Power, Politics, and Influence

This chapter describes how power and politics influence the roles of leaders and managers and how leaders and managers use power and politics to be influential. Contemporary concepts of power, empowerment, types of power exercised by nurses, key factors in developing a powerful image, personal and organizational strategies for exercising power, and the power of nurses to shape health policy by taking action in the arena of legislative politics are explored. Engaging in the politics of the workplace is critical for effective nursing leadership and management.

Terms to Know

The Challenge

Anonymous, a retired emergency department staff nurse

Our hospital was trying hard to improve customer service. The emergency department (ED) had been receiving frequent calls that were not relevant to the work of the ED, such as asking how long to cook a turkey and where the closest 24-hour veterinary clinic is. In some cases, in efforts to provide good customer service, the ED staff provided phone numbers (e.g., the Butterball turkey hotline; the phone number for a 24-hour animal hospital). Often we had to tell callers we could not provide them with the information requested; these responses were met with hostile and even obscene reactions from some callers. Other calls (e.g., calls to determine how much a 20-minute late-night visit to the ED or an X-ray would cost) were also met with hostility at times. Staff requested an in-service on how to handle such calls while providing good customer service. Our director provided us with such a program. We learned to deal with verbal hostility with assertive communication.

Shortly after the in-service, late on a Friday morning, I took a call from a woman who wanted to know how to treat an infected wound on her cat’s back. I gave her the name and phone number of the 24-hour animal clinic. The woman responded by screaming obscenities at me, indicating she had taken the cat to a veterinarian and wasn’t going to go back. She screamed so loudly that the ED’s medical director and other staff heard the woman’s tirade. Feeling empowered, I used my new skills to assertively end the conversation. A secretary paged our nursing director to come to the ED while the call was in progress. She arrived just as the call ended. I was debriefed by the director. The others who overheard the call gave her the same account of the call. I began to write an incident report on the event before my director was paged to go to the office of the vice president (VP) of nursing.

The VP had just gotten off the phone with the chief executive officer (CEO) of the hospital. The woman with the cat called him to accuse me of calling her obscene names and refusing to help her. The director told my VP what I had told her. She emphasized that the caller was the one using obscenities, not me. The VP directed her to suspend me immediately to placate the CEO; my director insisted that I had done nothing wrong and refused to suspend me, based on the information the others had given her. The VP came to the ED after the director left her office. She then confronted me, threatening to fire me unless I called the woman and apologized. The VP left only when the medical director of the ED insisted that I had used no obscenities and had not responded to the call inappropriately. Badly shaken, I paged the director to come back to the ED as soon as the VP left.

What do you think you would do if you were this nurse?

Introduction

The profession of nursing developed in the United States at a time when women had limited legal rights (e.g., most were prohibited from voting, and many could not own property). Women were viewed as neither powerful nor political; in the late nineteenth century, feminine and powerful were practically contradictory terms. During the twentieth century, as the status and role of women changed, so did the status and role of nurses. As the economic and social power of women evolved, so did the power of nurses. This is significant because nursing historically has been and continues to be a discipline comprising primarily women.

Now in the twenty-first century, nurses must exercise their power to create a strong voice for nursing in shaping an evolving healthcare environment. This is an era of rapid and often unplanned change with a dramatic nursing shortage like none before. Nurses must use their collective power and flex their political muscles to create a preferred future for the healthcare system, healthcare consumers, and the profession of nursing.

History

The word power comes from the Latin word potere, meaning “to be able.” Simply defined, power is the ability to influence others in an effort to achieve goals. Power was once considered almost a taboo in nursing. In nursing’s formative years, the exercise of power was considered inappropriate, unladylike, and unprofessional. During nursing’s earliest decades in America, many decisions about nursing education and practice were made by persons outside of nursing (Ashley, 1976). Nurses began to exercise their collective power with the rise of early nursing leaders such as Lillian Wald, Isabel Stewart, Annie Goodrich, Lavinia Dock, M. Adelaide Nutting, Mary Eliza Mahoney, and Isabel Hampton Robb and the development of organizations that evolved into the American Nurses Association (ANA) and the National League for Nursing (NLN).

Many social, technologic, scientific, and economic trends have shaped nursing and nurses and nursing’s ability to exercise power during the twentieth century. The American Medical Association (AMA), in 1988, proposed a new category of healthcare worker (the registered care technologist or RCT) to replace nurses during a time of nursing shortage. Nurses and nursing organizations responded powerfully. Nursing leaders came together in “summit meetings” to formulate powerful responses to the AMA and implemented a range of actions, including public education and the education of legislators. The new healthcare worker did not materialize from this proposal. Today, in an era of expanding nursing roles (e.g., advanced practice nurses, clinical nurse leaders, and new roles for graduates of doctor of nursing practice [DNP] programs), nurses must continue to exercise their power to shape the continuing development of the profession of nursing and the future of the healthcare system.

Sadly, the media, politicians, organized medicine, some healthcare executives, and some nurses have traditionally viewed nurses and nursing as powerless. That view began to change dramatically in the 1990s as nurses began to appear more often on local and national news and on talk shows as experts on health care, the changes occurring in the healthcare system, and the effect of these changes on the public. Nurses have become increasingly visible in political campaigns on the local, state, and national levels, both as candidates and as political influentials. For example, Congresswoman Lois Capps, MA, BSN, RN, represents a California congressional district; she assumed the office held by her husband upon his death. A former school nurse, Congresswoman Capps has since been re-elected by her constituents to the House seat. Nurses and nursing have gained new respect in the political arena in recent years. Sheila Burke, MPA, RN, FAAN, served as Chief of Staff for Senator Robert Dole while he was Senate Majority Leader in the United States Congress, making her one of the most powerful congressional staff people in Washington. During the Clinton administration, nurse leaders were prominent: two former ANA presidents, Virginia Trotter Betts, MSN, JD, RN, FAAN, and Beverly Malone, PhD, RN, FAAN, served in roles that helped shape health policy for the nation. Diana J. Mason, PhD, RN, FAAN, editor emerita of the American Journal of Nursing, has long hosted a radio talk show in New York City on healthcare issues. Mary Wakefield, PhD, RN, FAAN, serves as the administrator of the Health Resources and Services Administration (HRSA) under President Barack Obama. She served in the 1990s as chief of staff to North Dakota senators Kent Conrad and Quentin Burdick.

As we experience a new and different era of nursing shortage, there are still some nurses who see themselves as powerless and oppressed, demonstrating aspects of oppressed group behavior. Roberts (1983) addressed the historical evidence of oppressed group behavior among nurses, based on models developed from the study of politically and economically oppressed populations. Oppressed group behavior is apparent when a population is dominated by another group. This subordinate or oppressed group begins to take on the characteristics of the dominant group and reject the characteristics of their own group, although this behavior fails to create a balance of power with the dominant group (Roberts 1983). Matheson and Bobay (2007) conducted a review of the literature to validate oppressed group behavior in nursing. They noted that nurses continue to demonstrate some of the behaviors characteristic of oppressed groups, but they could not validate that these behaviors occur directly as a result of oppression by outside groups. Among nurses, oppressed group behavior is manifested in low self-esteem (e.g., “I’m just a nurse”), passive aggressiveness (e.g., nurse-on-nurse bullying), distancing oneself from other nurses (e.g., the failure of nurses to join professional organizations), and engaging in intragroup conflicts (e.g., “infighting” or horizontal violence) (Matheson & Bobay, 2007; Roberts, 1983).

Schools of nursing too often fail to socialize students to be activists. Students need to be exposed to the concepts of political action and public policy. Students need to recognize that policy is just a plan for action related to an issue that affects a group’s well-being. All nurses need to continue to expand their understanding of the concept of power and to develop their skills in exercising power. Avoiding involvement in the politics of nursing in the workplace, in the profession at large, or in the area of public policy limits the power of the individual nurse and the profession as a whole.

Some nurses are still uncomfortable with politics and the use of power, treating “politics” as if it were a dirty word. Historically, politics has been viewed with some disdain. Writer Robert Louis Stevenson noted, “Politics is perhaps the only profession for which no preparation is thought necessary.” But contemporary nursing’s need to thrive within a healthcare system demands that nursing education prepare nurses to engage in professional, workplace, and legislative politics.

Politics can be defined in many ways. One simple definition of politics that this author uses when teaching health policy and politics in nursing is “a process of human interaction within organizations.” Politics permeates all organizations, including workplaces, legislatures, professions, and even families. Young children often learn that one parent is more likely to readily give permission for special activities or more likely to buy toys and other desired items. They quickly learn to ask permission or ask for a desired item from that parent before asking the other. This is an unwritten political rule in many families. Political activism should be an unwritten rule in nursing (see the Literature Perspective at right).

Literature Perspective

Resource: Kelly, K. (2007). From apathy to savvy to activism: Becoming a politically active nurse. American Nurse Today, 2(8), 55-56.

Politics in nursing can refer to both legislative and professional politics. Legislative politics deals with law and public policy. Professional politics focuses on the workplace and professional nursing organizations. Too often, nurses view politics as irrelevant to their daily practice. Yet public policy and politics shape what we do as nurses, from the nurse practice acts that allow for the licensure of nurses to policies that drive reimbursement for healthcare services. Nursing exists because public policy acknowledges that nursing meets a need to provide for the health care of the public.

Nurses can move from political apathy to activism by learning the requisite skills through (1) holding an active membership in professional organizations that provide information and opportunities for networking; (2) attending workshops, conferences, and academic courses that support the development of political skills and expansion of political/policy knowledge; (3) engaging with legislators through lobbying and campaign work; and (4) moving into leadership roles in nursing organizations.

Implications for Practice

If all nurses became actively engaged in professional nursing organizations, the entire profession could move ahead in a dramatic manner. Activism involves being politically active on behalf of patients and the profession.

The model of political activism, noted below, is based on elements from models of political activism (Leavitt, Chaffee, & Vance, 2007). This model can be applied to the political development and activism of individual nurses related to both professional and legislative political arenas (Kelly, 2007):

1. Apathy: no membership in professional organizations; little or no interest in legislative politics as they relate to nursing and health care

2. Buy-in: recognition of the importance of activism within professional organizations (without active participation) and legislative politics related to critical nursing issues

3. Self-interest: involvement in professional organizations to further one’s own career; the development and use of political expertise to further the profession’s self-interests

4. Political sophistication: high level of professional organization activism (e.g., holding office at the local and state level) moving beyond self-interests; recognition of the need for activism on behalf of the public and the profession

5. Leading the way: serving in elected or appointed positions in professional organizations at the state and national levels; providing true leadership on broad healthcare interests within legislative politics, including seeking appointment to policy-making bodies and election to political positions

Focus on Power

Some nurses, including both new graduates and seasoned veterans, have too often viewed power as if it were something immoral, corrupting, and totally contradictory to the caring nature of nursing. However, the definition on p. 176 (the ability to influence others in an effort to achieve goals) demonstrates the essential nature of power to nursing. Nurses routinely influence patients to improve their health status, an essential element of nursing practice. When nurses provide health teaching to patients and their families, the goal is to change patient/family behavior to promote optimal health. That is an exercise of power in nursing practice. Changing the behavior of one’s colleagues by instructing them about a new policy being implemented on the nursing unit is another example of how nurses exercise power. Coaching nurses to improve their performances is an exercise of power. Serving as the chief nursing officer of a hospital, managing a multimillion-dollar budget, demonstrates another exercise of power.

Exercise 10-1

Recall a recent opportunity in which you observed the work of an expert nurse. Think about that nurse’s interactions with patients, family members, nursing colleagues, and other professionals. What kinds of power did you observe this nurse using? What did the nurse do that told you, “This is a powerful person”?

Social scientists have studied the use and abuse of power in human organizations. They have analyzed and categorized the sources and applications of power in human experience. Hersey, Blanchard, and Natemeyer (1979) offer a classic formulation on the basis of social power. Sullivan (2004, p. 33) offers a revised view of types of power that readily apply to the efforts of nurses in the workplace, in professional organizations, and in politics (see the Theory Box on p. 180). These types of power are not mutually exclusive. They are often used in concert to exert influence on individuals or groups.

Theory Box

Types of Power *

KEY CONTRIBUTORS	KEY IDEAS	APPLICATION TO PRACTICE
Types or bases of social power were formulated by Hersey, Blanchard, and Natemeyer (1979) to explain the personal use of power. Sullivan (2004) reorganized these types, eliminating much of the overlap in the original categories.	Personal power: Based on one’s reputation and credibility.	The leader of a state nurses’ association (SNA) may have access to the leaders of the state legislature based on the leader’s personal power, which is based on years of work with members of the legislature.The SNA president has always delivered on promises of support and provided useful information to legislators on matters of health policy.
	Expert power: Results from the knowledge and skills one possesses that are needed by others.	An advanced practice nurse is viewed as the clinical expert on a nursing unit and as a powerful person.
	Position power: Possessed by virtue of one’s position within an organization or status within a group.	The dean of a college of nursing is viewed on campus as powerful because this dean leads the fastest growing academic unit on campus.
	Perceived power: Results from one’s reputation as a powerful person.	A nursing student seeks a certain nurse manager as a preceptor during a senior clinical practicum because of the manager’s reputation as an effective manager within the organization.
	Information power: Stems from one’s possession of selected information that is needed by others.	A staff nurse demonstrates great skill in teaching patients difficult self-care activities and is sought out by colleagues to help them teach their patients.
	Connection power: Gained by association with people who have links to powerful people.	At a Nurses’ Week celebration, nurses take advantage of the opportunity to have extended, informal conversations with those who report to the chief nursing officer.

^*These categories help explain how we use power to influence others. The categories are not mutually exclusive and usually are used in concert with one another.

Nurses commonly use all of these types of power while implementing a wide range of nursing activities. Nurses who teach patients use expert and information power by virtue of the information they share with patients; they also exercise position power because they are registered nurses and therefore are accorded a certain status by society. Members of a state nurses’ association who lobby members of the state legislature use expert, perceived, personal, and position power when trying to gain legislators’ support for healthcare legislation. New graduates, employed on probationary status until they demonstrate the initial clinical competencies of a position, may view the nurse manager as exercising both position and expert power related to their evaluation for continued employment. Nursing faculty and skilled clinicians exercise expert and perceived power as students emulate their behavior. Connection power is evident at any social gathering in the workplace. People of high status (e.g., vice presidents, directors, deans) within an organization may be sought out for conversation by those who want to move up the organizational hierarchy.

Having a high-status position in an organization immediately provides stature, but power depends on the ability to accomplish goals from that position. Although some may think that “knowledge is power,” acting on that knowledge is where the real power lies. Sharing knowledge expands one’s power and, in turn, empowers others, including colleagues and patients, by giving them information or skills that they need to take action in a situation.

Nursing’s early history in the United States was marked by powerlessness (Ashley, 1976). Nurses were absent from the decision-making processes about their education, practice, and employment. As the social, political, and economic status of women and nurses changed, so did the exercise of power by nursing as a profession and nurses as individuals. Powerlessness, a behavior still exhibited by some nurses, results in negative emotions such as apathy and anger. This can result in a workplace culture that is marked by conflict, anger, and other dysfunctional behaviors. Sharing power and facilitating the empowerment of colleagues so that they exercise their power are strong forces in creating vibrant workplace cultures.

Influence is the process of using power. Influence can range from the punitive power of coercion to the interactive power of collaboration. Coaching a new graduate nurse to complete a complicated nursing procedure successfully vividly demonstrates the ability of the experienced nurse to influence that orientee. The coach uses expert, position, perceived, and information power to influence the orientee not only at that moment but also perhaps over the span of a career. A nurse who lobbies legislators uses expertise, information, and perceived power to encourage support for a bill to expand healthcare services to the children of the working poor. Nurses can use personal, expert, and perceived power while working on the campaigns of legislators who support nursing and healthcare issues.