Women have not always perceived themselves to be powerful, but understanding power and learning how to use it are essential if nurses expect to influence practice and their work environments (Ponte et al., 2007). Nursing has been characterized as an “oppressed group” (Roberts, 2000). The “good” nurse was considered obedient. The Nightingale Pledge reinforced obedience: “With loyalty will I endeavor to aid the physician in his work …” (Dock & Stewart, 1920). This obedience or acquiescence to authority appears to have been transferred to other authority figures, including but not limited to hospital administrators.

Minarik and Catramabone (1998) described four main purposes of collective participation for nurses: (1) to promote the practice of professional nursing, (2) to establish and maintain standards of care, (3) to allocate resources effectively and efficiently, and (4) to create satisfaction and support in the practice environment. Collective action helps define and sustain individual nurses in achieving these purposes. In the absence of collective action, the average individual has limited influence in achieving his or her purpose. Many children learned the strength and value of collective action early in life as siblings banded together to make a request to their parents. The same strategy has probably served in an organization when, together, a group of peers makes a point or pleads a case. Nurses have identified practice concerns and have joined together to bring about change in numerous practice settings.

The strategies for developing networks, developing a collective voice, and cultivating a collective require strong leaders and a broad followership. Leaders and followers have separate and distinct roles. Those roles are complementary—each requires the other. The relationship is interdependent. Followers and leaders also share many characteristics. Successful people move easily between the roles of follower and leader. Though the knowledge and skills of followers may differ from those of the leader, they are not less. Leaders and followers are knowledgeable of the context and content of their practice. Followers are active, involved participants committed to an agreed-upon agenda. They are loyal and supportive to the individual who is setting the pace and the agenda. Good leaders will need good followers to accomplish goals. The nurse who becomes a leader finds that the absence of followers is personally painful.

Exercise 19-1

Identify two groups in which you have been a leader (e.g., school, church, sports, clubs, and work). Identify two groups in which you have been a follower. How did your role as a leader differ from your role as a follower? List the skills you used in each role.

Changes in an initiative or an agenda may result in today’s leader being tomorrow’s follower. The opposite may also be applicable: today’s follower may be tomorrow’s leader. The change may result from the context of the situation. In the operating room, the surgeon is the acknowledged leader and the anesthesiologist follows that lead with respect to the extent of the anesthesia. If the patient’s condition changes, the anesthesiologist becomes the leader and the surgeon may simply step away from the table, an overt act that demonstrates a change in leadership. As healthcare consumers and participants, we salute the clarity.

Informed followers are not submissive participants blindly following a cultist personality. They are effective group members, not “groupies.” They are skilled in group dynamics and accountable for their actions. They are willing and able to question, debate, compromise, collaborate, and act. Box 19-1 lists the traits of a good follower.

BOX 19-1

Traits of a Good Follower

• Trustworthy

• Dependable

• Excellent Communicator and Listener

• Team Player

• Courage of Convictions

• Collaborator

• Questioner

From Kouzes, J.M., & Posner, B.Z. (2007). The leadership challenge (4th ed.). San Francisco: Jossey-Bass.

Collective action provides a mechanism for achieving professional practice through greater participation in decision making. The governance structure provides the framework for participation. Participation in decision making regarding one’s practice is an appropriate expectation for professional nurses, provides for greater autonomy and authority over practice decisions, contributes to supporting the professional nurse, and is a major component of job satisfaction (Kramer et al., 2008; Pittman, 2007). The privilege and the obligation to participate are inherent in the discipline of nursing. Consistent with the Code of Ethics for Nurses (American Nurses Association [ANA], 2005), members of the discipline participate based on their competence. Although nurses are expected to be informed, active participants, not all nurses wish to participate in decisions. For these nurses, going to work and doing their assigned job may fulfill their expectations. They may not perceive themselves as being in a subordinate position, or if they do, it is not a concern for them. Their orientation is to serve the care recipient and to be loyal to the organization. For these individuals, asserting the right and responsibility to participate in decisions may be considered disrespectful to the organization’s policies and to the physician, or they may be energy-draining. However, for the professional nurse, participation in practice-related decisions is critical to quality patient care, is expected by society, and is essential to autonomy for nursing. Today’s healthcare environment demands that nurses exercise the four key historical concepts identified by Lewis and Batey (1982): responsibility, authority, autonomy, and accountability.

Responsibility

The history of nursing provides evidence of nurses accepting responsibility or the “charge to act.” Historically, this charge took the form of unquestioningly and meticulously following the physician’s orders and hospital procedures. The “good” nurse rendered disclosure at the convenience of the physician and management. Today, healthcare organizations achieving Magnet™ recognition are characterized by the control of nursing practice by nurses (Kramer & Schmalenberg, 2004). Nursing and individual nurses must have the power to control practice. The recognition of credentialing, especially certification, has contributed to the exercise of expert power by nurses.

Authority

Authority based on preparation and experience suggests a departure from the tradition of delegating authority to individual nurses based on the physician’s or nurse manager’s knowledge of the nurse—knowledge that too often was based on personal characteristics, not clinical competence. That statement does not denigrate the collegial relationship between and among nurses and physicians, relationships that are based on mutual respect and trust. There is evidence that patient care improves when these relationships exist. Authority suggests that nurses use the power of their professional status to act in behalf of the best interest of patients.

Autonomy

Autonomy, the freedom to make independent decisions exceeding the standard nursing practice and that are in the best interest of the patient (Kramer & Schmalenberg, 2004), is critical to the control of nursing practice. To maximize the clinical effectiveness of registered nurses (RNs), they must have autonomy consistent with their scope of practice. Multiple studies demonstrate that a healthcare organization that provides a climate in which nurses have authority and autonomy has better patient outcomes, retains nurses at a higher rate, is more cost-effective, and has evidence of greater patient satisfaction than an organization in which such a climate does not exist (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Dunton, Gajewski, Klaus, & Pierson, 2007; Kramer & Schmalenberg, 2004). According to Kennerly (2000), the future depends on designing delivery models and implementing freedom in decision making to create and sustain positive work environments in nursing. Nurse involvement in decision making contributes to higher levels of job satisfaction for the nurse and higher levels of satisfaction with care for the patient and positively influences health outcomes.

Autonomy encourages innovation and increases productivity. A lack of autonomy and advocacy for standards frequently results in organizational silence and marginalization of nurses (Duchscher & Cowin, 2004; Hascup, 2003). Nurse managers have influence in this area of working with staff. Mrayyan (2004) found that nurses in an international study reported that the three most important variables in increasing nurse autonomy were supportive management, education, and experience. Specific managerial actions were defined as elements of interactions with others, especially when conflict was involved. Helping nurses communicate and supporting them in dealing with conflict help nurses describe themselves as having more autonomy. According to the U.S. Department of Health & Human Services (1988):

Failure on the part of healthcare delivery organizations, physicians, and policy-making bodies to fully recognize the decision-making abilities of RNs has contributed to problems in recruiting and retaining nurses, hindered the development of a career orientation in professional nursing, and limited the efficiency and effectiveness of patient care delivery. (p. vii)

This statement was accurate when written and has become more important as the delivery of and payment for health care evolves and healthcare reform becomes a reality.

Although automobile manufacturing is a highly mechanized process, management has learned that it is cost-effective to give the employee on the shop floor the autonomy to “stop the line” when the potential for error is detected. Stopping errors before they occur is more efficient than recalling items and retrofitting and is more humane than causing injury and perhaps death. Unlocking minds by providing greater autonomy and diversifying tasks decreases fear, specifically fear of ridicule, fear of punishment, and fear of job loss. The Institute for Healthcare Improvement (IHI) (2006) took the concept of change to the nursing unit level with its “Protecting 5 Million Lives from Harm” campaign. By supporting unit-level change without complex organizational structure approvals, change will occur more quickly and efficiently and patients will benefit.

Accountability

Accountability focuses the organization and all its members on the purposes and the outcomes of their collective activities. Accountability requires ownership. Porter-O’Grady and Malloch (2002) assert, “Accountability is always internally generated. It rests first and foremost within” (p. 261). Although Porter-O’Grady and Malloch (2010) make many points about accountability, the following are six critical considerations in shared governance:

• Defined by the person in the role

• Defined by role, not job or task

• Based on outcomes

• Set in advance

• Linked to results

• Has observable processes

The value of process is determined by the extent to which individuals observe a particular protocol while accomplishing a goal. Accountability focuses on the achievement of the specified outcome. This shift in thinking has had a tremendous effect on healthcare reimbursement. An example of the shift is evident in patient education. Initialing a form to indicate that patient teaching has occurred is no longer acceptable. The criteria now expect that the patient’s behavior has changed. Porter-O’Grady and Malloch (2002) call this the Age of Accountability; work is viewed in terms of outcomes. To achieve positive outcomes within an organization, shared accountability is critical. “When responsible adults refuse to share accountability, it poisons human relationships, corrupts professions, and makes self-esteem impossible” (Kupperschmidt, 2004, p. 115).

Exercise 19-2

Review the American Nurses Association’s (ANA) position statement on “Take Action on Safe Staffing” on www.nursingworld.org. From the perspective of a staff nurse, how do you feel about your professional organization’s call to action regarding safe staffing? As a nurse manager, do you have the same perspective? Why or why not?

Governance

Nursing governance is the methodology or system by which a department of nursing controls and directs the formulation and the administration of nursing policy. Organizational structure provides a framework for fulfilling the organization’s mission. Organizational charts show the relationship among and between roles. The structure of the organization and the relationship among the components of the structure are influenced by the individuals selected to interpret and implement the organization’s philosophy. A particular form of governance evolves from the mission and values of the organization and the relationships among and between its components. Thus managers and leaders who enact the mission and values on a daily basis support nursing more openly. To paraphrase an adage, behavior speaks louder and has more clout than organizational charts.

Nurses have multiple strategies to achieve collective action at their disposal; three prevalent ones are shared governance, workplace advocacy, and collective bargaining. These strategies are not mutually exclusive. As noted, governance is influenced by the context within which the organizational culture is embedded. Often the culture itself dictates the avenue of collective action.

The culture of the geographic area influences the organizational culture and the selected governance structure. For example, in right-to-work states, collective bargaining may be tolerated more than supported by nurses and administration. Although mobility and the mass media have diluted the “purity” of geographic cultures, it is prudent to acknowledge how deeply embedded these cultural influences are within the fabric of American society.

When a subculture is clearly rooted in the mission of the organization (e.g., delivery of quality care in a cost-effective environment), the possibility of genuine negotiation or problem solving is enhanced. A subculture has its own unique and distinctive features, even as other features overlap with those of the larger culture. Members may adhere to values that are specific to their group while espousing values of the larger society. The presence of congruent subcultures supports healthy relationships. Healthy relationships are an important variable in the development of a strong internal governance structure capable of supporting a professional practice environment that works well for everyone involved.

Nurses and administrators are often members of separate subcultures. This phenomenon should not be given a negative connotation. Several factors may increase the distinct ideologies of the two groups, including the existence of a distant corporate structure and the presence of a union. Both factors may be considered external tensions. By tradition, decision making in the United States has been centralized at the top administrative level. There is a tendency to increase the concentration of decision making during economic downturns and the pressures inherent in maintaining a healthy “bottom line.” Actions are taken to avoid risk. However, history shows that broader input, not less, is important during these times.

When efforts have been made to address nurses’ perceptions about job satisfaction, the relationship between nursing and the top administration of a hospital has been affected. Work environment factors that have a direct impact on nurses’ job satisfaction and the ability to influence patient care include supervisory support in patient care decisions and the provision of adequate staffing to provide quality care, positive working relationships with physicians and nurses, and a clear philosophy of nursing; all of these factors are influenced by the relationship between nurses and administration (Cummings et al., 2008; Manojlovich, 2005; Mrayyan, 2004).

Exercise 19-3

Identify four factors in your practice (experience) that contribute to job satisfaction. Compare your responses with those of three practicing nurses who are not supervisors and three practicing nurses who are supervisors. Are your factors similar to the responses of others? Are you surprised by the responses?

In the past, nurses experienced practice environments and working conditions controlled by the medical profession and hospital administration. In today’s work environment, nurses expect a motivating, satisfying work environment that includes a role in decision making. Many nurses today are unwilling to remain outside the decision-making loop. Work redesign efforts to increase productivity and lower costs have contributed to increased tension regarding the role of nursing and nurses in decision making. Evolving or creating a system that incorporates others in the decision-making process may be difficult for many individuals in upper-management positions. High-performing organizations that provide quality health care create climates that provide for participation by all stakeholders. Each stakeholder shares responsibility and risk, and that requires optimism and trust.

Contractual models allow nurses to form an organization and contract with the healthcare organization to provide nursing services. A contractual model can be characterized as a self-governance model as opposed to shared governance. Nurses become contract providers instead of employees. Historically, nurses were direct contractors as private-duty nurses before becoming hospital employees. Free agency may be the contractual model for the future (Manion, 2000).

Shared Governance

Shared governance is described as a democratic, egalitarian concept; it is a dynamic process resulting from shared decision making and accountability (Porter-O’Grady, 2009). According to Porter-O’Grady, Hawkins, and Parker (1997), basic principles of shared governance include partnerships, equity, accountability, and ownership. It is more accurate to say that shared governance demands participation in decision making rather than provides for participation. Characteristics of self-governance that empowered nurses were career ladders, access to power, participation in decision making, recognition of accomplishments, and evidence-based practice (Kramer et al., 2008) (see the Research Perspective on p. 378).

Research Perspective