INTRODUCTION

This chapter is about leading and facilitating the transformation of a culture of health care in a large hospital that professed to be moving from a provider-driven system to one that truly manifests the values of patient-focused care. It is also an examination of nursing leadership and the impact that nursing theory can have on the quality of care and quality of work life for nurses. I have the privilege of being in a leadership role with approximately 2700 nurses and also of belonging to a senior team that is courageous and committed to values and principles, as well as clinical excellence. Sunnybrook and Women’s (S&W’s) College Health Sciences Centre is a three-campus teaching hospital with more than 7000 employees and with services that include clinical specialties such as oncology, perinatal care, critical care, ambulatory care, trauma, and gerontology—to name several.

S&W’s staff have a unique and innovative commitment to promote and integrate four corporate themes or directives throughout the entire organisation. The four themes are ageing, strategic alliances/partnerships, women’s health, and patient-focused care. A corporate focus on patient-focused care means that program and discipline leaders, as well as practitioners and providers of care are expected to and held accountable for advancing the organisational commitment to a specific patient-focused philosophy and set of standards. Nurses at S&W have provided leadership in the integration of patient-focused care and the chief nursing officer (CNO) role has been supported as pivotal to the change process (Bournes & DasGupta 1997; Linscott et al. 1999; Mitchell et al. 2000; Saltmarche et al. 1998). Almost a decade of leadership has provided learning, joy, excitement and struggle. Becoming a leader has been a journey that for me began with opportunities to develop a view of nursing as a discipline, a basic science and an art.

DEVELOPING A VIEW OF NURSING

An essential requirement of nursing leaders is that they can articulate and promote the art and science of nursing. Prior to leading others, most nursing leaders have examined and clarified their own beliefs about the nature of nursing and the ultimate purpose of nursing work. Clarifying one’s personal beliefs requires exploration, contemplation, interrogation and confident articulation (Mitchell 1990, 1991, 1994, 1999, 2001; Mitchell & Cody 2002). It is not possible to be a strong leader or a strong nurse until clarity of intent and consistency of action emerge in one’s thoughts and expressions about nursing.

I believe that nursing is a discipline, meaning that the discipline of nursing consists of particular knowledge essential to nursing practice and research (Barrett 2002; Cody 2001; Daly & Jackson 1999; Daly et al. 1996; Major et al. 2001; Mitchell 1994, 1999, 2001; Mitchell & Pilkington 2000; Parse 1993, 2001a, 2001b). Nursing knowledge is housed in extant nursing theories that provide different views about the nature of reality and the intent of nursing practice. Theories define context and direct nurses to attend to specific purposes and goals in the nurse–person process. Nursing knowledge is expanded through research projects that examine human experiences of health and quality of life through the lens of a specific nursing theory (see for example, Bournes & Mitchell 2002; Carson & Mitchell 1998; Cody 1991, 1995; Mitchell & Lawton 2000; Parse 2001c; Pilkington 1993).

Not all nurse leaders agree with the idea that nursing is a discipline in its own right. Fralic (2000), for example, considers nursing knowledge to be based in physiology, pharmacology, chemistry, anatomy, psychology, technology and physics. In contrast, I would suggest that although nurses have a broad base of knowledge in all these areas, as do physicians, physiotherapists and dentists, this generic knowledge does not make a nurse. Nurses require a unique focus or area of concern that provides unity and community towards a common vision and purpose. Fralic (2000) contends that if it cannot be measured, nursing should not be doing it. Her statement limits nursing phenomena to sensory data that can be measured. In contrast to Fralic’s views are others, including myself, who suggest that although nurses do indeed perform critically important activities based on sensory data, primarily for persons in hospital settings, the phenomena of concern for nurses, as a group of professionals and scholars, requires foundations in human lived experiences of health, illness, dying, healing and quality of life (Barrett 2002; Cody 2001; Cody et al. 2000; Cody & Mitchell 1992, 2002; Daly & Jackson 1999; Daly et al. 1996; Mitchell & Cody 1999). The point of this discussion is that there are very different views about nursing and that is why a nurse leader requires clarity about personal beliefs and professional theories that guide practice and research.

I also believe that nursing is a basic science and a human science (Cody & Mitchell 2002; Fawcett 2002; Mitchell & Cody 1999; Malinski 2002; Parse 1987, 1998). This means that nursing knowledge, as developed in nursing theories, is extended through research that expands understanding of nursing phenomena—such as the lived experiences of health—as opposed to an applied science that expands the knowledge base of other disciplines. There are different views about the meaning of human science (Fawcett 2002; Malinski 2002), but the most critical view to contemplate is whether nursing knowledge needs to be different from medical, social or psychological knowledge (Mitchell & Cody 1999). From my perspective, the knowledge nurses require to care for human beings is different from what other disciplines generate and it is also different from the technical and clinical expertise that nurses develop on the job. In addition to the medical, clinical and technical knowledge nurses use on the job, there is a critical need for knowledge that helps nurses to be with people in ways that make a difference to the person’s health and quality of life (for example, see Cody & Mitchell 1992; Daly et al. 1996; Fisher & Mitchell 1998; Jonas-Simpson 2001).

Nursing theories help nurses to articulate an intent that informs the nursing process and thus the nurse–person relationship. I think it would be very helpful if nurses could clearly state the purpose of their practices and the contributions they make to human health and quality of life. Nurses may identify self-care, quality of life or expanding consciousness when they address the contribution of their unique and autonomous practice. Nursing theories help to make the work of nursing understandable to the discipline and to the public at large. It is important to note that the knowledge of nursing theory co-exists with other knowledge about how to complete clinical skills and how to promote patient safety. All disciplines need knowledge about clinical skill and patient safety, but in addition to this general biomedical expertise, nurses require a purpose for being in a relationship with patients and for being a unique player on the health care team.

I had many opportunities during my career and during my scholarly pursuits to question my own beliefs and values. After years of exploring and clarifying, I choose the human becoming theory (Parse 1981, 1987, 1992, 1995, 1997, 1998), because it best aligns with my personal beliefs and vision of how nursing practice can happen with others. I have remained committed to the human becoming theory because it is a source of understanding and discovery, and because it supports a philosophy of health care delivery called patient-focused care (Linscott et al. 1999; Mitchell et al. 2000). I explored many other theories and models along the way but the human becoming theory provided the best fit with the kind of nurse I want to be, as well as the kind of nursing I want to experience. Perhaps you might think about the kind of nursing you want to experience as you consider the questions in the reflective exercise at the end of the chapter, regarding your beliefs about nursing theory.

Nursing practices underpinned by human science beliefs provide a unique service to humankind and one that is closest to the primary responsibility nurses bear—to be helpful to people during their life experiences. Nurses change, for better or for worse, what people experience and that change can enhance or diminish quality of life in important and lasting ways. The human becoming theory helps health care professionals to create a reality or a culture where persons who engage health services are met with a genuine regard for their humanity and for the wisdom people possess about their own quality of life and potential for change. Helping to create a reality where specific values are lived in relationships with others provides for leadership opportunities and challenges.

LEADERSHIP OPPORTUNITIES: A CHALLENGING JOURNEY

The pathway to becoming a nursing leader began when I started to question my practice, about six years after graduating from a hospital diploma program. I began to see my practice as limited and unsatisfying. I am not sure why I became dissatisfied, but I recall feeling disappointed and even ashamed of some of the things I was participating in. I loved nursing but I found the culture of nursing and the focus on tasks was not always helpful for the people we were supposed to be caring for.

After considering alternatives, I recommitted myself to nursing and returned to school with the hope that I might find ways to become the kind of nurse I wanted to be, and so that I could contribute to the discipline of nursing in ways that might benefit others. The discomfort and shame I experienced early in my career helped me to clarify what I was not willing to sacrifice in my work as a nurse. I think that professional integrity is critical for nurses and I sometimes wonder how many other nurses experience this kind of dissonance and disappointment in their careers. It became clear to me over time that at least part of my disappointment was with the knowledge and skill that I lacked to inform the kind of care I wanted to provide.

It was through my own growth as a practitioner of nursing that I learnt about being a leader for others who struggled as I did in the modern world of health care. I believe that people (patients, families, clients) experience unnecessary suffering because of nurses’ insufficient understanding and knowledge about human beings and their meanings, relationships, and experiences of health and quality of life. Like others, I believe that the choice of one’s nursing approach and theoretical guide is a moral matter with important ethical implications (Gadow 1990; Milton 1999; White 2001; Young-Mason 2001), and that the quality of nursing influences health outcomes and quality of life for clients.

During my years of learning about nursing as a field of study, I thought about the times I had walked away from difficult situations because I did not know how to be with people or how to be helpful. I had seen too many people hang their heads in shame when lectured by a health care professional about how they should have known better. I learned along the way that I did not want to be a nurse who punished, lectured, ignored or pressured people. I saw that life and lived experiences were far more complex than I could possibly understand. I realised that what I wanted was knowledge that would help me to be with the realities that people were experiencing—and to be there in ways that showed the compassion and caring I felt for others.

I will never forget the day a doctor asked me to go and talk with a young girl who was considered obese by physicians, to see if she realised she should lose weight. I recall looking at him and trying to understand the abyss that separated professionals from the people they were there to serve. Or other times when patients were punished for not complying with what professionals thought was best for them, even when people were not involved in decisions about their care. Still today I observe or hear about how some health care providers show hurtful and judgemental attitudes and actions toward patients and families, and it both angers me and strengthens my resolve to keep trying to contribute to systems that truly demonstrate a genuine regard for patients.

Study and contemplation, analysis and reflection, helped me to make the choice to align my nursing practice and research with the theory of human becoming (Parse 1981, 1987, 1992, 1995, 1997, 1998). It has been 15 years since I first began to learn what the human becoming school of thought could offer me as a nurse searching for meaningful practice. Learning the theory is not a swift or easy matter because it requires openness and a persistence to question predominant views and the status quo (Linscott et al 1999; Mitchell 1990; Saltmarche et al. 1998). It takes time to unlearn and repattern understanding and intentions in practice. Personally, the theory of human becoming has been a source of discovery and has provided alternative views helpful to me in practice (Cody et al. 2000; Cody & Mitchell 1992; Mitchell 1988, 1990, 1991, 1999, 2001; Mitchell & Bournes 2000; Mitchell et al. 2000; Mitchell & Cody 1999; Mitchell & Pilkington 2000) and research (Bournes & Mitchell 2002; Carson & Mitchell 1998; Mitchell & Lawton 2000; Fisher & Mitchell 1998; Mitchell 1998). Leadership in nursing requires passionate beliefs and a breadth of knowledge that includes knowledge of nursing theory. It is with this history and the personal commitment to human becoming that I embraced the opportunity to become a leader of nursing at a large teaching hospital in Canada.

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