Nursing leadership and management phần 46

13Jones Leadership(F)-ch 13 1/14/07 3:44 PM Page 203 Power, Politics, and Policy 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 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 healthcare goals 203 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 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 13Jones Leadership(F)-ch 13 204 1/14/07 3:44 PM Page 204 Skills for Being an Effective Leader 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 13Jones Leadership(F)-ch 13 1/14/07 3:44 PM Page 205 Power, Politics, and Policy 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, 205 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) Abuse of Power Abuse of power is the control of people by some kind of force It is the use of power for one’s own benefit (individual or group) and can be present in families, organizations, and all levels of domestic and international government It is always unethical Poor, developing nations around the world are obvious examples Dictators abuse their people often to the point of genocide Industrialized nations engage in unfair trade and often exploit workers Abuse of women, children, the elderly, the sick, and innumerable others who cannot assert themselves is not uncommon To combat these types of abuse of power, we use political negotiations to develop policies to assuage or eliminate the problem We have child protection laws, laws to protect people with disabilities, and laws that prevent emergency patients from being transferred to other health-care organizations when doing so puts the patient at risk Around the world, abuse of power causes violence, human suffering, and tragedy on unimaginable scale (Farmer, 2005) Violence can be physical, psychological, or structural (the absence of health care, education, and just law enforcement for the poor, for example) Leaders who enforce structural and societal inequalities abuse power 13Jones Leadership(F)-ch 13 206 1/14/07 3:44 PM Page 206 Skills for Being an Effective Leader 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 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- chapter star: Florence Nightingale (1820–1910) Florence Nightingale had a major impact on health-care policy in the British army, in India, as well as on the development of nursing Indeed, her effect on nursing and health care is still felt today; her book, Notes on Nursing, is still in print That she was Victorian has special significance She gained power and affected policy in ways that were unheard of for a woman to accomplish Her leadership skills were formidable Nightingale was born into a wealthy, educated, extended family The women especially were social activists whose thinking was ahead of their time in significant ways Women had no public role and received education only insofar as it would increase marriage possibilities Florence was a talented, gifted child who was educated by her father She learned Latin, Greek, mathematics, and religion; read English classics; and learned controversial topics such as poetry, philosophy, science, economics, and political theory Her Greek, which is more difficult than Latin, was at the level where scholars consulted with her (Gill, 2005, p 128) From her father she learned to excel and to compete with the men who ruled the British Empire And she nursed people in her family and on family estates and towns, which taught her a great deal about caring for the sick Nightingale understood when she was in her early 20s that the women she knew had no desire or want of power; but she did want power “In pursuit of knowledge Florence was remorseless She was brilliant, she was focused, she was competitive, and she identified learning, correctly, as an avenue to power” (Gill, 2005 p 129) Nightingale also understood that knowledge would not be enough “considered how she, a woman of high social status, could use her personal friendships and family alliances to effect larger social goals such as improvement in national health care” (p 177) Her intellectual skills, family connections, and understanding of power and politics enabled her to go to Turkey to improve and reform care for the wounded of the Crimean War She was successful, had tested her abilities, and had gained powerful authority in the highest reaches of government, including Queen Victoria and Prince Albert Upon her return to England, she was appointed to two commissions to reform public health Nightingale was the “chief strategist, chief correspondent, chief worker; in other words, the one essential person upon whom the whole male team of experts relied.” The work Nightingale accomplished had significant effect on the army’s support services, public health in England and India, and the development of professional nursing Even without consideration that she was a Victorian woman, her work was enormous Understanding and use of power and politics in development of effective health policy, which is rare even in the early 21st century, made her a hero for the ages 13Jones Leadership(F)-ch 13 1/14/07 3:44 PM Page 207 Power, Politics, and Policy 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 207 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 ... 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... health in England and India, and the development of professional nursing Even without consideration that she was a Victorian woman, her work was enormous Understanding and use of power and politics... political, and economic realities of their situation or environment and society They are aware of culture and diversity and of gender, race, 205 and class biases, prejudices, discrimination, and stereotyping