acceptable certifying organizations, (3) procedures in the event of examination failure, and (4) a process for communicating this information to the nursing community (Ponto et al., 2002).

Scope of Practice for Clinical Nurse Specialists

A clinical nurse specialist (CNS) is an APN who has specialized education and training in one clinical area. For example, the psychiatric CNS focuses on treating the patient in the clinical area through patient or staff education, consultation with psychiatric nursing or other staff, and structuring patient therapies. See Box 6-4 for the scope of practice for the APN.

Heitkemper and Bond (2004) believed that the CNS is critical to providing leadership to improve patient care, advancing nursing practice, and strengthening health-care delivery systems.

The scope of nursing practice has been expanded to encompass nursing via various technologies. For example, with the advent of telenursing, states must now extend the scope of practice across state boundaries.

The Effects of Telenursing Upon Expansion of Nursing Practice Acts

Nursing practice acts—developed by the individual states—traditionally have regulated the nurses that practice within the state. Telenursing challenges this boundary-driven regulation. Telenursing is

the “electronic transfer of nursing data, nursing information, and nursing expertise between two points” (O’Keefe, 2001, p. 552). Because nurses are now able to practice outside of their state without actually traveling, telenursing has had a considerable impact on the expansion of nursing practice acts. Hutcherson (2001, p. 4) opined: “During the last century the world has become increasingly reliant on a variety of technologies to manage information needs. Escalation in deployment of remote technology to enhance health care, accompanied by expanded public and private reimbursement for distant care, indicates increasing acceptance of these technologies. Yet many legal and regulatory questions regarding the provision of health care using these technologies remain.”

The age of informatics has opened a new era for nursing practice, taking advantage of advances in telecommunications technology that has allowed nurses to provide patient care in different geographic locations throughout the country (Hardin & Langford, 2001). The state-based system of nursing practice acts is being challenged by this new practice environment.

The Nurse Licensure Compact

To accommodate new technology, states have created the interstate compact (Hardin & Langford, 2001). An interstate compact “is an agreement between two or more states established for the purpose of remedying a particular problem of multi-state concern” (National Council of State Boards of Nursing, 2005, citing Black’s Law Dictionary). In this instance, the compact, developed by the National Council of State Boards ofNursing, “allows nurses to practice outside their state of licensure, as long as the nurse adheres to the nurse practice act in the state in which he/she practices” (O’Keefe, 2001, p. 541).

The compact utilizes the mutual recognition model, which is a model of nursing licensure that “allows a nurse to have one license (in the nurse’s state of residency) and to practice in other states, as long as that individual acknowledges that he or she is subject to each state’s practice laws and discipline. Under mutual recognition, practice across state lines is allowed, whether physical or electronic, unless the nurse is under discipline or a monitoring agreement that restricts practice across state lines. In order to achieve mutual recognition, each state must enter into an interstate compact, called the Nurse Licensure Compact (NLC or Compact)” (National Council of State Boards of Nursing, 2005).

The NLC grants the nurse a multistate licensure privilege, meaning “the authority to practice nursing in any compact state that is not the state of residency,” without the need of an additional license. See Box 6-5 for a listing of states currently participating and/or pending participation in the NLC.

But the NLC also provides that the nurse is accountable for complying with the nursing practice laws, regulations, standards of care, and competencies in the state where the patient is located at the time care is provided (National Council of State Boards of Nursing, 2005). This is a daunting task because the terminology within the nursing practice acts varies from state to state.

NURSING PRACTICE ACTS LACK UNIFORMITY FROM STATE TO STATE

The terminology used within the acts differs and varies from state to state. For example, Lavin, Meyer, and Carlson (1999) reviewed the use of the term “nursing diagnosis” in the nursing practice acts in the United States. They divided the nursing practice acts of the 50 states and the District of Columbia into those that did or did not include within a nursing context: (1) the term “nursing diagnosis” or (2) the word “diagnosis.” The ﬁndings revealed that 33 of the 51 nursing practice acts used the term “diagnosis” within the nursing context. They concluded (p. 57): “The majority of practice acts now deﬁne the practice of professional

nursing as including the diagnostic act, althoughthe manner in which they use the term varies.”Marrs and Alley (2004) conducted a descriptive study to explore related regulatory terminology used in nurse practice acts from the 50 states and Washington, DC. They discovered, for example, that although terms such as moral turpitude, moral character, and morality were used by approximately half of the states, the terms typically were not deﬁned.

They suggested: “Agreement among states on uniform deﬁnitions and standards of nursing practice can be a step toward aligning practice acts, bringing consistency to disciplinary actions, and informing the public about the profession’s standards for practice.”

DISCIPLINE AND REHABILITATION UNDER THE TERMS OF THE NURSING PRACTICE ACT

Nursing regulatory boards have the power to take disciplinary action against licensees who have violated the state’s act. Typically, license suspension is a common penalty. For examples of violations of an act and grounds for disciplinary action, see Box 6-6. Disciplinary action in most states is a function of the state board of nursing. But boards also promote rehabilitation for nurses while they regain competence. Lewallen and McMullan (2001) reported that as part of the disciplinary process, the state board of nursing may require licensees to take courses in legal-ethical decision making and/or pharmacology. They indicate that this form of rehabilitative discipline redevelops nursing competence in the following manner: (1) during the courses, the licensees must acknowledge their speciﬁc violation and explore the reasons for occurrence and strategies for prevention and (2) on completion of the courses, instructors submit required course materials that are used for consideration of relicensure decisions. These rehabilitation courses, designed to return the nurse to competence, are developed based on nursing standards and required competencies identiﬁed in the state’s nursing practice act.

Nursing Competencies

The graduate nurse must possess the competence to practice independently, a declaration that must be demonstrated and supported by documentation (Texas Board of Nurse Examiners, 2004). A nursing competency is the skill and behavior required to perform the role of a nurse. Carlson, Kotze, and van Rooyen (2003, p. 30) have noted “the clinical learning environment creates many opportunities for student learning and the development of critical competencies in the

nursing profession.” They conducted a study that “revealed that the students experience uncertainty due to the lack of opportunities to develop competence in providing nursing care.” Four factors these researchers identiﬁed as contributing to the students’ ability to develop essential nursing competencies included (1) availability and accessibility of competent staff; (2) sufficient equipment to fulﬁll nursing duties and meet the needs of patients; (3) consensus in the expectations of nursing school and clinical nursing personnel in hospitals on the patient standard of care; and (4) awareness among faculty of the needs and problems of ﬁrst-year nursing students in the clinical health-care environment in meeting standards of care. Unfortunately, students often ﬁnd that the very nature of the clinical learning experience may interfere with their abilityto develop nursing competencies, as the guidance and support by nursing personnel in the clinical learning environment are often inadequate due to the current critical nursing shortage.

The development, measurement, and documentation of essential nursing competencies will be discussed through exploration of (1) essential nursing competencies, (2) measurement of competencies in clinical practice, (3) competencies critical to nursing management, (4) competencies critical to advanced nursing practice, and (5) competencies in nursing informatics.

ESSENTIAL NURSING COMPETENCIES

Nursing competencies to be developed, documented, and validated in the student’s clinical setting include (1) the core competency of caring, (2) competencies essential to patient care, and (3) competencies in specialty practice.

The Core Competency of Caring

Care is a competency often elusive of measurement and/or validation. But caring in professional nursing has been described as the essence of nursing (Sadler 2003). Woodward (2003, p. 215) postulated: “Human caring, while instinctive, can also be taught, learned, and measured through the nursing education system … suggest[ing] people enter nursing because they value interpersonal relationships, altruism, and a desire to help others.” This “caring ethic” can be built upon. Woodward (2003) believes that nursing students can be professionally trained to develop the competency of caring through the concepts of modeling and role modeling. Modeling is “the process used by the nurse to develop an image and understanding of the client’s world—an image and understanding developed within the client’s framework and from the client’s perspective.” This simply means to “walk a mile” in the patient’s shoes. “Role modeling” was deﬁned as utilizing “the facilitation and nurturance of the individual in attaining, maintaining and/or promoting health through purposeful interventions” (Woodward, 2003, p. 215; citing Erickson, Tomlin, & Swain, 1983, p. 95). But Sadler (2003) measured the self-reported competency of caring in baccalaureate nursing students, using the Coates Caring Efficacy Scale (CES) (2003). Sadler found that “ﬁnal semester seniors identiﬁed their families as making the greatest contribution to their development of caring; only a few reported the inﬂuence of the nursing curriculum” (Sadler, 2003, p. 295). Regardless of its origin, the competency of caring appears to be the basis and framework for the development of other essential nursing competencies.

Competencies Essential to Patient Care

Part of the challenge of preparing new graduates for practice is ensuring skill in providing a broad continuum of patient care. Utley-Smith (2004, pp. 166–170) identiﬁed six categories of competencies for new baccalaureate graduates in today’s healthcare environment:

1. Health Promotion Competency: involves interventions initiated by the nurse to promote and improve health in individuals, families, and communities. The focus of the intervention “is on assisting clients to maximize their health potential and enhance their well-being.” Therefore, client assessment and intervention are equally important parts of this competency.

2. Supervision Competency: involves the graduate nurse’s ability to coordinate the implementation of a nursing care plan, by ancillary or subordinate members of the health-care team who are responsible for carrying out speciﬁc aspects of the health plan.

3. Interpersonal Communication Competency: “encompasses relationship skills that enable the nurse to work effectively on a team … such as communication, negotiating, problem-solving, and collaboration.”

4. Direct Care Competency: encompasses the psychomotor skills necessary to deliver patient care including, for example, medication administration, wound care, and injections. Essentially, these competencies are those skills that “require the nurse to use hands or body to manipulate equipment and the client.”

5. Computer Competency: “refers to the ability of the nurse to use electronic and technological equipment to access, retrieve, and store information that assists in the delivery of effective nursing care.”

6. Caseload Management Competency: concerns the nurse’s ability to coordinate care for a speciﬁc number of clients. This may involve direct care as well as time and resource management over a particular period.

These ﬁndings identify and encompass critical outcome competencies that deﬁne the standards of care for the graduate nurse in both the classroom and clinical settings (Utley-Smith, 2004). Graduate nurse will also have the opportunity to develop specialty competencies within their traditional course work.

Competencies in Specialty Practice

RN-to-BSN specialty courses often move from a traditional model to a competency-based model, according to Foss, Janken, Langford, and Patton (2004). For example, within a psychiatric nursing program, a student may be assigned to work with a probate court as the court’s visitor, assessing the ward’s psychiatric status and need for continuing guardianship. Specialty competencies as a court visitor are then used to measure the student’s course learning outcomes, such as the student’s ability to determine if the psychiatric ward meets the standard of care for the psychiatric patient. Faculty can then document not only student learning outcomes but also mastery of competencies within this specialty area of practice.

MEASUREMENT OF COMPETENCIES IN CLINICAL PRACTICE

Staff development professionals and continuing education instructors have always been concerned with maintaining continued competency of the clinical practitioner in nursing practice. Waddell (2001) reported that the issue of competence reached new levels of signiﬁcance because of proposals made by the Pew Commission Taskforce on Health Care Workforce Regulation and the National Council of State Boards of Nursing. Waddell (2001, p. 2) believed that these two powerful organizations have forced the nursing profession to re-examine the question, “How do we promote and assure continued competence?” Waddell believed competence should be assessed via (1) mandatory continuing education, (2) peer

review, and (3) practice or process audits used to assess continued competence. But Waddell suggested that the actual measurement involved in the assessment and veriﬁcation of nursing competence should be established by (1) utilization of appropriate measurement scales; (2) selection of accurate measurement instruments, i.e., a reliable, validated competency scale; and (3) interpretation of the measurement data by nurses qualiﬁed in informatics.

Nursing competence may be measured and validated by utilizing a variety of mechanisms to document compliance, including the (1) videotaping, (2) preceptors’ record of competency-based orientation, (3) development of a portfolio of competence in clinical practice, (4) nurse’s self-assessment of competence, and (5) utilization of the hospital intranet.

Videotaping to Assess and Document Competencies and Course Outcomes

The challenge in nursing education, according to Winters et al. (2003, p. 472), is how to develop a mechanism for “effectively teaching competencies and allowing students to safely practice essential nursing skills.” They suggested videotaping, as this medium “offers a safe way … to practice skills and develop conﬁdence prior to actual performance …[it] is a teaching-learning strategy used to help…develop effective communication, physical assessment, and selected psychomotor skills … [and] also provides … a mechanism for detailed instructor feedback to improve performance.” For example, the graduate nurse or registered nurse, both required to attend annual cardiopulmonary resuscitation training exercises, may provide videotaped documentation of either attainment or updating of this competence.

The Preceptors’ Record of Competency-Based Orientation

According to Harper (2002, p. 198, quoting Alspach, 1995): “Competency-based orientation is [a program that is] learner focused … based on the attainment of core [nursing] competencies … that are necessary for new employees to function in their [health care] role at the completion of the orientation period.”

Harper (2002) conducted a research study designed to describe preceptors’ perceptions of a competency-based orientation. The results of a 26-item questionnaire indicated that the majority of preceptors agreed on the following components as necessary to meet standards for a basic nursing orientation: (1) attainment of core competencies that are role- and unit-speciﬁc, (2) sufficient time for attainment and completion of core competencies, and (3) a preceptor to ensure that competencies are in fact attained and validated, e.g., via an orientation checklist.

Development of Portfolios of Competence in Clinical Practice

A portfolio is a set of documents that “captures learning from experience, enables an assessor to measure student learning, acts as a tool for reﬂective thinking, illustrates critical analytical skills and evidence of self-directed learning and provides a collection of detailed evidence of a person’s competence” (Scholes, et al., 2004, p. 595).

The purpose of a portfolio is to document and verify achievement of the clinical competencies required to meet the standard of patient care in the area of practice to which the nurse is assigned. They concluded (p. 595): “To achieve maximum beneﬁt from the portfolio as a learning tool to link theory and practice, there needs to be a clear ﬁt between the model of portfolio and the professional practice that is to be assessed.”

When designing a portfolio, nurses, faculty,and/or nursing students must match learning outcomes and/or competencies to their practice, reconstructing those clinical experiences into the format required for portfolio documentation, such as a skills checklist. Through this process, nursing faculty and students undergo a process of deconstructing learning outcomes/competencies, then ﬁtting this information into their unique practice.

Competencies are then reconstructed to ﬁt the structure of the portfolio. According to the University of Michigan School of Nursing (2005), when comparing a résumé with a portfolio: “A career portfolio … is a much more in-depth document, and supplements—not replaces—your résumé … a key feature is the inclusion of artifacts … [or] tangible objects that demonstrate your work … [such as] care plans, brochures, outlines of training sessions, manuals, spreadsheets, memos, etc., that you created by yourself or as part of a group effort.”

These portfolios can be in many formats, including paper or electronic, Web pages, PDF documents, and even PowerPoint. Included within the portfolio may also be documents addressing the nurse’s good faith self-assessment of competency.

A Nurse’s Self-Assessment of Competence Self-assessment tools can also be utilized to document and measure competence in clinical practice. Meretoja, Isoaho, and Leino-Kilpi (2004, p. 124) reported that “self-assessment assists nurses to maintain and improve their practice by identifying their strengths and areas that may need to be further developed … encourag[ing] them to take an active part in the learning process of continuing education.”

Meretoja, Eriksson, and Leino-Kilpi (2002, p.95) collected descriptive data addressing competent nursing practice in a variety of settings. The data came from staff nurses, head nurses, and nursing directors in an acute 1000-bed university hospital.

The descriptive data obtained were then analyzed to identify a set of clinical indicators for generic competencies that could be applied to all clinical practice environments. The Nurse Competence Scale, an instrument utilized to measure the level of nurse competence, was then designed and developed by Meretoja et al. (2004). The 73 competencies were categorized into the following seven roles and functions: (1) helping role, (2) teaching-coaching role, (3) diagnostic functions, (4) managing situations, (5) therapeutic interventions, (6) ensuring quality, and (7) work role. Categories of the scale were derived from Benner’s From Novice to Expert competency framework. The results revealed that the higher the frequency of using competencies, the higher the nurse’s self-assessed level of competence. Age and length of work experience had a weak positive correlation with level of competence (Meretoja et al.,2004). See Box 6-8. The nurses’ self-evaluation of competence in their own job performance may be conceptualized as an indicator of the standards for the quality of nursing care. Tzeng (2004) clustered nursing competencies into the following three general groups: (1) basic-level patient care skills, (2) intermediatelevel patient care and fundamental management skills, and (3) advanced-level patient care and supervision skills. The results of the study revealed “that nurses’ self-assessment of intermediate

patient care skills, the difference between nurses’ self-assessment and job demands for basic patient care skills, and nurses’ overall satisfaction with their own nursing competencies were three signiﬁcant predictors of overall satisfaction with nurses’ own job performance. Nurses’ self-assessment on basic patient care skills and advanced patient care skills contributed to nurses’ levels of overall satisfaction with their own nursing competencies. These results suggest a relationship between competency and performance” (Tzeng, 2004, p. 487).

Based on these findings, academic nursing courses and on-the-job training programs may be amended to place emphasis on these competencies required to provide high-quality patient care (Tzeng, 2004). Further, self-assessments demonstrate to nursing regulatory bodies good faith in the nurse’s efforts to either achieve or maintain competencies essential to meet the standard of practice.

Utilization of the Hospital Intranet to validate and document compliance with state competency standards

Currently, regulatory agencies require hospitals to provide evidence that employees are in compliance with state-mandated competencies. Wolford and Hughes (2001, pp. 188–189) identiﬁed “Intranetdelivered computer-based training as an effective and efficient method of providing and documenting training to meet regulatory requirements.”

For example, regulatory agencies require competency in adapting nursing care standards to the developmental needs of patients. Although Welton, Nieves-Khouw, Schreiber, and McElreath (2000) suggested that training programs on age-speciﬁccare competencies vary widely in format, content, and method, these authors developed computer based training (CBT) programs on age-speciﬁc care competencies, using traditional self-paced learning modules. The authors converted printed modules to CBT and pilot-tested experiences of using CBT with clinical staff, ultimately implementing an organization-wide CBT deployment for age-speciﬁc care competency and other mandatory training.

COMPETENCIES CRITICAL TO NURSING MANAGEMENT

Nursing management has its own set of unique competence functions. Connelly, Yoder, and MinerWilliams (2003) categorized a total of 54 charge nurse competencies within the following four categories: (1) clinical/technical competencies, (2) critical thinking competencies, (3) organizational competencies, and (4) human relations skills.

These researchers believe that these competencies deﬁne the standard for leadership and management skills required to function as effective, front-line charge nurses. See Box 6-9. Kleinman (2003) noted, “nurse managers are often less well prepared to manage the business activities than the clinical activities.” The nurse managers and nurse executives who were subjects of this research identiﬁed staffing and scheduling, management, and human resources as the three most important competencies for nurse managers.

Based on the results of Kleinman’s research (p. 451), and in an effort to develop and validate knowledge of the regulations and standards of practice for a nurse manager that encompass not only the organizational but also the clinical/technical competencies, the subjects of this research suggested: “Strategies nurse executives may employ to develop nurse manager business knowledge include traditional undergraduate and graduate degree programs, online programs, certiﬁcate programs, continuing education, in-service education offerings, seminars, and mentoring activities.”

COMPETENCIES CRITICAL TO ADVANCED NURSING PRACTICE

The level and type of competence and education required in advanced nursing practice depend on the area of specialty practice and vary from state to state. The following section discusses (1) generalist versus specialist nursing competencies and (2) competencies required in critical care.

Generalist Versus Specialist Nursing Competencies

A generalist nurse is one who has a duty to comply with the standards of nursing practice as identiﬁed in the nursing practice act of the state of licensure. A specialist nurse has a duty to comply with the state’s standards of nursing practice and a duty to comply with the standards of practice as identiﬁed in the specialty area, e.g., psychiatric nursing. This distinction between the standards of practice for generalist versus specialist nursing requires analysis of the “characteristics of knowledge, skills, abilities, values and qualities displayed in the context of professional work for both groups of nurses” (Gibson, Fletcher, & Casey, 2003, p. 591). These authors conducted a research study to determine if there was a difference between the basic competencies of a generalist versus those of a specialist nurse. They ordered 198 competencies into 26 subcategories that were then classiﬁed into 12 categories. See Box 6-10.

In conclusion, the researchers noted: “There is a signiﬁcant common element in these two areas of nursing practice, and generalist preparation in … nursing is the foundation of specialist … nursing practice. Generalist knowledge and skills are 80 Understanding Organizations Box 6-9 Categories of Generalist Versus Specialist Nursing Competencies

expanded in specialist practice and there is also evidence of specialist practice that is beyond the scope of general nursing practice” (Gibson et al., 2003, p. 591).

Competencies Required in Critical Care

Nationally accepted critical care competencies have not been formulated. Therefore, critical care programs in each educational institution tend to redeﬁne the essential competencies necessary to meet the standards of practice in the area of critical care, resulting in variations in accepted practice from state by state basis and within practice. But core critical care competencies can be identiﬁed on a national basis. Jones (2002) conducted a research study designed to elicit core critical care competency statements from a sample of nurses working in London, England, in critical care.

According to Jones, a core critical care competency framework can be developed by expert nurses drawing on their own experience and knowledge of critical care nursing. The author suggested that this process would be useful to (1) educationalists designing competency-based curricula, (2) critical care managers as a tool for recruitment and retention and for education and training of staff, and (3) individual critical care nurses to facilitate continuous professional development.

Competencies Required in Nursing Informatics

Informatics is the “application of computer and statistical techniques to the management of information” (University of New Castle upon Tyne, 2004). The standards on which nursing informatics competencies are based are still evolving. Some of the essential nursing informatics competencies will be categorized according to their relevancy to (1) national nursing education strategies designed to develop nursing informatics competencies, (2) nurses at four levels of practice, (3) risk assessment, and (4) computerization of records

National Education Strategies Designed to Develop Nursing Informatics Competencies

Herbert (2000) proposed that advances in the sophistication of information and communication technologies offer the nurse practitioner opportunities for (1) better information management, (2) more complete documentation of work, and (3) knowledge development to support evidence-based nursing practice. Herbert suggested a shift in emphasis from specialists in nursing informatics (NI) to NI being integrated into all domains of nursing clinical practice, pointing to the need for nursing informatics education strategies on a national level. According to Herbert (2000), steps in developing a plan to implement an education program on informatics competencies and standards must include (1) recognizing the role and history of the NI specialists, (2) deﬁning NI and the required NI competencies, and (3) adapting the educational infrastructure required to support this initiative. A national committee, the National Nursing Informatics Project, was working on a plan to address these competencies in nursing informatics (Herbert, 2000). This project ultimately demonstrated, however, that informatics does not seem to be as successful in providing evidence-based research for establishing standards and competencies for practice as individual nursing researchers, such as Staggers, Gassert, and Curran (2002).

Informatics Competencies for Nurses at Four Levels of Practice

Bickford (2002) noted that, although nurses have always dealt with data, information, and knowledge, the standard for nursing now requires core competencies not only in computer skills but also in data and information management. Informatics competencies differ according to the nurse’s level of skill.

Staggers, Gassert, and Curran (2002, p. 383) conducted a research study designed “to produce a research-based master list of informatics competencies for nurses and differentiate these competencies by level of nursing practice.” The four levels of practice were identiﬁed as the beginning nurse, the experienced nurse, the informatics specialist, and the informatics innovator. Based on a comprehensive literature review and item consolidation, an expert panel of informatics nurse specialists deﬁned initial competencies for the beginning informatics nurse. See Box 6-11 for a master list of valid computer competencies for the Level 1 Beginning Nurse.

The results of the research of Staggers, et al.(2002) indicated that: (1) computer skills are only one set of competencies within the larger category of informatics standards, and (2) programming skills or competencies of the third-level informatics specialist nurse are generally not a necessary standard for the ﬁrst-level beginning and/or secondlevel experienced nurse.

Thus, Staggers, et al. (2002) agreed with Herbert’s (2000) conclusion that general, not specialized, informatics should be the standard for integration into all areas of clinical nursing practice.

Informatics Utilized in Regulating Safety Standards

Nursing informatics may be utilized to design or redesign computerized risk assessment programs that monitor whether patient safety standards have been met. Browne, Covington, and Davila (2004) reported that such computerized tools provide (1) an accurate assessment of the safety risk to each patient; (2) indicators that are embedded into routine assessment documentation, eliminating added charting time and ensuring safety; (3) tailored interventions for speciﬁc patient safety risks; (4) an integration of fall-risk information into the care

plan, report sheets, and care conferences; and (5) an interdisciplinary communication network regarding the standards of care for safety.

Informatics Utilized in Establishing the Standard of Care A descriptive study, designed by Scott and Elstein (2004) using the Nursing Home Quality Initiative, found that the standard of nursing care may be achieved, regulated, and maintained through nursing informatics by (1) utilizing quality measurement methods and tools in monitoring patient care, (2) utilizing quality data to ensure desired patient care outcomes, (3) monitoring organizational and cultural factors affecting utilization of quality data in the clinical setting, (4) utilizing informatics systems to gather and implement quality data, and (5) documenting and measuring impact evaluation and research outcomes. The ﬁndings of this study may be generalized to establish the standard of care, ensuring quality nursing care. Thus, the nursing standard becomes regulated through evidence-based research.

Evidence-Based Practice: The Standard of Care

Evidence-based nursing practice is an expected part of the nursing standard of care. Evidence-based nursing practice utilizes the best current clinical evidence or research when implementing the nursing process. Evidence-based practice is the basis upon which nursing standards are developed. Thus, evidence-based nursing practice is a clinical decision-making process that is integrated into the nursing process. This scientiﬁc, step-by-step process combines (1) the best available research evidence, (2) the nurses’ clinical expertise, and (3) the patient’s preferences for patient care. Nurses integrate evidence-based nursing into the nursing process by doing the following:

1. Identifying the patient’s care need by assessment, based on analysis using current nursing knowledge, expertise, and clinical practice

2. Researching the literature for best evidence relevant to meeting the patient care need.

3. Evaluating the research, or best evidence, for interventions speciﬁc to the patient care need.

4. Choosing the best intervention designed to meet the patient care need, justifying the selection based on valid, reliable research (University of Minnesota, 2004).

Evidence-based practice challenges nurses to develop patient care interventions and expand the relevant knowledge, based on the best research. But van Meijel, Gamel, van Swieten-Duijfjes, and Grypdonck (2004) reported limited literature on the development of evidence-based nursing interventions. They presented a model for developing evidence-based nursing interventions, designed to guide the process of developing and testing complex nursing interventions while incorporating the experience of the client.

The model consisted of four stages: (1) problem deﬁnition, (2) accumulation of building blocks for intervention design, (3) intervention design, and (4) intervention validation.

The model allowed for the accumulation of empirical evidence and theory development during the formulation of the evidence-based intervention. The authors suggested (p. 84) that the “use of the model could facilitate effective communication among nurses, researchers and educators when discussing the development and testing of nursing interventions.”

Plouffe and Seniuk (2004) promoted evidencebased clinical practice as the goal of professional nursing. Unfortunately, they reported (p. 14) that “linking research to the clinical realm appears logical and sounds simplistic, yet frequently our preconceived thoughts and ideas of ease of change do not equate with the reality of the situation.” Although relevant research may exist, and the patient care need may be there, the question remains of “how shall the two meet?”

For example, a study was designed by Olade (2004), whose purpose was: (1) to identify the extent to which rural nurses utilize evidence-based practice guidelines from scientiﬁc research in their practice, (2) to describe previous and current research utilization activities, and (3) to identify the speciﬁc barriers they face in their practice settings. The results of the study revealed that only 20.8% of the participants, nurses with bachelor’s degrees, were involved in research utilization. The two most common areas of research were pain management and pressure ulcer prevention and management. Barriers to research identiﬁed by Olade included rural isolation and lack of nursing research consultants.

But Winch, Creedy, and Chaboyer (2002, p. 56) commented that evidence-based nursing practice either will or does direct nursing practice, arguing: “It is possible to identify the governance of nursing practice and hence nurses across two distinct axes; that of the political (governance through political and economic means) and the personal (governance of the self through the cultivation of the practices required by nurses to put evidence into practice.) …

Evidence-based nursing is an emerging technology of government that judges nursing research and knowledge and has the capacity to direct nursing practice at both the political and personal level.”

EVIDENCE-BASED PRACTICE THROUGH NURSING RESEARCH: THE ROAD TO BEST PRACTICE

Best practice is the process through which competence and evidence-based practice lead to the desired health-care outcome. Nursing research is the mechanism to provide evidence-based practice.

Thus, for desired patient outcomes and to ensure cost-efficient and effective best practice, application of nursing research ﬁndings is essential to the establishment and regulation of the standard of nursing practice.

Many variables affect regulations and standards that are the subject and/or outcome of nursing research. Olsen (2003) identiﬁed Health Insurance Portability and Accountability Act (HIPAA) privacy regulations, which became effective April 14, 2003, as having had the most signiﬁcant current impact on nursing research. The privacy requirements of the regulations have affected nursing research in (1) the research process, (2) accessing data (including recruitment and using medical records), (3) creating data (including intervention studies, survey, and interview research), and (4) disclosing data to others, such as nursing colleagues at other health-care institutions.

Hodge, Kochie, Larsen, and Santiago (2003) identiﬁed a “research-practice gap,” a situation in which research ﬁndings that should become best nursing practice are not implemented. In anattempt to diminish the research-practice gap via evidence-based nursing practice, the authors studied ways to implement best practice. A patient care research utilization committee was formed to review and revise each patient care policy and procedure, based on best research evidence. The impetus for the project was a belief that current patient care policies and procedures were (1) based on tradition rather than on science and (2) did not provide best practice in patient care, missing skills required for new equipment, treatments, and research ﬁndings. The beneﬁcial outcomes of this research project included (1) a revision of patient care policies and procedures, based on scientiﬁc evidence; (2) generation of new research questions, based on gaps in the nursing literature; and (3) an increase in the number of clinical nurses involved in using research to provide best practice. Staff education is another important component of best practice. A research utilization project was designed by Cruz, Abdul-Hamid, and Heater (1997) for the purpose of (1) selecting and implementing a research-based restraint education program, (2) reducing the use of restraints in an acute care setting, and (3) changing the perception about restraints in the direction of decreased importance.

The existing restraint policy and procedure and new restraint products and alternative restraint methods were reviewed by a multidisciplinary team. Based on the evidence provided by a review of the literature on restraint education programs, the multidisciplinary team concluded that education was the key component in promoting best practice.

Education programs could be monitored by risk management and quality assurance to ensure best practice in accordance with nursing regulations.

Accreditation as Nursing Regulation

Accreditation is a voluntary process of compliance with a set of standards established by a nongovernmental organization (University of New Castle upon Tyne, 2004). Accreditation is the process utilized by an organization, such as a school of nursing or health-care facility, to verify a competent educational or health-care program, respectively. For example, the state’s governing board for nursing typically provides accreditation for schools of nursing, providing validation that the educational program is in compliance with the state’s standards of instruction for teaching qualiﬁed students how to provide standardized nursing care. Private accrediting agencies like the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) monitor compliance with state and federal standards, but utilization of these private accrediting agencies is voluntary, not mandatory.

JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS (JCAHO)

Established over 50 years ago, JCAHO is an independent, not-for-proﬁt accreditation organization. Governed by a board that includes physicians, nurses, and consumers, JCAHO sets the standards by which quality of health care provided in hospitals is measured in the United States and around the world (JCAHO, 2004).

Hospitals and ambulatory surgery centers may voluntarily choose to apply for accreditation through JCAHO or other such organizations. According to Sauﬂ and Fieldus (2003), before accrediting a hospital, JCAHO requires compliance with its standards regarding the environment of care, provision of care, and quality of care. Quality of care is ensured by JCAHO conducting regular surveys of each agency’s performance. The value of the accreditation, according to the authors (p. 152), is that this process “… certiﬁes to the health care community and the community-at-large that the facilities meet nationally accepted standards through a recognized accreditation program.”

JCAHO is committed to improving and regulating safety in patient care by providing (1) standards of patient care, (2) survey evaluations on the healthcare provider’s status in meeting standards of care, and (3) professional consultative and educational services on mechanisms for meeting the standard of patient care (Sauﬂ & Fieldus, 2003). To meet JCAHO standards, nursing standards and operating strategies of health-care organizations must be in a continual state of readiness, including performance improvement practices. Gantz, Sorenson, and Howard (2003) believe that nurses have a unique role in identifying and guiding the nursing process, central to quality care, and the commitment to establishing and maintaining quality care, as identiﬁed by JCAHO. They believe that the paradigm of health care must be shifted from just meeting the standards to continual readiness and performance improvement throughout the organization.

COMPLIANCE WITH POLICIES AND PROCEDURES

A policy is a stated system by which health care is administered. A procedure is a step-by-step process by which a health-care outcome is achieved. The American Nurses Association (ANA) plays a signiﬁcant role in the development of model policies and procedures on both the state and national levels. Standards of care also affect the development of policies and procedures regulating nursing practice. Policies and procedures must meet or exceed minimum standards of care as set by nurse practice acts and other sources.

For example, the ANA provides a foundation for policies and procedures related to patient safety by (1) developing and disseminating policies and procedures to meet the standard for patient safety, (2) lobbying for legislation and regulations that protect and serve users of nursing services, and (3) advocating for patients and issues that affect a nurse’s ability to meet the standards for safe care.

Policies and procedures are designed to regulate, standardize, and drive nursing practice (Zeitz & McCutcheon 2002). Evidence-based nursing practice is essential in developing policies and procedures. Zeitz and McCutcheon (2003) reported that although evidence-based nursing is the mechanism for achieving best practice in the clinical setting, in reality it has had very little impact on the clinical

practice that nurses deliver on a daily basis. For example, the authors noted that although the collection of vital signs is a ubiquitous component of practice in the postoperative general surgical setting, there is little evidence, in the form of evidence-based policies and procedures, to support this practice. Further, they indicated that nursing policies and textbooks, in general, present traditional, routineregulated clinical practice without an evidence base. Traditional policies and procedures are being used to (1) control rather than support evidence-based practice and (2) limit opportunities for clinicians to make patient-speciﬁc decisions. They suggested that evidence-based practice, and ultimately best practice, may be achieved through creation of policies and procedures based on (1) rigorous relevant evidence that supports standardized nursing interventions, (2) the nurse’s clinical expertise, and (3) the changing and expanding environment in which nurses develop and practice. One of the most important environmental factors affecting nursing practice is the level of staffing.

Compliance With Staffing Requirements

Regulation of staffing affects productivity, the delivery of patient care, and thus the standard of nursing care. Bednar, Haight and Street (2003, p. 47) reported that: “… state-mandated staffing ratios, coupled with restrictive nurse practice acts, may be impacting the delivery of care to … patients.” They found that patient-to-staff ratios vary state by state. Mark, Harless, McCue, and Xu (2004) conducted a study designed to evaluate previous research ﬁndings exploring the relationship between nurse staffing and quality of care. In evaluating this relationship, they examined the effects of change in registered nurse staffing on change in quality of patient care from 1990 to 1995 They found (p. 279) that “improving registered nurse (RN) staffing unconditionally improves quality of care.” Levels of registered nurse staffing must also comply with state and federal legislative and administrative regulations. Legislative and Administrative

Regulation of Nursing

Nursing practice is regulated through state and federal legislative and administrative laws and agencies. The state and federal legislatures develop and pass laws. Federal administrative agencies, such as the Veterans Administration, oversee compliance with regulations by their agencies. Some examples of federal administrative regulatory agencies include the Centers for Medicare and Medicaid Services (CMS), the Occupational Safety and Health Administration (OSHA), and the Centers for Disease Control and Prevention (CDC). State administrative agencies, such as state boards of nursing, create regulations to accompany, detail, and implement state laws.

CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS)

The CMS administers the Medicare program and collaborate with states to administer Medicaid, theState Children’s Insurance Health Care Program, and HIPAA. CMS is speciﬁcally responsible for simpliﬁcation of standards for implementation of and HIPAA and maintenance of quality standards for health care through its surveys and certiﬁcation functions (CMS, 2004).

HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)

CMS oversees implementation of HIPAA standards and regulations. Title I of HIPAA is designed to protect health insurance coverage for workers and their families when they change or lose their jobs. Title II of HIPAA, The Administrative Simpliﬁcation provisions, “requires strict security measures to protect the electronic health data of patients” (Follansbee, 2002, p. 42). Consequently, nursing policies and procedures associated with the management of health-care information have changed dramatically (Follansbee, 2002).

Requirements under HIPAA require nursing service to comply with privacy standards by (1) developing appropriate policies and procedures, (2) providing notice of privacy practices and other forms, (3) implementing measures to secure privacy, (4) contracting with business associates to secure privacy, and (5) training all nursing staff involved in patient care (Lucas, Adams, & Wachs, 2004). According to these authors (pp. 178–179):

“HIPAA’s privacy regulations are considered ‘the ﬂoor’ or minimum standard for the protection of PHI [protected health information]. As such, it is likely that these privacy regulations will become the ‘industry standard’ to which all health care professionals will be held.”

Research in Long-Term Care: Issues, Dilemmas, and Challenges

Scott and Elstein (2004) reported that as the American population ages, already sizable longterm care expenditures are likely to increase. The CMS, as the largest purchaser of health care for the aging population, is continuously working to improve the standard of long-term patient care through (1) quality monitoring and enforcing of patient care standards, (2) providing information to beneﬁciaries about the standard of patient care, and (3) enhancing resources to improve standardized patient care.

Medicare and Medicaid also establish program requirements in long-term care facilities. For example, according to regulations created by CMS (CMS, 2003, September), long-term care facilities may, in speciﬁc circumstances, utilize paid feeding assistants to supplement the services of certiﬁed nurse aides. The training and certiﬁcation of the feeding assistants must have occurred under standardized guidelines, established by CMS.

OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION

The Occupational Safety and Health Administration (OSHA, 2004) is a federal agency whose mission is designed to: “assure the safety and health of America’s workers by setting and enforcing standards; providing training, outreach, and education; establishing partnerships; and encouraging continual improvement in workplace safety and health.” OSHA provides a foundation for understanding workplace health and safety by producing publications, pamphlets, audiovisual programs, computer access programs, and other documents designed to promote compliance with safety standards (Nester, 1996). OSHA works to build partnerships between occupational safety and health-care administration, according to Nester (1996). For example, the Office of Occupational Health Nursing within OSHA is an active advocate for health-care workers, such as nurses, assisting with the establishment of standards that protect and provide for the safety of patients and all health-care providers.

The OSHA Pathogens Standard

In 1991 the OSHA standard designed to protect health-care providers from exposure to blood and other potentially infectious materials became mandatory. According to Goldstein and Johnson (1991), health-care employers were required to institute an infection control plan based upon this OSHA standard, which included universal precautions, engineering and work practice controls, personal protective equipment, and housekeeping. Occupational health nurses (1) coordinated the development, maintenance, and revision of this infection control program, in compliance with the OSHA regulations, (2) educated management about the hazards of blood-borne pathogens, and (3) provided assistance to ensure compliance with theOSHA standard, resulting in a safe and healthy work environment for the health-care provider. Nursing plays an active role in OSHA’s functions. Nurses are not only regulated/protected by OSHA standards but also play an important role in their implementation to meet standards for patient safety.

CENTERS FOR DISEASE CONTROL (CDC)

The Centers for Disease Control and Prevention (CDC, 2004) is the leading federal agency for protecting the patient’s health and safety both at home and abroad. The CDC is responsible for (1) developing and applying disease prevention and control, (2) maintaining environmental health, and (3) promoting health and education activities designed to improve the well-being of the people of the United States. But research has demonstrated that more nursing expertise is needed in the area of disease control, as this environmental concern is a “front line” patient care safety issue in nursing practice.

Disease Control: A Safety

Issue in Nursing Practice

According to Larson and Butterﬁeld (2002), clients often use nurses as their primary contact for expressing concerns about health problems related to environmental disease control. In response to this need, core competencies for nursing expertise in the ﬁeld of environmental disease control were developed by the Institute of Medicine, Agency for Toxic Substances and Disease Registry, and National Institute of Nursing Research. These core disease control competencies comprise a baseline of knowledge and awareness as well as a standard by which nurses intervene to prevent and minimize environmental disease. Nursing standards for disease control focused on the following four competencies:

1. Basic knowledge and disease control concepts: “Understanding scientiﬁc principles [of] basic mechanisms of exposure…prevention and control strategies applied research, and the interdisciplinary nature of environmental health.”

2. Assessment and referral: “Completing a comprehensive environmental exposure history and making appropriate referrals … locating and providing appropriate scientiﬁc information for individual patients and communities.”

3. Advocacy, ethics, and risk communication: “Understanding the role of advocacy, principles of environmental justice, and risk communication in addressing environmental health issues.”

4. Legislation and regulation: “Understanding environmental health policy as well as state and national regulations” (Larson & Butterﬁeld, 2002, pp. 301–308; quoting Pope, Snyder, & Mood, 1995).

Establishing Safety Protocols Based

Upon CDC and OSHA Recommendations In 1987 OSHA was petitioned by the ANA and labor unions to issue an emergency infection control standard, subsequent to the ﬁrst documented reports of occupationally acquired human immunodeﬁciency virus (HIV) in health-care providers (Miramontes, 1990). OSHA responded by enforcing voluntary guidelines developed by the CDC 4 years earlier. Subsequently, OSHA drafted regulations containing the ﬁnal set of HIV safety protocols in1991.

According to Miramontes (1990), OSHA established HIV safety standards and protocols to be utilized by all health-care providers, addressing (1) types of protective clothing and equipment, (2) housekeeping and laundry areas, (3) infectious waste disposal, and (4) tracking employees, preand postexposure. In enforcing these standards, hospitals stress continued education and training in order to increase compliance. Miramontes (pp. 561–562) cited a research study that found “after a two-year training/evaluation period, physician compliance with infection control procedures increased from 20% to 80%, and nurse compliance rose from 50% to 86%.”

All Good Things…

Nursing practice is regulated on the state and federal levels. On the state level, nursing is regulated via the state’s nursing practice act, which provides for licensure as a registered nurse. Subsequently

certiﬁcation acknowledges nursing competence at an advanced level of practice. The nursing practice act establishes the standard of care and scope of practice, which are monitored by the state’s governing board, usually the board of nursing examiners. The nursing practice act also regulates advanced practice; for example, the clinical nurse specialist. The scope of nursing practice has been expanded by telenursing, requiring the development of the Nurse Licensure Compact (NLC). The NLC creates standardization within nurse practice acts that vary and lack uniformity from state to state, providing more standard methods of compliance, discipline, and rehabilitation.

Nursing has been developed upon the core competence of caring, a concept difficult to measure, document, or legislate. Other essential competencies, which appear to be measurable behaviors, include health promotion, supervision, interpersonal communication, direct care, computer, and case load competencies. Competencies may be documented with videotaping, orientation records, portfolios, self-assessment tools, records of mandatory intranet training courses, and continuing education records. Advanced areas of nursing practice have more specialized sets of competencies.

Speciﬁc competencies are required in nursing informatics at four levels, consisting of the beginning, experienced, informatics specialist, and informatics innovator nurse. Informatics may be integrated into the nursing standards. Evidence-based nursing practice is the expected standard of care. Nursing research is the mechanism to provide evidence-based practice. The nurse may integrate evidence-based practice into the nursing process, for example, by following a four-step clinical decision-making process. Policies and procedures also establish the standard of care and thus regulate nursing practice.

Independent organizations, such as JCAHO, monitor a health-care provider’s compliance with state and federal laws and regulations. Accreditation is the process utilized by an organization, such as a school of nursing or health-care facility, to verify competency of its educational or health-care program, respectively. Staffing and productivity must also be regulated under these accreditation guidelines to meet the standard of care.

Legislative and administrative regulation of nursing occurs on the federal level; for example, through CMS. CMS oversees the administration of HIPAA, a federal law that regulates conﬁdentiality issues related to patient care. OSHA is a federal agency that promotes standards for patient safety in the health-care environment. The CDC is the federal agency that develops and promotes disease prevention and control.

Power, Politics, and Policy

Power, politics, and policy should be familiar concepts for all nurses and are especially important for nursing leaders. Power, politics, and policy inﬂuence nursing practice, education, and research, which in turn inﬂuence health care. Power and politics are intricately entwined concepts and are sometimes difficult to differentiate. Both are used to achieve ends or goals, and both do so through manipulation of others. Power and politics also interact. People who are powerful are able to exert more political pressure; political success brings power that allows people to accomplish goals through policy development and implementation. Power is the ability to do or act; it is a state in which one can manipulate others. Politics is negotiation for (scarce) resources; it is a process through which one tries successfully or unsuccessfully to reach a goal. Policy is the “consciously chosen course of action (or inaction) directed toward some end” (Kalish & Kalish, 1982, p. 61). Obtaining and allocating resources are two examples of possession and use of power. They also exemplify the use of politics in that inﬂuence is needed to get what you want and need. Policies are guidelines that tell us how we obtain and allocate those resources. Understanding power, politics, and policy is crucial to effective patient care because these concepts have a signiﬁcant impact on access to care, allocation of funds, and standards of care.

Power

There are multiple deﬁnitions of power. Some assert that power is an overall concept that includes authority and inﬂuence. Others see authority and inﬂuence as separate ideas or concepts; as such, they require individual consideration. Power is the ability to inﬂuence other people despite their resistance and may be actual or potential, intended or unintended. It may be used for good or evil, for serious purposes or for frivolous and selﬁsh ones. Power is the ability to control, dominate, or manipulate the actions of others or, as Rollo May stated, “power is the ability to cause or prevent change” (1972, p. 99). It is a term used freely by politicians, policy analysts, and many others. Power is important to nursing because having it is necessary to achieve goals as individuals, professionals, and leaders. There are no deﬁnitive models of power, which often makes aspects of power complex and contradictory. Power can shift; it is dynamic. There are a variety of sources (types or bases) of power that have been identiﬁed, as derived from the work of French and Raven (1959), Hersey, Blanchard, and Natemeyer (1979), Ferguson (1993), and Joel and Kelly (2002). Understanding sources of power facilitates analysis of individual and organizational behavior and enables prediction in speciﬁc situations. Power sources or types are presented below.

TYPES OR SOURCES

Power can be either positional and personal. Positional power is awarded or granted to a person, but it is derived from a person’s position, office, or rank in a formal organization system. Personal power, on the other hand, is derived from followers. Leaders who act in ways that are important to followers are given power. An example is the nurse managers who have power because they are seen as highly competent, are good role models, or have some personal attribute that makes them effective in their roles. Expertise (which is discussed below) is a way to gain personal power. Common types of power include (a) authority, (b) expertise, (c) reward, (d) coercive, and (e) referent.

Authority and Administrative

Administrative (sometimes called legitimate) or positional power requires that one serve in a line position and have responsibility for management and actions of other employees. This kind of authority is given to a position rather than to a particular person, for it is part of a role regardless of who ﬁlls that role. For example, although the chief executive officer (CEO) in a health-care organization has the most power, the CEO is still answerable to the board of trustees or directors. The chief nurse executive (CNE) has the most power relative to the nurses who are situated further down the chart of the organization, such as supervisory staff, nurse managers, and staff nurses. It is power accorded to a person by virtue of the position held by that person. Nurse managers and team leaders have more power than do staff nurses. CNEs, deans, senators, mayors, governors, presidents, and other elected officials have administrative power.

Administrative authority is the power or right to give orders or commands, to enforce compliance, to take action, and to make ﬁnal decisions. For example, the dean of a nursing school has authoritative power from her position. As dean, she has the power to make decisions that have both short- and long-term consequences and that directly affect education and student life. Similarly, the primary nurse has more authority in regard to her primary patients than do other nurses or nursing assistants. Authority can also be personal and as such is deﬁned as power or inﬂuence that results from knowledge or expertise. Professional authority is granted by choice, not position, and applies to competent professionals, whereas administrative authority depends upon job descriptions and place in the organization. Authority has been a problem for nursing since at least the Victorian Era, when nurses were ﬁrst seen in the aggregate. For most of nursing’s modern history, nurses were kept under the authority of physicians. Reverby (1987a, b) states that nurses had to limit revelation of the scope of their knowledge and the effectiveness of their care. They had the responsibility for patient care without needed authority. Reverby asserts that nurses are ordered to care by a society that does not value care. Nurses gained authority through knowledge, feminist inﬂuences on society, and slow increases in the scope of practice. Nurse leaders worked hard to gain the power of authority. Judicious, skilled use of power and politics in an environment set for change helped them to change policy with legislation and regulations to achieve their goals. Nursing leaders fought hard for standardization of nursing education, development of knowledge, and professionalization. Feminism from the late 19th century to the present helped achieve increasing professionalization and improved status. As education and professionalization grew, so did nursing’s scope of practice. In 1972, New York State passed the ﬁrst nurse practice act. For the ﬁrst time, the essential role of nursing in dealing with human response to illness or treatment was stated, debated, and legislated (Diers & Molde, 1983). The nurse practice act conferred authority on nurses and nursing. Authority was, and is, necessary to nursing as it gives status and power within institutions and communities to mobilize resources to achieve health care goals.

Expert

Expert power is inﬂuence that results from knowledge or expertise that is needed by others. It is similar to personal authority, but it is gained and affirmed through respect for expertise. Expertise can be an indispensable source of power within health-care organizations. Such power is granted by choice to a person, not to a position, and applies to competent professionals. Nurses work in dynamic environments where change is rapid and where power and inﬂuence often take new forms. Expertise brings knowledge and skills to the assessment of problems and issues, which brings about solutions and change. Those who are lifelong learners have an important effect on deliberations and decision making because they understand those changes and can participate fully and ﬁnd and implement important and creative solutions to situations or problems. Those who do not keep their knowledge current fail to earn or retain expert power. Continued acquisition of new knowledge and skills is essential to maintain this form of power. Expert nurses, nurse practitioners, clinical specialists, and other nurses have power based on their knowledge and expertise. Benner (1984) asserts that nurses can use this power source as they become expert practitioners. This is a source of power that nurses can and must use, because they have expertise that policy makers generally lack. Such professionals have power to exert successful change. Expert power follows the person as long as the person maintains his skills. Reward Reward power is the ability to offer rewards, which is a potent type of power. It is the promise or perception of money, goods, services, recognition, and other recompense in exchange for some action that beneﬁts the powerful person. Behavior is affected in that a person will often honor wishes or demands for the potential (or actual) rewards from the powerful person. Managers, supervisors, and administrators have access and ability to use this power through their authority to reward people with bonuses, salary increases, promotions, and recognition. Appropriate use of reward power is the promotion of a nurse who has earned and is qualiﬁed for a new position. Inappropriate use of rewards is the assignment of a rotating nurse (bypassing others) to the day shift in return for favors or friendship

Power to punish is included in the concept of reward. Those who have the capacity to reward also have the ability to punish. In organizations the person with reward power can usually also discipline and ﬁre employees.

Lobbyists often use reward power. They educate legislators and other government officials. Lobbyists bring a high degree of access to and accountability from elected officials. They form coalitions to inﬂuence needed legislation and policy change and development. The American Nurses Association (ANA) lobbies for legislation that is important to patient care and nursing. Lobbyists or advocates can have relationships with legislators where one rewards the other. For example, lobbyists promise monetary support for reelection campaigns in exchange for favorable votes on beneﬁcial legislation. Legislators who are found to participate in this kind of power brokering are prosecuted.

Coercion

Coercion is the real or perceived threat of pain or harm of one person by another. Coercive power may be physical, psychological, social, or economic and involves the use of force in the form of penalties and rewards to effect change. It shows a lack of respect for the autonomy of others and is seen in sexual harassment and threats to livelihood. Those who use coercion are interested in their own goals and are rarely interested in the wants and needs of subordinates. An example is the threat by a supervisor to ﬁre whistle-blowers (people who speak out about a wrong). The threat of a state health commissioner to implement onerous regulations for nurse practitioners or visiting nurses if some action is not done is coercion. A volunteer religious group that demands religious conversion by threatening to withhold or withdraw education, expertise, materials, or care coerces the people it is there to help.

Referent

A leader who is followed based on admiration and belief has referent power. The chair of a committee, for example, has referent power for those who work closely with her. Referent power is gained through association with a powerful person or organization. Selection of a powerful person as a mentor and working on powerful committees are ways to develop and hold referent power.

THE NEED FOR POWER

Nurses are predominantly women and provide the most direct patient care in male-dominated organizations. Nurses have rarely had signiﬁcant power in health-care organizations. Over the past 15 years, nurse administrators have made progress in gaining recognition at the top levels; some have even made inroads to governance. These leaders are all too often terminated, however, which is an all too graphic indication that role acceptance has not been accomplished (Camuñas, 1994a, b, 1998; Carroll, DiVincenti, & Show, 1995; Donnelly, 2006; Kopala, 2001; Sabiston & Laschinger, 1995; Vestal, 1990; Vestal, 1995). Power commensurate with knowledge and expertise is needed to enable nurses to provide competent, humanistic, and affordable care to people; to participate in health-care policy development; to gain leverage proportionate with their numbers; and to ensure that nursing is an attractive career choice for all who want to provide care, inﬂuence, and improve nursing, health care, and health policy.

WAYS TO ACHIEVE POWER

There are multiple ways to accumulate, or gain, power. Some may be more appropriate at higher positions in an organization. Skills to achieve and maintain power take time and patience to learn, develop, and reﬁne. Methods to acquire power include the following:

■ Broad human networks: the more networks and the more extensive they are, the more power potential.

■ Broad information networks: the more diverse types of information controlled, the more power.

■ Multiple formal and informal leadership roles: high engagement and visibility bring increased power.

■ Ability to assess situations accurately (especially unstructured ones) and to solve problems.

■ Authority over others and resources via legitimate work organizational roles.

■ Vision for the future and creativity.

■ Ability to grant services to others, which builds debts.

■ Expertise that is sought by others.

Ways to Increase Expert Power

There are many ways to enhance your power, for example. Professionals, to maintain their competence and develop their careers, use these tactics:

■ Participate in interdisciplinary conferences to broaden knowledge, develop skills, and build networks

■ Keep knowledge and skills current to maintain and extend power. Continuing education offerings, books, and journals are effective means.

■ Earn higher degrees; education brings expertise and enhances credibility.

■ Participate actively in professional associations such as the ANA, state nurses associations, and specialty groups to broaden networks, hone expertise, and develop legitimate and referent power.

■ Participate in nursing research to develop knowledge and increase expertise.

■ Problem-solve with colleagues in nursing and other disciplines to develop expertise and networks and to polish skills.

■ Participate in nursing and interdisciplinary committees to develop and enhance expert, referent, and legitimate power.

■ Publish to develop expert power.

■ Learn from mentors; be a mentor (Flynn, 1997; Vance & Olson, 1998) to develop expertise and connections or referent power.

EMPOWERMENT

Empowerment is a sense of having both the ability and the opportunity to act effectively. Empowerment is a process or strategy the goal of which is to change the nature and distribution of power in a speciﬁc context. It is a group activity that increases political and social consciousness, is based on the need for autonomy, and is accomplished with continuing cycles of assessment and action. Nursing organizations seek to empower nurses; nurses endeavor to empower patients to seek and adopt healthy lifestyles. Likewise, nursing managers and administrators take actions to empower nurses to achieve effective, rewarding, competent practice. Empowered nurses have three required characteristics that enable them to participate in policy development. The ﬁrst is a raised consciousness of the social, political, and economic realities of their situation or environment and society. They are aware of culture and diversity and of gender, race, and class biases, prejudices, discrimination, and stereotyping that produce the need for policy development or change. Such nurses can evaluate and understand the dynamics of a situation or issue in which they ﬁnd themselves and can more readily ﬁnd or help to ﬁnd remedies. The second quality empowered nurses have is a positive sense of self and self-efficacy regarding their ability to effect, or facilitate, change. They value themselves and have voice to articulate and effect change. Within an institution, for example, they can identify situations that constrict professional practice, lower quality of care, waste resources, and cause myriad other problems. They can also contribute to the resolution of problems that affect health at the community, state, and national levels. Development of skills that allow active participation in change processes is the third important characteristic. Empowered nurses know how to use traditional methods of power and politics in policy making. Concrete knowledge and information are necessary, as is understanding interpersonal communication skills, politics, and power and how to use them (Kuokkanen & Katajisto, 2003; Manojlovich & Laschinger, 2002).

Power and politics are often discussed together in the nursing literature. The linkage may be due to the difficulty that arises in attempts to distinguish them. Those with power ﬁnd it easy to participate in politics, and those who participate in politics gain power. Both power and politics serve to achieve goals, and both do so through the ability to use skills to convince others to serve the power holder’s purposes. Power and politics are the means to achieve health-care goals in a compassionate and humane way. Application of power and politics through collaboration, creativity, and empowerment are effective ways to inﬂuence policy.

Politics

Politics is the negotiation for, or inﬂuencing of, allocation of scarce resources. Inﬂuence is the act or power to produce an effect without apparent use of force or direct command. Politics is a neutral term and a process. Flexibility is perhaps the most important trait of a good politician.

POLITICAL ACTION SPHERES

The process of inﬂuencing others, or politics, in order to achieve ends can be seen in relation to four arenas, spheres, or domains. These spheres are (a) the workplace, (b) professional organizations, (c) community, and (d) local, state, and federal governments. Although the ranges of these domains differ, and the target publics to be inﬂuenced differ, the political tactics and strategies are similar. These spheres overlap; what happens in one affects the other. Ignoring one can jeopardize outcomes in the others. The fact that nurses have not consistently paid attention to this has contributed to the fact that the level of inﬂuence nurses possess is not com

mensurate with the numbers of nurses, their abilities, and their responsibilities and contributions.

Workplace

Nurses work in organizations with varied characteristics—private or public; proﬁt, nonproﬁt, or charitable; large, small, or medium; and in large or small cities, towns, small towns, or rural areas. In the workplace, there are many issues with which nurses are involved. Power and politics may be necessary to resolve issues. Some issues that may be found in some, or all, workplaces include the following:

■ Mandatory overtime work requirements.

■ A nursing clinical ladder program that rewards excellence with promotions and pay incentives.

■ Work scheduling length of shift, evening and night rotation, vacation priority.

■ A smoking ban in the entire facility; designation of smoking areas.

■ Visiting hours in special care units.

■ Identiﬁcation and security procedures.

■ Authority to delay discharge from or admission to special care units based on professional nurse assessment.

■ Authority to refer patients to a home healthcare agency.

■ Decisions regarding substitution of unlicensed personnel for RNs to provide care.

Politics are part of every organization; nurse executives have to use politics to administer their areas of control. They have to negotiate with CEOs and other administrators (their peers) for budgets to meet organizational goals.

Professional Organizations

Professional organizations have been essential to the “professionalization” of nursing. The modern nursing movement began in 1873 in response to the changing role of women. Pioneers of this movement worked for a new profession for women and for better health for the public (Reverby, 1987a). These women used political power to open nurse training schools, organize professional associations, and participate in social issues such as women’s suffrage, public health, and integration (Rogge, 1987). These leaders sharpened their political expertise in nursing organizations they created beginning in 1893. Professional organizations have made signiﬁcant contributions in developing nursing practice. They have set standards of practice, advocated for change in the scope of practice and passage of nurse practice acts, and advocated for nurses in collective action in the workplace. Such organizations have an ever-increasing role in health policy development. Fewer than 10% of nurses belong to the ANA, even though it represents the interests of all nurses in the United States (Foley, 2001). Membership in specialty nursing organizations rarely exceeds 30% of those eligible to join (Foley, 2001). These organizations are essential for advocating for nurses and for humanistic health promotion. A strong professional organization needs to be a visible force: a national organization should have national visibility; a local organization should be known locally. For example, the ANA works on national issues in Washington, DC; the state nurse associations work on state-wide issues; and the local districts work on issues in the local community. These three levels of the ANA work in concert. Organizations can identify issues that concern nursing and health care, bring them to the public, and take a leadership role in advocating for development of policies that improve health and ensure high-quality nursing care. To achieve this, organizations need support of nurses through their membership and through their political acumen.

The New York State Nurses Association (NYSNA), for instance, developed and championed the legal deﬁnition of professional nursing in New York State. The New York State Nurse Practice Act was passed in 1972 and was the ﬁrst law to deﬁne nursing as an independent profession. This deﬁnition of nursing still stands and has served as the model for nurse practice acts in the other states. The ANA is working to inﬂuence legislation to deal with overcrowded emergency departments (Trossman, 2006).

Community

Community is most often deﬁned as a geographic area with boundaries, but during the 1960s the idea of community empowerment grew to deﬁne a group with a common good that required coordinated action. Power, politics, and policy became attached; community, in this context, is deﬁned as a population, a neighborhood, a state, a nation, and the world. It can be a nursing organization or an online group. An individual is usually a member of more than one community. The other three political action spheres exist in the sphere of community. For example, an individual can be a member of the education, religious, and nursing communities. The countries of Western Europe have joined together to become the European Economic Community; they are also joined with the United States in the North Atlantic Treaty Organization.

Nurses are members of a community with the responsibility to promote the wellbeing of the community and its members. In exchange, the community provides important resources for nurses’ work in health promotion and health-care delivery. Many of the people who live in a community, such as health-care administrators, corporate managers, industrial leaders, elected and career government officials, and patients, have power. These people can, and do, participate in community activities; they have status, expertise, and connections. By building relationships with community members, nurses can gain supporters to achieve goals. The connections they make can transform into networks, and the people in the networks can be asked to support agendas.

In exchange, nurses should support community agendas to work to improve community life. There are innumerable ways to participate actively in the community. Groups such as parent-teacher associations, community boards, councils, conservancies, civic groups, and soup kitchens are but some groups that need and welcome participation and help. Nurses can help mobilize communities on issues such as recycling, environmental clean-up, safety, energy conservation, health screening, and the like. Although activism may grow out of private inter-

ests, it can affect professional life with increased skills, knowledge, experience, and power development. In addition, nurses who are active and form connections in their communities become role models and represent the whole profession.

Government

Government affects most aspects of our lives. We must document births, marriages, and deaths; the buying and selling of real estate; and mandatory childhood immunizations. Government establishes the age at which people may drink alcohol, drive a car, cast a vote, and join the military. Laws determine the health services and social security available to people in old age. Our collective society is organized in ways that make us interdependent; the health and welfare of each of us are dependent on the health and welfare of all. Government is needed to ensure that what we need to get done is accomplished.

Government plays an essential role in nursing and in health care. State government deﬁnes what nursing is, and it deﬁnes what nurses do. It inﬂuences how our health-care system is organized. Government inﬂuences reimbursement systems, such as Medicare and Medicaid. Government inﬂuences and supports the current managed care arrangement, which provides for reimbursement for health and nursing care. To a large extent, government determines who has access to care and to what type of care. Federal, state, and local governments make decisions about major health issues in our society. Recent decisions include:

■ The kinds of foods and snacks available to children at schools

■ Prohibition of smoking in some public places

■ The initiation and continuation of Head Start

■ Provision of meals for the poorest children

■ The health services available at schools and whether schools may provide sexual and reproductive information; whether schools may provide condoms to sexually active students to prevent the spread of human immunodeﬁciency virus (HIV) and acquired immunodeﬁciency syndrome (AIDS)

■ Whether public funds can be used to distribute clean needles to intravenous drug users to reduce the spread of HIV and AIDS

■ Whether women can receive full information about reproductive rights and who can provide that information

■ Whether violence is treated only as a crime or also as a public health issue and whether to regulate the use of hand guns

■ Allocation of funds for housing development and maintenance

POLITICAL ANALYSIS

Effective use of power and politics to facilitate strategy development for the policy process requires systematic analysis of the issues. The following is a framework for systematic analysis. Adroit use will increase nurses’ political leverage. Although this is directed at broad political action in government and the community, it is also applicable to workplace and organizational policy processes (see Box 13-1).

Components of Political Analysis Identify and Analyze the Problem

Identiﬁcation and analysis of the problem or issue is the ﬁrst step. The problem must be understood in order to frame it in ways that will move elected officials to action. It must be carefully crafted in terms that make sense; calls for public action must be clearly justiﬁed. Use of public relations theory will help with the expression of, or framing, the issue. To frame the problem adequately, state the scope, duration, and history of the problem. An important point is to be explicit about whom this problem affects. Then collect all data that are available to describe the issue and its implications. Identify any gaps in the data. Identify whether more research might be useful and, if so, what types would help. Outline and Analyze Proposed Solutions Present possible solutions to public officials along with the identiﬁed problem. It is best to develop more than one solution because costs, effectiveness, and durability differ from approach to approach. For example, an enduring problem is the nursing shortage; multiple proposals have been developed to correct it and its effects. If increased access to nursing education is a proposed solution, then the proposal must include how this is to be accomplished.

The federal budget is limited; there are many demands for funding for worthy goals, and they must be considered. Competition for federal funds is stiff; nursing education and health care are only two goods among many. Each funding solution— grants, tax incentives, and other sources—has different implications, and each must be understood before making a proposal for federal aid.

A proposal for addressing safe patient handling and prevention of musculoskeletal disorders (MSDs) among nurses was promoted by NYSNA and proposed for legislation. Research showed that promoting proper body mechanics alone is an ineffective way to reduce MSDs in health-care workers. The governor signed a measure for funding a demonstration project. A change in policy will protect patients and health-care workers. Added beneﬁts include increased employee retention and reduced worker replacement and compensation costs (ANA, 2005, p. 4). The ANA and NYSNA performed an effective problem analysis based on solid data. They now have state funding to gather more data and ultimately work for a change in policy.

Understand the Background, Including Its History and Attempts to Solve the Problem It is important to understand what attempts have been made to address an issue. The history, including why and how previous attempts failed, will provide an estimation of the potential success of the current proposal. For example, the reform of our health-care system, especially implementation of a national health service, would require a review of the background of the Medicare/Medicaid system and also a review of President Clinton’s Health Security Act. Assessment of the public’s perceptions of public funding and American emphasis on individualism is needed so that political action can be planned thoroughly. Knowledge of positions of key public officials will also assist in planning. Even in a workplace context, understanding the background of an issue is important. If you believe that the staffing on a unit needs to be changed to improve patient care, efficiency, and nurse satisfaction, you must assess how the staffing was structured, why it was done in that particular way, and why and how that format is outdated before you present your proposal to the nurse manager or appropriate committee.

Locate the Political Situation and Its Structure After the problem and solutions have been delineated, assess and choose the appropriate political venues. The choice is between the private sector and government. If the decision made is to approach government, decide on the level and branch. There are times when both the public and private sectors are involved, but in that case, only one has the decision-making responsibility. When all sectors have equal power, no one sector has the responsibility to make a decision nor the vested interest to prevent a decision. Be sure to identify the political settingaccurately, because making an error can cause you a loss of credibility and a loss of power. For example, if nurses are concerned about an aspect of patient care, the employer must be approached through the organization structure. It is unfair and impolitic to go to public officials before internal mechanisms have been exhausted. It is also imprudent to exclude the nurse manager and go directly to the chief nurse executive or a supervisor. Again, so doing will cause loss of face, credibility, and power.

Evaluate the Stakeholders

The next step is to identify the stakeholders. Stakeholders are those who are affected by or have inﬂuence over an issue or who could be recruited to care about it. Stakeholders include policy makers who have proposals related to the issue, special interest groups, and those with a position on the issue. For example, after her husband was fatally shot and her son seriously wounded, Congresswoman Carolyn McCarthy, an LPN, became a respected and powerful proponent for gun control.

She was able to recruit other stakeholders, such as victims of gun violence, during her campaign. One of the most important stakeholders she identiﬁed was the American Academy of Pediatrics, which has signiﬁcant power and resources. The congresswoman recently established the Carolyn McCarthy Center on Gun Violence and Harm Reduction to mobilize public support at the grassroots level for new gun safety legislation.

Conduct a Values Assessment

All political issues have value or moral aspects. Human rights, international health law, the right to health, genetic engineering, embryonic stem cell research, genetic technologies, terrorism, abortion, and the death penalty are among the most visible moral issues today (Annas, 2005). Issues necessitate that stakeholders assess their own values and those of their opponents.

Ascertain Financial and Personnel Needs to Attain Goals

Any effective political strategy must include assessment of resources needed to reach goals. In addition to money, other needed resources include time, connections or network, volunteers, contributors, and intangibles, such as people who are strategists and those with creative ideas. Short- and long-term tactics and goals must be considered in resource analysis.

The budget structure within an organization or government agency must be considered. It is important to understand the budget process, including how money is allocated to a cost center or line budget, who makes decisions regarding expenditures, how use of funds is evaluated, and how an individual or group can inﬂuence budget development and implementation.

Analyze Power Bases

In any setting, assessment of power bases of both proponents and opponents is essential. Review the section on power for further discussion. After the political analysis is accomplished, it is time to plan political strategies and identify tactics and guidelines.

POLITICAL STRATEGIES

After the political analysis is completed, a plan of action with strategies is developed. Strategies are the plans to achieve political and policy goals. One strategy does not work in all situations. To achieve goals, it is useful to follow these tactics:

■ Persistence. Change takes time; conﬂict is almost always part of policy change. Usually there is much discussion, negotiation, and col

laboration with attendant delays, retrenchment, and realignments. Policy change or new policy development and implementation is a long-term commitment and requires commitment and endurance.

■ Look at big picture. Always prepare for the political process of policy development by clarifying aspects of the issue. This includes knowing your position and possible solutions supported by data, assessing your power base and that of others involved, planning strategies, and knowing the opposition and their plans and rationales. Understand the context of the issue.

■ Frame issue adequately. Understand the stakeholders and target audience to present the issue in ways that are congruent with their values.

■ Develop and use networks. Use power that accrues through personal connections, which requires keeping track of what you have done for others and asking them to reciprocate.

■ Assess timing. Consider carefully when is the most opportune time to act. Knowing when the time is right requires accurate assessment of the values, concerns, goals, and resources of those you have to convince that your way is best.

■ Collaborate. Work with others to achieve policy goals. Collaboration usually achieves goals more effectively than does individual action.

■ Prepare to take risks. Do a risk-and-beneﬁt analysis of an action. This analysis entails consideration of the beneﬁts gained or goals achieved in relation to the expenditure of all resources, including personnel, money, time spent that could have been used on another endeavor, and coherence with values.

■ Understand the opposition. Put aside emotional positions, focus on the issues, and try to understand the fears and concerns of the opposition. Educate the opposition to appreciate the nursing position.

Political Tactics

The effective functioning of an organization depends on the relationships between individuals and groups. Effective use of politics in the workplace can facilitate achievement of goals. A characteristic of political action is that it creates obligation; that is, to get something, something may be expected in return. Such an approach may achieve only part of a goal, but that partial achievement is a step toward the goal.

■ Employ opportunism; act when the time is right.

■ Use trade-offs; support a cause or person in exchange for the goal at hand.

■ Sell votes on one issue for votes on another.

■ Negotiate; each side gives up lesser values to achieve greater values.

■ Form coalitions; two or more smaller groups band together to defeat a larger power.

■ Compromise; each side settles for a partial win or part of what it hopes to achieve.

■ Lobby; attempt to build collectible debts with persons who may inﬂuence (or vote) in your favor.

Skills and Tactics in the Workplace

The effective functioning of an organization depends on relationships between individuals and groups. Often, problematic conﬂicts arise that are threatening to groups. Resolution of these conﬂicts requires signiﬁcant managerial skill. Effective use of politics can facilitate conﬂict resolution and achieve goals. Not all the following skills and tactics may be acceptable, useful, or necessary in a particular situation, but they are useful and have a high probability of success:

■ Build your own team. Executives, administrators, and managers are often defeated in their roles because persons from the previous team are unhappy, jealous, and disgruntled and do not support, or actively sabotage, the work of the new boss.

■ Choose your second-in-command carefully. “An aggressive, ambitious, upwardly mobile number two man (or woman) is dangerous and often difficult to control” (McMurray, 1973, p. 70).

■ Establish alliances with superiors and peers. Determine expectations and motivations of others before you form true friendships. Alliances with superiors and peers are needed to achieve goals.

■ Use all possible channels of communication. Develop and maintain open, effective channels of communication to avoid isolation pre-emption, and loss in power struggles. Be fair, but learn to recognize aggressive, manipulative people.

■ Do not be naïve about how decisions are made.Learn and understand the preferences and the way powerful people act in the organization in order to predict how they will make a decision; then plan accordingly.

■ Know what takes priority. Know what the goals are and how the organization generally works to achieve those goals. In other words, know the modus operandi.

■ Be courteous. Treat others with respect. Respect can prevent feelings that can lead to sabotage and retaliation.

■ Maintain a ﬂexible position and maneuverability. Identify what is ethically important and nonnegotiable. Then you can maneuver conﬁdently to change and power.

■ Disclose information judiciously. In order to work effectively, it may be necessary not to disclose how power strategies are used.

■ Use passive resistance when appropriate to gain time. Delay can be useful when time is needed for gathering information.

■ Project an image of conﬁdence, status, power, and material success. The image of weakness conveys a lack of power and decreases ability to act and achieve goals.

■ Learn to negotiate and collaborate. Do not be ingratiating or conciliatory.

COALITIONS

Coalitions have great power to achieve a speciﬁc, common goal. They bring diverse people together, with different worldviews, and encourage collaboration, creativity, and empowerment. There is strength in numbers, so coalitions increase the probability for success in political and policy processes. Coalitions take many forms and usually arise out of a challenge or opportunity. They are often disbanded when the goal is achieved, but sometimes they can be long-term and function for years. When they stay together, it is generally because after they achieve their goal, another goal becomes apparent and they choose to continue to work together. Effective coalitions have three important characteristics that are necessary to use power and politics skillfully and to inﬂuence policy processes. These characteristics are (a) leadership, (b) membership, and (c) creativity. Without these attributes, a coalition cannot identify, assess, plan, and implement or seize opportunities to further its goals. A coalition needs two types of leaders. One has to have spirit and passion for the cause. This leader has to motivate the membership to get the job done. The second leader must be an organizational leader who is adept at administration that supports the coalition. This leader may be paid if the coalition has funds; other leaders and members are volunteers.

The more members, the more effective the coalition becomes. Without members, the coalition would not exist. Members do the work of the coalition and increase its visibility. Members beneﬁt the coalition, but the coalition also beneﬁts them because they learn and hone skills (Berkowitz & Wolff, 2000).

The ability to recognize and seize an unexpected opportunity and make the most of it is essential. This requires creativity, innovation, and the willingness to take risks. It also requires that leaders and members continually assess their environment, use and enlarge their networks, and keep track of politics associated with their goals in their community. It is hard work to keep a coalition on target to achieve goals. Effective leadership, management, and active, interested, and participating membership are essential to success. Coalitions bring diverse people together for a common cause. They meet regularly and implement or act on their plans. Members must be active and receptive to fresh ideas and innovations. Nurses and nursing must participate in coalitions to improve health care through policy change. An example of an effective coalition is that formed by nurse practitioners and nurse midwives in Maine. Although they had won a change in the nurse practice act, they did not have third-party reimbursement. A coalition was formed and after much work, they ﬁnally won payment (Leavitt, 2002).

CONFLICT RESOLUTION

We have deﬁned power as the ability to act and politics as the allocation of resources that are used for an identiﬁed end, goal, or policy. Often during this process, conﬂicts develop and must be resolved. The resolution process includes negotiation, which can result in one side winning or both sides getting something (often referred to respectively as winlose and win-win resolutions, discussed in Chapter 20). A summary of win-lose methods was identiﬁed and characterized by Roe (1995): (1) denial or withdrawal, (2) suppression or smoothing over, (3) power or dominance, and (4) compromise. Win-Win Solutions Win-win solutions, on the other hand, manage conﬂict in a way that neither party loses and the outcome is creative and productive. Collaboration and principled negotiation are two approaches to winwin resolution to conﬂict. See Chapter 20 for further discussion.

Collaboration

The goal of collaboration is for parties to work cooperatively with one another in a way that everyone wins and no one has to give up anything. Marquis and Hurston (1994) explain that in collaboration “both parties set aside their original goals and work together to establish a supraordinate goal or common goal. Because both parties have identiﬁed the joint goal, each believes they have achieved their goal and an acceptable solution. The focus throughout collaboration remains on problem solving, and not on defeating the other party”(p. 290). Collaboration requires time and full commitment to the resolution process. Mutual respect, communication skills, and an environment where all are heard and considered are necessary for successful collaboration. Collaboration is the ideal solution where all parties are satisﬁed and all win. Senators from opposite sides of the aisle collaborate when they jointly propose a bill in the U.S. Senate.

Principled Negotiation

Principled negotiation is a form of conﬂict resolution developed at the Harvard Negotiation Project and has four basic steps as identiﬁed by Fisher, Ury, and Patton (1992). These steps are as follows.

■ Separate the people from the problem. This step strives to depersonalize the argument. All parties in the negotiation are persons with feelings, needs, values, experiences, and perceptions and come from different backgrounds. Each person has a personal worldview that must be respected. Because negotiation is easily inﬂuenced by the relationships and the problem, it is essential to keep to the issues and not let personalities and feelings intervene in the conﬂict in such a way as to cut off communication and productive search for a solution. Again, U.S. Senators may ﬁght on the ﬂoor but it is done in a way that keeps the person out of the argument. Mutual respect is a must.

■ Focus on interests, not positions. Interests deﬁne the problem and are the motivators. Positions are generally conﬂict needs, wants, discomforts, and fears. For example, nursing staff suffers because patients are difficult, abusive, and manipulative, and they are increasingly unhappy. Staff members believe that they do not matter as people, that they cannot continue to act in professional ways. The interests are adequate staff, material resources, and support to care for these patients. The positions of the staff are anger at administration for allowing the situation to persist, anger at patients who do not appreciate their hard work, fears that they are inadequate, and so forth. The administration fears for their jobs if they do not allocate resources to in a responsible way. Positions are the objectives that arise out of interests. Identiﬁcation of interests leaves room for alternative positions that serve mutual interests. It is important to identify the facts and feelings behind each party’s wants and fears. Doing so will identify shared and compatible interests. To focus on positions limits ability to consider other options as parties will be too engaged in defending their positions to negotiate in a meaningful way.

■ Invent options for mutual gain. Develop a large number of possible solutions to avoid stymied, narrow negotiations. The more options identiﬁed, the greater the possibility of creative, productive solutions.

■ Brainstorming is a frequently used successful method to create options free of judgment. Participants in the negotiation identify as many ideas as possible without critique. The expectation is that ideas should be congruent with shared interests. These interests are goals and need to be made explicit.

Insist on using objective criteria. Use of objective criteria such as research ﬁndings will ensure a better agreement. The criteria must be based on a fair standard and should be identiﬁed before agreement. Discuss criteria rather than positions to be gained or lost. Focus on objectives will preserve ego and keep relationships intact.

Nurses will continue to need expertise in conﬂict resolution as change continues to challenge health care. After all, so much is at stake. Negotiation often occurs with participants of unequal power, which puts the less powerful at a disadvantage that is not often acknowledged. Justice, equity, and fairness are uncertain or unlikely in such situations. Successful negotiation requires broad and deep knowledge, the ability to synthesize diverse components of a situation in order to bring trust and respect needed for conﬂict resolution. Adversity can be a good teacher and impetus for change. Conﬂict provides an opportunity for personal growth and development, creativity, and innovation that nurses would do well to use to improve health care. The steps outlined in Box 13-2 are useful in conﬂict resolution.

Power and politics are used to achieve goals. In nursing and health care, the goals are policies that help nurses to deliver appropriate care to persons in local, state, national, and international communities.

Policy

Policies are written directives or actions to follow to meet identiﬁed ends or goals. Policies reﬂect values; stakeholders work for policies that are morally congruent with their values. A policy is a guideline that has been formalized by administrative authority and guides or directs action to an identiﬁed purpose or speciﬁc goals. Policies are developed within organizations, associations, and governments at local, state, federal, and international levels. Values and goals are reﬂected in the choices an organization, community, and society make. In nursing and in health care, major choices relate to policies governing access to care, allocation of resources, and standards of care. Policies help organizations run smoothly and protect both health-care providers and patients.

A policy system is the total group of events and rules to that policy. The three major parts of a policy system are (1) a purpose or goal, (2), a policy rule, or how to achieve the goal, and (3) a written directive (procedure) on actions to follow in implementing the rule. For instance, an institution may have a policy that all nurses must participate in continuing education each year. This policy rule requires a written directive on the actions to be taken because the policy is still open to many interpretations. What is the content to be required? Can it be done in-house or outside? When must it be done? How many hours are needed? In the United States, health-care policy is particularly rife with disagreement because of four goals that are in conﬂict. These conﬂicting goals are (1) provision of the best possible care for all, (2) provision of equal care for all, (3) freedom of choice on the part of health-care providers and consumers, and (4) containment of costs. These conﬂicting goals and values demonstrate the reasons we have not been able to develop satisfactory health-care system reform. Accessible, cost-effective, equitable, and high-quality care has been elusive. The power, politics, and interests of the special lobbies of big business, such as the insurance, pharmaceutical, and supply industries, champion the free market for health-care system reform. These industries have great wealth and therefore great power to gain and keep control of reform. Weakest in this equation are the poor, the underinsured and the uninsured, and increasingly the working and middle classes who have little or no voice and power. Research has consistently demonstrated prevalent race and gender discrimination in health-care allocation (Bach et al., 2004; Bloche, 2004; Jha et al., 2005; Shischehbor et al., 2006; Smedley, Stith, & Nelson, 2003; Steinbrook, 2004.) The free market reforms that were implemented have failed to achieve important goals of the system. The amount of money spent on health care now exceeds 15% of the gross domestic product (Centers for Medicare & Medicaid Services, 2003). The Kaiser Family Foundation found that health care grew to over 16% in 2006. Administration costs of third-party payers have risen sharply. Both providers and consumers have little, if any, choice regarding care. Disparities in standards of care are growing. Fewer people have access to care; the number of people in 2004 without access was 45.8 million (American Journal of Nursing, 2006), which is up from 37 million in 1990 (Kaiser Commission, 2004). These statistics reveal that the free-market reforms have failed to improve access to care, control costs, and maintain standards of care. With increased free-market policies, the number of people without access to care has increased, costs have increased, and quality of care has decreased. The health-care system is extremely complex and is not wholly amenable to free-market forces. The marketplace has failed to reform the health-care system because of six characteristics or factors (Alward & Camuñas, 1991). These factors are (1) imperfect information, (2) third-party payers, (3) gatekeepers, (4) forced purchase, (5) lack of competition, and (6) distorted proﬁt motives. These factors are discussed below. In the free market, consumers have the ability to gather all of the information they need to make informed choices. This is not the case in health care. It is difficult to obtain and understand all of the relevant information. In many cases, data simply do not exist.

Third-party payers remove the issue of cost for users (patients) and the direct providers of the service (physicians, nurses, hospitals). It is possible for consumers of goods, such as televisions, compact discs, clothing, or services such as lawn and hair care, to shop for what they can afford and for that which meets their wants and needs. When shopping for health care, it is the third-party payer who pays, which decreases the importance of price as a criterion regarding choice. Third-party payers also allow providers, such as physicians and hospitals, to charge what the market will bear. The patient is not the consumer who pays, so there is little incentive on the part of providers and consumers alike to contain costs. And yet, if individuals were left to pay all the costs, only the very rich could afford health care, as is the case in many developing nations. The system would be tattered indeed; modern health care and innovations would not be available and health-care science would falter. Gatekeepers have a profound effect on the efficacy of the free market in health care. When consumers decide to eat in a restaurant, buy a new car, or see a movie, they decide when, where, and how to make the purchase. In regard to health care, it is the physician, nurse, or hospital insurance company who decides. Very often, the purchase of health care is forced. The woman who has a heart attack, the man who has prostate cancer, the child who breaks a leg cannot plan, delay, or reasonably refuse or postpone the purchase of care. Persons need health care when they are hurt or sick. It is hard and often deadly to put off health care in the face of illness and injury. The lack of competition in health care further distorts the marketplace. Insurance is most often bought by employers who want to minimize costs, bypassing patient choice. Patients do not know with certainty if they will need health care, when, and what type. When patients are given a wide choice, it is confusing and difficult to make sense of all the options. The plethora of drug prescription plans available to Medicare recipients clearly demonstrates this. A case in point is the diabetes epidemic. In New York City, diabetes centers that delivered comprehensive care to diabetics had to close because they could not ﬁnancially keep aﬂoat. Good care means bad business (Urbina, 2006). Care that keeps people well is not affordable; insurance does not adequately reimburse preventive care, such as hypertension, diabetic, and cardiac chronic care. They do reimburse for care that deals with the complications of diabetes (and other chronic illnesses) such as renal dialysis and amputation.

POLICY DEVELOPMENT

The speciﬁc steps taken from identiﬁcation of a policy problem to a functioning program to solve the problem are referred to as the policy process. Several models have been developed to implement the policy process. These models include Kingdon’s policy stream model (1995), Cohen, March, and Olsen’s “garbage can” model (1972), and the stagesequential models of Ripley (1996) and Anderson (1996). Stage-sequential models are systems-based approaches and may be more accessible and useful to the novice. A discussion of the stage-sequential approach to the policy process follows. A series of stages constitutes stage-sequential models. These stages are analogous to the nursing process (see Table 13-1).

A policy problem is identiﬁed and added to the policy agenda. Then the policy is developed, accepted, implemented, and evaluated. As with the nursing process, the policy process is dynamic and cyclical. Both are cyclical in that evaluation often leads back to assessment, and so the process continues. Areas that are not well delineated by the stagesequential model are (a) who gets what and why, and (b) the effect of stakeholder wants and the implications of their ideas, values, and agendas during policy development. The growing problem of childhood obesity and its solution can be examined from a stage-sequential model. Childhood obesity and its attendant risks are identiﬁed and are added to the policy agenda. Assessment revealed that easy access to junk food, high-calorie soft and sports drinks, and poor school cafeteria menu choices are major contributors to obesity. Additionally, lack of knowledge of good healthy food choices and lack of exercise worsen the problem. Policies that change foods available at schools, educate students and families about good nutrition, change gym and sports requirements, and educate regarding exercise are developed and implemented. Outcomes of new policies are evaluated for effectiveness, which brings the process back to assessment.

Aspects of Policy Development

Health-care agencies, organizations, institutions, and associations make private policy. Such policies include directives that govern employment conditions and service guidelines or provisions. For example, there are policies that stipulate licensure, education, and experience requirements for speciﬁc nursing positions. Other policies provide guidelines for patient care: the use of side rails and methods for dispensing medications are examples of service provisions. Local, state, and federal governments make public policy. Included are legislation, regulation, and court rulings that are made at respective levels and jurisdictions. In New York City, for example, a local policy regarding health care is the no-smoking law in public and workplaces. States control licensure for professional practice, and the federal govern

Comparison of Nursing Process and Policy-Setting Process

ment controls Medicare. Private and public policy have a linked relationship because public policy directly affects private policy, and the need for new or changed public policy arises from private institutions. Included in health policy are the private and public policies that control service delivery and reimbursement,

Government also develops and implements policies at the local, state, and federal levels. Health-care organizations must develop and implement internal policies as well. All policies have unanticipated outcomes that have both detrimental and positive effects. Within an organization, positive outcomes of a policy include rules that protect departmental autonomy, provide support when making unpleasant decisions, and help decide between choices when one does not have a clear advantage. Unanticipated effects of policies are seen when the original purpose is covert, unknown, or forgotten. Organizations sometimes have policies that are blindly followed long after their usefulness has been outgrown. An example is taking temperatures at 5 a.m. even when not warranted by patient condition because it is policy and procedure. Change in circumstances without concomitant change in policy can have detrimental consequences. Detrimental effects also occur when policies are implemented in ways not intended.

Despite the difficulties, risks, and hazards of policy change, change is often necessary. Change is a better alternative than continuing with outdated policies or working without a policy when one is clearly needed. Given the difficulties of change, it is essential to adhere to two rules before implementing the change: (1) test any new policy on a small group or unit; this is similar to conducting a pilot or feasibility study before initiating a research project or study; and (2) identify the purpose of the policy in the procedure or action directive. These steps will identify problems with the new procedure early so that changes may be made and will help with the implementation of the new policy as intended. This information will also be used in measuring the effectiveness of the policy.

All Good Things...

From the beginning, nurses have used power, politics, and policy to further and achieve their goals. It is important for nurses to develop group process, problem-solving, conﬂict management, crisis intervention, and communication skills to effectively help move toward goals to improve health and health care. These human relation activities are essential to exert such inﬂuence to make a positive impact on policy. Collectivity and collegiality help to empower nurse leaders who must position themselves to act to make policy rather than to react to policy proposals of others.

Calls for health-care delivery reform are coming from all segments of society. Big and small businesses want reform because the current system is costly and in many ways ineffective, resulting in reduced competitiveness. The high cost of health care is passed on to the consumer and makes products more expensive. Providers of health care have greatly reduced resources with which to provide care. Fewer resources jeopardize access and quality of care, resulting in less healthy populations, which decreases productivity and increases costs throughout the economy.

Patients, families, and communities are increasingly dissatisﬁed with the quality and kinds of health care and services available and received. Frustration, fear, and helplessness are growing in the face of a system unresponsive to needs. The health-care system is in dire need of major policy change. Health-care professionals must be proactive and participate in health-care reform. Nurses can and should be major participants in reform. They know well the problematic areas, the gaps, the weaknesses, the dysfunctionalities, and the strengths of the current system. Nurses have insight and knowledge of what works and what does not in setting standards of care, access to care, and allocation of resources. With adroit use of power and political theory, nurses can participate in shaping health policy to improve efficacy and distribution in an equitable way. Health-care reform is a major challenge. With

increased scope of knowledge and skills, coupled with conscious and conscientious development and use of political action, nurses can participate in and support policy development. Nurses are needed to change and improve health care at the institutional, community, state, and national levels. Nursing provides abundant resources to do so; nurses must develop and use political know-how to influence important needed changes and reforms.

NCLEX Questions

1. Empowerment is an important concept in nursing. Nurses often talk about empowering patients. Empowerment is also important in leadership as it inﬂuences:

A. Social and political reform

B. Productivity and effectiveness

C. Individual attributes

D. A and B

E. All of the above

2. Three characteristics of empowered nurses are:

A. Raised consciousness of social, political, and economic realities

B. Conﬁdence in self as a change agent

C. Motivation to develop skills

D. All of the above

E. B and C

3. Power can be deﬁned as:

A. Authority or inﬂuence

B. Ability to cause or maintain the status quo

C. A negative attribute related to authoritative leadership and hierarchical organization

D. All of the above

E. A and B

4. Politics are used in the following arena(s):

A. Federal and state government

B. Workplace

C. Organizations and associations

D. All of the above

E. A and C

5. Among decisions that politics inﬂuences are:

A. Allocation of resources such as staffing in hospitals

B. Vacations

C. Scope of professional practice

D. All of the above

E. None of the above

6. In solving a problem, it is important to:

A. Identify your position and stick with it

B. Present your solution as best

C. Identify ﬂaws in other positions

D. Seek a compromise

E. Collaborate

7. When evaluating courses of action, it is important to:

A. Identify your values and those of stakeholders

B. Recognize that values are not important

C. Recognize that values confuse the issue and increase difficulties

D. Always insist on your values

E. B and D

8. Policies in the workplace are:

A. Not needed; no one ever looks at the policy and procedure book

B. Common sense

C. Not important to patient care

D. All of the above

E. None of the above

9. Policies:

A. Eliminate disparities in care

B. Do not need to be reviewed and revised

C. Are inﬂexible

D. All of the above

E. None of the above

10. All of the following are true about power except:

A. Used to enable nurses to provide optimal care

B. Used to inﬂuence national health policy

C. Is increased with an authoritarian approach to leadership

D. Is not always commensurate with position

E. Is enhanced with education and continuing education

NCLEX Questions

1. A nursing competency:

A. Is a skill that the nurse has to perform.

B. Is a speciﬁc behavior that a nurse must demonstrate.

C. A and B.

D. Is the proﬁciency level that the nurse must obtain.

2. A standard of care:

A. Requires use of the nursing process.

B. Is the degree of care, expertise, and judgment exercised by nurses under similar circumstances.

C. A and B.

D. Is the number of patients that a competent nurse can care for on any given shift.

3. What affects nursing regulation?

A. A state nurse practice act.

B. Accreditation by an official body.

C. Policies and procedures.

D. All of the above.

4. The goal of state and federal legislation is to:

A. Protect the public.

B. Regulate nursing education.

C. Oversee nurse competency via licensure and discipline.

D. All of the above.

5. A nurse practice act:

A. Governs the role of the nurse.

B. Governs nursing education.

C. A and B.

D. Prescribes the competencies for the nursing role.

6. Certiﬁcation is:

A. An examination.

B. Developed by a professional organization.

C. Aids a nurse in demonstrating competency.

D. All of the above.

7. What types of disciplinary action can a board of nursing take?

A. License suspension.

B. Licensure denial.

C. Mandate that the offender take courses in legal ethical decision making or pharmacology.

D. All of the above.

8. An advanced practice nurse:

A. Is a registered nurse.

B. Has studied in a post-basic or advanced educational program of study.

C. Acts independently of other health-care professionals in the delivery of health-care services.

D. All of the above.

9. Portfolios:

A. Can be used to demonstrate to state boards of nursing that one is qualiﬁed to be a registered nurse.

B. Can be designed to demonstrate one’s competence.

C. Consist of documentation that captures learning from experience.

D. B and C.

10. Modeling:

A. Is the facilitation and nurturance of an individual.

B. Assists one in attaining, maintaining, and promoting health.

C. Is a purposeful nursing intervention.

D. Is a process used by nurses to develop an understanding of the client’s world.

List of educational literature:

A. Main:

1. Kelly, P. (2008). Nursing Leadership and Management. (2nd ed.). Clifton Park, NY: Delmar Learning

2. Huber, D. (2000), Leadership and Nursing Care Management, (2nd ed.), Philadelphia: W.B. Saunders.

3. Nagelkerk, J. (2000), Study Guide for Huber Leadership and Nursing Care Management, (2nd ed.), Philadelphia: W.B. Saunders.

4. Sullivan, E. J. (2004). Becoming influential: A guide for nurses. Upper Saddle River, NJ: Pearson.

B. Additional:

1. See required Websites:

http://www.health.gov/healthypeople/.

www.health.state.mn.us/divs/chs/phn/definitions.pdf

2. Course Website – Log in @ http://www.tdmu.edu.te.ua/ukr/general/index.php

Prepared by Volkova N.M.

Adopted by Department of Medical Bioethics and Deontology sitting

11 June 2012, Minute № 2

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