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Reframing Nursing Leadership for 21st Century Practice, 2010


It comes as no surprise that nursing and health care are at a crossroads.  As we confront a new age for human experience, the very foundations of health practices and therapeutic interventions are being dramatically altered by significantly transformed scientific, technological, cultural, political, and social realities (Tim Porter-O’Grady, 2003).  It is within the context of these emerging realities that the future framework for nursing practice and for those that will lead it must now be re-conceptualized (Hein, 2001).  The traditional realities that form the frame of reference and contextual framework for thinking and acting for the majority of nurses no longer operates to form the foundations for reality for contemporary and future nursing practice and leadership (Sheila Grossman & Valiga, 2000).


It is vital for those leading the profession to carefully consider these emerging contextual realities and to apply the impact of their transformations to the thinking and applications related to creating new models and modes of practice for the future of nursing.  At every level of consideration, from system, profession, self, and the relationship to patient and family, every aspect of nursing practice must now be re-examined.  This transformation calls the profession to make decisions about what principles and foundations established over the past century of considered thought and relevant action can be easily translated into this new world of digital and virtual reality and political and social globalization (Friedman, 2006).  Certainly, the principles and foundations upon which the nursing profession is based can stand the stress of shifting realities and new applications and call practitioners and leaders to determine a new goodness of fit between those principles and future practice (S. Grossman & Valiga, 2005).  In this endeavor, it becomes essential for nursing leaders to successfully re-language the practice of nursing and to formulate a new frame for nursing practice which reflects the emerging realities impacting practice in the domains of system, profession, person, and the interaction (Domains of Nursing Leadership: system, person, patient/family, profession) of all of these with regard to patient and families (the “users”).


Nursing in a Transforming Health System


The challenges of technology, culture, society, and globalization have worked together to create a challenging context for the contemporary delivery of healthcare services (Porter-O’Grady et al., 2005).  The traditional medically dominated and medically prescribed model of high intensity and late stage intervention which has comprised the majority framework for the American healthcare system has failed to yield in the United States a standard of health and health status comparable to the other GATT (General Agreement on Tariffs & Trade) nations (Commonwealth Fund, 2007).  Across almost all measures of social health status, the United States fails to reach the top tier of health status measures with the notable exception of one measure, the national price of health care.  Without reiterating what has been clearly evidenced in other reports, it is notably apparent that the system as currently constructed fails to adequately serve the needs of the American population (Kleinke, 2001).  The evidence is overwhelming; the devastating and shameful fact that approaching 50 million people fail to have adequate health coverage to the more clinically notable deficits located across the lifespan revealing devastating data related to infant mortality, childhood illness, adult heart disease, diabetes, obesity, and a growing looming crisis related to aging (Porter & Teisberg, 2006).



The System


This is the healthcare system within which nurses spend the majority of their time in processes and activities which ultimately serve to support and sustain the existing infrastructure, processes, and clinical focus through a wide ranging array of functions and activities (Siegler, Mirafzali, & Foust, 2003).  Increasingly, nurses are finding their usual and ordinary clinical practices, activities, and functions both less viable and less sustainable (L. Aiken, Clarke, Sloane, Sochalski, & Silber, 2002).  Increasingly, nurses at every level of function are finding it impossible to continue to apply traditional approaches in practice within the clinical setting (Kuokkanen, Leino-Kilpi, & Katajisto, 2003).  In addition, contemporary data suggest that nurses are less motivated, energized, or satisfied by their current realities and practice obligations in accelerating challenging circumstances (Ulrich, Buerhaus, Donelan, Norman, & Dittus, 2005).  In short, nurses sense the failure of the system to support practice, and the failure of current practices to heal either the professional or the patient (Bowles & Candela, 2005).


Many nurses suggest a sense of being overwhelmed by the breadth of the systems issues and the complexity of its problems (Vonfrolio, 2006).  From issues of regulation and accreditation and performance expectations for excellence and impact, these growing demands overwhelm the capacity of the individual practitioner to adequately address them.  Issues of a lack of control over one’s practice, an inability to contest regulations, rules, protocols, accreditation and internal quality demands increasingly draw the life and energy from each practitioner until little remains except for the intent to do what one can within the context of a narrowing scope of perceived opportunity (Roman, 2006).


Adding to this generalized professional malaise is the nursing leader’s sense of being overwhelmed and challenged beyond any existing level of competence (Kane-Urrabazo, 2006).  The growing dichotomy between current infrastructure and service frameworks and the accelerating need for a transformed approach to healthcare delivery continually serve to overwhelm and challenge even the most committed and motivated leaders.  In many ways, leaders feel as though they are simply maintaining the status quo and barely keeping their own efforts one step ahead of the next challenge or requisite which will take them beyond their capacity to adequately respond (Judkins, Massey, & Huff, 2006).  As a result, there is increasing fallout in the roles of leadership and a growing difficulty in finding qualified and motivated nurses to assume vacant leadership positions (Bonczek & Woodard, 2006).


This contemporary reality serves to create an opportunity to recognize the changing characteristics of the health system, the need for strong leadership in creating new models and approaches to health service, and in challenging past practices to the extent that they act as an impediment to relevance and viability for future nursing practice (Chaska, 2001; Christensen, Bohmer, & Kenagy, 2000; Kathy Malloch & Tim Porter-O’Grady, 2006).  No longer can leaders at any level of conception move forward without acknowledging the necessity to create newer models, approaches, and practices in the new world of healthcare.  This will require leaders, whether they be management or clinical, to recognize their inclusion and involvement in planning and decision-making at every level of the health system (McClure & Hinshaw, 2002).  It will no longer be appropriate for nursing leadership, in any capacity, to simply undertake any mechanism of change in health care delivery involving the nursing resource without having first been actively involved in the conceiving, planning, and designing a new and relevant approaches to meeting healthcare needs (Kleinman, 2003).  These leaders will need to be educated for and exhibit systems savvy and readiness by demonstrating commitment and skill in the following capacities:


  1. Nurse leaders must recognize that political competence is not an option in leadership and engaging political realities is a fundamental construct of the leader’s role at all levels of leadership.
  2. It is not acceptable to implement approaches, plans, or programs which will require nurses, at the end stage, to either facilitate, coordinate, or integrate without the active inclusion and incorporation of nurses in the planning and designing stages.
  3. It is not optional for nurse leaders at any level of performance to be unaware of the political, cultural, social, and professional fit of nursing in the broader health system within the context of the historical realities of Nursing’s professional journey.
  4. Nursing leaders must articulate an understanding of the financial framework for the payment of health services including the ability to articulate the challenges to leadership and nursing services contemporary payment policies and processes create.
  5. The role of advocacy in nursing operates at a level broader than individual patient considerations.  Failure to advocate on behalf of the patients from a systems perspective is equally ethically comparable with failure to advocate for individual patient needs.
  6. Leaders understand that, for the professions, power is driven by practice.  Nursing leaders understand and commit professional energies to creating interdisciplinary equity related to nursing role, performance, contribution, and value at any place in the health system.
  7. The nurse leader understands the fundamental role in addressing systems problems and inequities related to profession and patient, joining with others to find and implement sustainable resolutions and innovations which advance the value of the nurse and the experience of the patient.
  8. Leadership involves the ability to engage new realities, translate them, and incorporate them into shifting applications for practice in a way that informs new practices and creates a foundation for constructing the future of nursing practice.
  9. Knowledge can no longer be considered a capacity.  It is, instead, a utility, available to all.  For the nurse leader, this informs leadership and nursing practice with emphasis on the implications related to knowledge creation, generation, utility, and evaluation.  Knowledge continually grows and transforms requiring practice leaders to guide the construction of infrastructure and process which keeps the profession and the professional open to the constant and ever-changing processes associated with knowledge management and application.
  10. The world is indeed flat, and mobility and portability are the contemporary visible characteristics of this reality.  Every discipline in every arena of human activity now must incorporate this reality of portability and mobility within the very construct guiding the thinking and practice of the professions.  Nursing leadership must help the profession and the professional translate out of past practice foundation’s born in a system that was fixed, finite, functional, and institutional to one that is now predominantly flexible, fluid, focused, portable and mobile.


Programs of leadership development and education must incorporate the above capacities as a part of basic expectation for adequate clinical and administrative leadership.  Any leadership program identified at the undergraduate level should introduce leadership concepts within the context of these systems realities (Hatch, Kostera, & Koþzmiþnski, 2005).  The American Organization of Nurse Executive’s “Guiding Principles for Patient Care Delivery” clearly serves as the template for leader competence and development in the service setting (Everett & Black, 2007). Graduate education in leadership requires that these realities be the cornerstone of systems leadership development and application for formal positions of clinical or management leadership.  Service-based leadership development programs must be constructed in a way that incorporates broader systems understanding into learned roles and functional attributes of practicing clinical and management leadership (AONE, 2005; Kleinman, 2003).  A failure to provide a systems contextual framework for the content of leadership learning ensures an inadequate contextual framework for the application of leadership skills and the use of shortsighted strategies for addressing issues and resolving problems (Van Wart, 2005).


The Profession


Unless the individual professional recognizes the obligation to both care for and advance the interests of the profession, it is impossible to claim any capacity in advancing the interests of the patient.  In nursing, to care for the patient is a direct corollary to care for the profession (ANA, 2004; ANCC, 2005a).  A lack of identification with and commitment to the profession as an agent of care for the patient creates a value impediment affecting the role and practice of every nurse.  Perhaps the source of the strongest systems malaise within the profession of nursing is the individual nurse’s lack of clear and understandable identity with the profession and failure to demonstrate a common understanding of what that means and how professional membership performs (Apker, Ford, & Fox, 2003).


Developing a sense of professionalism and a clear relationship to the profession is a foundational activity of all members of the profession.  Relationship to and membership in the profession does not imply that every person who works under the auspices of the profession meets the requisites of being defined as a professional.  However, those who define themselves as professionals must clearly demonstrate that they do meet such requisites (Cicatiello, 2001).  Professional accountability begins where role responsibility ends (Porter-O’Grady & Malloch, 2003).  It can be argued that licensed practical nurses and associate degree registered nurses can exercise high degrees of functional capacity and responsible practice behavior.  However, there are significant classification challenges when identifying these two roles within the context of professional definitions.  Clearly enumerating professional foundations in traditionally recognized academic frames (baccalaureate education), advanced education (masters and doctoral) and a growing body of knowledge created, generated, applied, and validated (research) are all essential foundations for professional definition (IOM, 2003).  Additional professional elements which include an ethical frame, code of conduct, and membership requisites, build on the knowledge generated foundations of education and practice (ANA, 2004).


These foundations are well defined and broadly accepted across a full range of disciplines and are generally acknowledged internationally as the medium for professional delineation (Corey, Schneider, & Callahan, 2006).  Slowly, yet inexorably, the profession of nursing is exemplifying, through implication and active application, these same foundations as a part of the maturation of the nursing profession.  Challenges continue to exist in clearly delineating differentiation between categories of practice aligned with role, function, preparation, application, assignment, and remuneration (Joel, 2002).  However, in order to exemplify professional delineation and act in comparable accord with other disciplines, these delineations must be clear, precise, and valid.


In addition, is the obligation of the profession and the professional to enumerate value not with process, but with outcome.  One of the growing realities of professional delineation is the understanding that the value of the profession is not so much located in what it does but instead in what it achieves; its impact (Freshwater & Rolfe, 2004).  The products of work are the best indicators of the value of the processes of work.  For the professional nurse in the contemporary values-driven world, it is important to identify the character of the profession and the professional in light of the impact, outcome, or difference that work achieves to affect the health of the individual and the community (K. Malloch & T. Porter-O’Grady, 2006).  This values-driven frame must now form the foundation of the definition of the profession, the professional, and their place in the world.  It is no longer sufficient for the profession or the professional to simply enumerate actions, activities, functions, scopes of practice, and rules as a way of delineating character, meaning, and value (Pfeffer & Sutton, 2006).  In the 21st century, sustainable value for any professional or workgroup relates directly to the contribution made to further refinement, development, innovation, and transformation of practices and approaches within the context of an emerging and fast-growing socio–technical reality.  Failing to accomplish this value, and failure to give evidence of engagement and translation of these emerging realities bodes ill for the profession and the professional and assures a short term future (Wickramasinghe, Gupta, & Sharma, 2005).


Advocacy for the profession means addressing these critical issues with the result that there be a clarity of definition, expectation, and commitment to retooling and reconfiguring the profession for a changing context.  It means that there is a general energy in the profession and the professional to evidence relevance and to demonstrate a full and overarching individual and collective participation in further refining and advancing the profession to meet the demands of a transforming clinical environment (Tim Porter-O’Grady, 2003).  Every activity associated with the innovation process and the developmental dynamics that serve as the necessary corollaries of change such as mentoring, coaching, challenging, harnessing normative conflict, novice to expert development, destructive technologies, shedding irrelevant practice capital, creativity, experimentation, and risk-taking must become the normative experience of the profession and of practice (Trompenaars & Hampden-Turner, 2002). 


The leadership capacity to engender the urgency of critical transformative activity can no longer be delayed.  The leader’s collegial obligation is to demonstrate a personal engagement of the agenda for change in the profession.  This leader converts that personal leadership energy into a framework for action.  For those in the profession, this person leads, guides, managers, coaches, and directs into new patterns of behavior and performance that better reflect the demands of value and the changing needs of “users”, our patients and communities (Bettis, 2005).  Therefore, the following elements are the necessary foundations for leaders who exemplify their identification within the profession of nursing:


  1. Professional practice leaders and educators must agree and commit to a clearly articulated set of professional parameters and associated behaviors which clearly enumerate the conditions and expectations for membership in the community of nursing professionals.  This set of expectations forms the foundation for education, development, performance, and evaluation of the professional character and role of professional nurses.
  2. Leaders must exemplify and demonstrate within the context of their own patterns of behavior, their commitment to a consistency with and a delineation of professional nursing expectations and the translation of those expectations into the framework which facilitates compatible behaviors in all categories of nursing practice.
  3. Advocacy for the profession is advocacy for the patient.  Academic and service educators and leaders need to communicate to groups and individuals within the profession the message that failing to attend to the interests and needs of the profession ultimately compromise patient care and fail to establish a generally accepted set of standards upon which measures of excellence in patient care can be based.  The long history of individual nurses assuring each other and the patient that they are offering excellent care with no reference to commonly accepted standards of performance or measures of outcome must now end.
  4. Evidence-based principles and practices must now form the foundation upon which the future of sound nursing practice and value is based.  In all nursing learning and service settings, the foundations in curriculum design, practice and performance expectations must be grounded in an evidentiary discipline that suggests a rigor which validates the effectiveness and efficacy of clinical practice.
  5. No discipline can sustain its place in the world without strong professional leadership and advocacy on the broader social and political stage.  A strong commitment and carefully constructed development and mentorship process for emerging leaders must be incorporated into both the structural and relational framework for development in nursing leadership.  Mentorship and coaching that issue from good leadership must be identified as a fundamental characteristic of leadership practice and incorporated into the development and expectations related to the application and exercise of the leader’s role.
  6. Good stewardship of the profession now demands that academic and service leaders ground the work of the profession on clear indicators of value and impact.  Process excellence, patient safety, risk reduction, are essentially more means than ends.  Nursing value suggests that the profession as a whole and professionals individually can articulate, specific to the work of nurses, the value of that work to patients and the system, the impact of nurse’s work on patient outcomes, and, ultimately, the difference nurses work makes in assuring or advancing the health of the community.  This measure of the difference nurses make must, in the age of evidence, be specific, precise, and meaningful.
  7. The history of the profession of nursing indicates its ascendant role in coordinating, integrating, and facilitating the patient’s health journey in all kinds of circumstances.  This central role of the profession is grounded in the value of continuity and integration and demands that nurses assume the chief obligation for addressing the issue of continuity and integration of health services at every place in healthcare delivery.  In the contemporary age, this means that nurses have the primary obligation to coordinate activities, systems, structures, and processes which address, advance, and improve the continuity of services across the patient’s health journey.
  8. The professional nurse generally operates at the center or in the middle of a broad array of multidisciplinary professionals.  The fundamental obligation of the nurse both by law and professional disposition is to ultimately ensure the safety of the patient’s healthcare experience and to advance the continuity of all the efforts directed to addressing the patient’s healthcare needs.  This primary obligation lies at the core of all professional nursing practice regardless of role.  Reflected in this obligation and implied by the nurse’s location, facilitating the integrative clinical efforts of the broad array of disciplines with specific roles and functions with regard to individual patients serves as a natural alignment within the role of the nurse.  Nursing leaders must fully understand the inherent integrative capacity in the role of nurse and the primary obligation of each professional nurse to lead initiatives, problem solving, and collective activity in the exercise of the coordinating, facilitating, and integrative role of Nursing in its relationship and interaction with other disciplines.
  9. The theoretical foundations of nursing practice are grounded in caring.  Whatever context, concepts, and applications of nursing practice unfold in a 21st-century framework, principles and the foundation of caring remain constant.  The application of theoretical constructs of caring in unfolding evidence-driven practice provide a firm underpinning for the translation of caring concepts and principles, practices, and patient outcomes.  Nursing leadership grounds its role firmly upon concepts of caring, evidencing the implications of the caring frame in all measures of value and outcome in patient care.
  10. The structural configuration and organizational infrastructure within which the profession operates and does its professional work is equal in importance to the work itself.  Creating an organization whose structural and operational configurations demonstrate professional characteristics in the way of undertaking the business of the profession and the application of its work is critical to its viability and sustainability.  Professional structures for shared decision-making and subsequent action reflect elements of internally congruent partnership, equity, accountability, and ownership.  Each member of the professional community exemplifies individual and collective accountability for contribution to the work of the profession, advancing its interests and translating its values into the work of patient care.


The profession of nursing has demonstrated an evolving and continuous commitment to advancing the health of individuals and communities (Diers, 2004).  The character and content of this historic commitment is radically changing in the 21st century digital and virtual world.  While the context and content for nursing care and professional services continues its rapid transformation, the foundations of human caring and professional integrity deeply embedded in the profession of nursing remains unchallenged (Baer, 2001).  However, if professional sustainability is to be advanced in the new millennium, reflecting radically shifting technological, global, political, and economic realities, the profession of nursing will just as radically need to alter its practices.  In this case, time is of the essence and a considerable level of urgency must drive the action of professional leadership.


The Person of the Nurse


The disposition and vision of the profession of nursing is seen through the lens of all those who observe or are influenced by the character and behavior of individual practitioners.  The full embodiment of the profession and all it implies is visibly and actually represented by the person in the action of each practicing nurse (Ambrose, 2005).  Who that person is and how she or he best exemplify in their own person and role the character and content of the profession is the only realistic window the observer has into the character and value of the profession.  All of the descriptors, principles, standards, codes, and behavioral protocols will serve as naught if the individual nurse does not represent them in her or his consciousness, attitude, behavior, and action.  To do so or to fail to do so reflects a lasting image, difficult, if not impossible, to extinguish, seared into the consciousness of other colleagues, disciplines, and patients with regard to what Nursing is or is not (Johns, 2004).


The profession simply cannot take the risk that emerges when individual nurses are not fully prepared to understand and exemplify in their own practice the character, obligations, and appropriate expressions of the nursing professional.  The profession has a right to expect that those identifying themselves as members of the profession understand what that means, embody that ownership in their own patterns of behavior and represent a strongly identified internal locus of control with regard to their representation of the profession to themselves and others (Arnold, 2002).  Leadership in the development of the individual nurse consistent with professional expectations includes the understanding of the power and influence embedded in language, disposition, communication, and action (Bennis, Spreitzer, & Cummings, 2001; T. Porter-O’Grady, 2003; Trompenaars & Hampden-Turner, 2002).  For example, language that moves from use of the word “job” toward the more professional word “practice” creates an entirely different vision and perspective of the work and actions of the nurse.  Job oriented language has the potential for removing the professional overlay to the work of the nurse and reducing it to a set of functions, processes, and procedures.  Contemporary nursing history is rife with the impact of this language on the nurse’s self perception of her or his work and its importance in the scheme of things when job orientation and considerations predominate over professional practice delineations.


Imagine for a moment a different mental model that is created when a new nurse goes to the work environment and applies for “privileges to practice nursing” instead of simply looking for a “job”.  Here the language shift implies a significantly different approach to identifying professional nurse expectations.  When applying for privileges, assumptions about the requisites of a “membership community” and the professional community’s obligation to provide a privileging mechanism are vital, where the individual can demonstrate and represent her or his individual compatibility with a set of professional expectations and accountabilities clearly enumerated in the requisites of privileging rather than simply delineating job characteristics.  In building the next stages of the nursing profession’s maturity, considerations of language, structure, performance, and the individual’s demonstrated capacity to exemplify the expectations of the profession will become increasingly essential (Joel & Kelly, 2002).


Nursing professionals will not be perceived equitably with other disciplines unless two conditions are met.  First, the academic delineations for professional practice must operate at a level of comparability with those same definitions accepted almost universally by other professional disciplines.  Secondly, professional and personal expectations of equity must be incorporated into the behavioral patterns and relational processes of practicing nurses (Higgs, Richardson, & Dahlgren, 2004; Schermer, 2002; Trossman, 2002).  Here clinical and management leadership plays a critical role in providing both the expectation and patterns of behavior that exemplify equity-based activities and expressions.  Here again, equity becomes evident to others through the language, interactions, expectations, and behaviors of the individual nurse and the perceptions of ownership, investment, and engagement through which those patterns are expressed (Stack & Burlington, 2002).  In short, if one seeks to be treated equitably one must live within the context of the expectation of equity.  This is a learned process and the skills attendant to the expression of equitable behavior have been well enumerated.  Leadership development should always include these elements as a part of more clearly elucidating the role of the professional and behavioral attributes which demonstrate value and equity (Goleman, Boyatzis, & McKee, 2002; Gunden & Crissman, 1992; Kotter & Cohen, 2002).


Advocacy for patients and for the profession requires a broader notion of the principle of advocacy and of its applications (Taylor, Lillis, & LeMone, 2001).  Nurses cannot adequately advocate for patients and healthcare if it is perceived that they have no right to do so.  Historic notions of physician ownership of patients are simply no longer relevant in any “user driven” social context (Rosenstein, 2002).  In contemporary thinking, patients have primary obligation for decisions and actions which affect what happens to them (Osborne, 2002).  In a multifocal, widely distributive, interdisciplinary healthcare delivery network, the patient will have many “captains” that partner with the patient at various points along the patient care continuum (Mycek, 2007).  The role of the nurse is to foster appropriate interactions, decisions, and relationships in a way that advances the interests of the patient and connects the various clinical stakeholders in a communion of efforts that, when well coordinated, serves to best advance the interests of the patient and effect positive outcomes (Orem, Renpenning, & Taylor, 2003).  It is no longer optional for nurses not to see themselves as a key coordinator of this effort, and the driving force for assuring the broadest range of access and partnership in a way that advances patient service.


Increasingly, the human dynamic partnership and interaction is accelerated by newer realities of patient data management and integration (Maysys, 2002).  The growing requisite for confidence in both “access” and “utility” skills with regard to the management of clinical information requires higher levels of information management competence from nurses.  The expanding efficacy of digital and virtual technologies now makes it a requisite for nurses to understand and utilize new tools for practice in ways that fundamentally alter the mechanisms with which nurses and others communicate, interact, and apply practice skills (Ball, 2000).  Virtuality now changes the definition of “presence” and today allows a broader array of relational options to be incorporated into practice applications that fundamentally alter the patient-provider relationship, the nurse’s role, and the application of clinical services (Power, 2005).  The following issues of individual nursing capacity and competence are now the requisites for every individual professional nurse in the exercise of her or his role:


  1. An ability to demonstrate an internal locus of control with regard to professional identity with emphasis on exemplifying as strong a commitment to the profession of nursing as one has to the practice of patient care.  This commitment to the profession is demonstrated through the individual nurse’s engagement and participation in activities and processes which address the governance and decisional needs of the profession in the workplace with the same equity as that devoted to the activities of patient care.
  2. Often implied but frequently unspoken in the front lines of professional practice is the prevailing historic reality of the growth of the profession within the context of the women’s movement in the United States.  The issues of historic gender inequity have been well postulated and clearly enumerated.  The nursing profession’s own history is rife with examples to this day of socially entrenched and systemic gender-based inequities, some of them conscious, some of them systemic.  The human obligation for changing the realities of inequity or oppression has always been the obligation of the oppressed if lasting change is to occur.  The well-established adage that one is treated precisely as one expects to be treated certainly is the operating rubric here.  Expectation of equity, role balance, and inclusion precede these factors operating in reality.  Therefore it is the obligation of clinical and management leadership to exemplify, model, and demonstrate the practices and behaviors, which illustrate living equity.  It will be only in clarifying and expecting equity and actively living the expectation in practice that past practices of discrimination, exclusion, and inequity will be overcome.
  3. Conflict is a normative circumstance of human existence.  At all levels of complexity in the universe, conflicting and opposing forces are constantly operating in a mosaic of movement that positively balances the dynamics of existence.  These realities affect human interaction and relationships as strongly as any other forces in the universe.  Conflict is always present, never disappears, and is a constituent in the vibrancy of all human relationships.  Clinical and management leaders in the profession must work diligently to overcome the systemic fear and ignorance of normative conflict and translate it into a catalyst for dynamic change that conflict truly represents.  Through skill and technique, conflict can be harnessed and act as a transformative agent between and among stakeholders in a way that can drive meaningful change.  The role of the nurse places her or him at the center of the conflict exchange, most able to harness and actualize the transformative power embedded at the heart of conflict.  Avoidance, fear, and trepidation for both the potential and presence of conflict create the very conditions that accelerate it and transform it into a dark and diminishing force.  Nursing leader’s capacity to develop good conflict skills, model them in practice, develop them in others, and apply them consistently can do much to create the vigorous balance that underpins all sustainable change.
  4. Nurses must exemplify a willingness and facility to develop the technical competence necessary to manage the communication and information systems with a high level of “access” and “utility” skills, incorporating them into the ordinary and usual practice activities of nursing.  Since digital and virtual technology will simply continue to expand, the expectation of every practicing nurse is full engagement and participation in the application of these technologies to the shifting requisites of nursing practice and patient care.
  5. The requisites of obtaining value in healthcare now demand nurses focus beyond process responsibility toward outcome accountability.  The practicing nurse must realize that the value in her or his practice more strongly relates to what one achieves with that practice rather than what one does in the work.  Nursing work is not inherently valuable because one is doing it.  The value of nursing’s work is located in its products; achieving clinical outcomes, improving the health of individuals, meeting individual health/life goals, and advancing the health of the larger community.  These form the sources of value and provide the framework for the expressed accountability of the profession and the work of each nurse.
  6. Educational preparation and competence is not the exclusive domain of the academic arena of nursing.  Continuing development and growing competence is even more the life blood of the profession in the 21st century.  The drama of shifting realities of practice and the emergence of new foundations for the exercise of clinical roles is creating a constant shift in the nurses work realities.  The ability of each nurse to respond to these shifts with flexibility, fluidity, portability, and mobility is no longer optional.  Educational preparation can no longer be looked at as foundational; instead, it must be seen by each nurse (as well as the profession) as a continuum, essential to maintaining an ongoing level of practice competence.  Entry into practice is no longer the issue, the continuum of learning is.  Regardless of the point of entry into the profession, every practicing nurse now must commit to a dynamic continuum of systematic education and learning as a fundamental set of her or his own practice activities.  The profession too, must reconfigure nursing education to increase the academic/service partnerships and make it easier and more fluid for nurses to incorporate ongoing practice with advancing education within the clinical setting in the normal course of doing the work of practice.
  7. There is a growing diversity in the membership of the profession of nursing.  Demographic realities representing the impact of ethnicity, age, preparation, and roles are together creating a broad mosaic of professional membership.  Accommodating these shifting demographic realities calls for a level of cultural sensitivity and leadership response to demonstrate effectiveness through programs of cultural awareness, leadership mechanisms which accommodate generational and ethnic variances, and a creation of an organizational framework that is inclusive, participative, and seamlessly addresses the normative conflicts embedded in the very nature of human diversity.
  8. Administrative, management, and clinical leadership must create a context that makes it possible for the practicing nurse to fully participate in those decisions which affect nursing practice, quality, and competence.  Professional shared governance models have been well described and their value well established.  It should no longer be optional that the profession of nursing be governed, led, and integrated through the auspice of a professional governance model unique to the discipline of nursing yet consonant with the equity-based and inclusive governance practices of other major professions.  Participation in the life of a profession by its professional members should not be an invitation; instead, it is an expectation of membership and mechanisms for assuring that expectation is fulfilled through the actions of every member is a precise requisite of each member.


Professional nurses at all levels of practice must now see themselves as equal partners with other disciplines in creating a new template and landscape for the future of health care in the United States.  The paradigm shift into an entirely new human actuality, driven by emerging and unfolding technical and economic realities on a global scale, creates a level playing field where there is no rational justification for inequitable change strategies and non-inclusion (Peterson & Mannix, 2003).  However, nurses must accept the elemental political reality that others do not make space at the broader table within the context of an invitational scenario.  Each professional nurse must carry the expectation for equity and inclusion and, if necessary, “set the table” with the expectation that nurses will coordinate, integrate, and facilitate the dialogue and activities necessary to create a thriving and effective response to the transformative demands of new realities in unfolding health care in the United States.


It is generally understood and indicated by contemporary measures of excellence, that nurses create the predominant culture in the organizations of which they are a part (Linda Aiken, Clark, Silber, & Sloane, 2003; ANCC, 2005b; Marlene Kramer, 1990; McClure & Hinshaw, 2002).  Because of their predominance and centrality of role, nurses, often unknowingly, exert a powerful influence over what initiatives in their health systems will succeed or fail.  Regardless of the prevailing awareness of this reality, direct or subtle influence by nurses is one of the significant critical factors which determine the success or failure of an undertaking regardless of where and by whom it was generated (Califano, 1993; Group & Roberts, 2001).  This referred influence exerts a powerful cultural force in the organization and calls for nurse leaders to understand its value and to manage it with care (Havens, 2001; Urden & Monarch, 2002).  Clinical and management leaders must come to more fully understand this dynamic, validate and enumerate its significance with greater clarity, and positively harness it in partnership with others in the organization in ways which best advance the interests of patient care and the integrity and viability of the organization (AONE, 2005; M. Kramer & Schmalenburg, 2003).


Nursing work is not easy.  The particular and unique demands of nursing practice require individuals who are knowledgeable, competent, and committed.  Professional nursing requires an aptitude for managing complex and competing circumstances, continuous learning, adaptability, critical change, differing interdisciplinary demands, radical technological shifts, and the inadequacies of resource allocation and time constraints (Apker, Ford, & Fox, 2003; Bower, 2000; Cherry & Jacob, 2005; Diers, 2004).  The one constant in the history of the nursing profession has been the consistent presence of these challenging and often conflicting forces.  They have not diminished and will remain constituents of nursing practice for the foreseeable future.  Individuals not prepared to confront and embrace these realities need not seek entry here.  Those who do become members of the nursing profession will find that their being available to these prevailing conditions and circumstances will yield to them levels of challenge, satisfaction, accomplishment, meaning, and value not as readily available to other pursuits (Katz, 2003).


The Patient and Community


There is perhaps no greater arena of change and transformation for the nursing profession than that related to direct patient care.  The shift in therapeutics and technology has created a contextual framework for practice that is so unique and different that it represents a radical alteration from the historic and traditional practices associated with nursing.  Innovations (some of them destructive technologies) in chemo-therapeutics, pharma-therapeutics, digital diagnostics and intervention, nanotechnology, and virtual reality have completely altered the clinical landscape and the patient’s experience (Schermer, 2002; Shi & Singh, 2004).  This shift has done more than simply change the conditions of healthcare work and the processes and activities associated with it.  What has occurred as a result of these changes is a complete paradigm shift for both provider and patient.  In fact, the shift has been so transformative that practices, roles, and behaviors have been dramatically altered.  Indeed, even the locus of control for decision-making has inexorably shifted from provider to “user” (Frampton, Gilpin, & Charmel, 2003).  The notion of “user” replacing the concept of “patient” indicates a significant shift in ownership, obligation, and locus of control for decision-making and for direction in the individual’s healthcare experience.


Notions related to consumer-driven healthcare, electronic medical record, pay for performance, universal access, patient safety, evidence-based clinical outcomes and a host of other contemporary initiatives are redefining the relationship between system, provider, and user (Siegler, Mirafzali, & Foust, 2003; Thielst, 2007).  Systematically affecting the nature of this interaction is the clinical and therapeutic shift from residency-based, long term, institutional, and patient-passive care (Maysys, 2002; McKenna, 2002; Stock, 2002).  Today the majority of therapeutic services are short-term, minimally invasive, early recovery, and mobility-facilitating experiences.  Users now spend less time inside the institution or the system with regard to their healing and therapeutic processes and more time recovering and healing in the context of their own lives and personal circumstances (Schappert & National Center for Health Statistics (U.S.), 2002).  Increasingly, the issue for the user is not so much the interruptive conditions and circumstances of the institution and health service setting, but more, what resources patients have to facilitate the healing experience in their own circumstances (Schermer, 2002).


It is the end of space and time as a major resource consideration for service provision (Alakeson, 2003; Carlson, 1994; Hildreth & Kimble, 2004; Lucas, 1995; Willmore, 2003).  Nurses simply do not have the same time content and conditions in the digital, virtual, portable, and mobility-based clinical environment.  Currently and for the foreseeable future, users will spend a shorter period of time in the intervention process where the majority of nurses have historically been located.  As the healthcare system continues to decentralize around more short-term, technology-driven, and minimally-invasive clinical services, more user access to information and support outside the clinical environment, at home, and in other settings will be required (Ball, 2000; Johnson, Kralwwski, Lemak, Cote, & Deane, 2002; Lumpkin & Richards, 2002).  Professional nurses will need to demonstrate their accommodation of this portability reality through reconfiguring practice activities, relocating to other points along the healthcare continuum, and to the use of increasingly technology-based and virtual strategies for the provision of nursing services (Cassey, 2007; McSherry, Simmons, & Abbott, 2002).


The principles of caring which underpin the very character of the profession clearly need to be reaffirmed and reconfigured in a way that represents inclusion of newer knowledge and technology in the expression of that care (Cassey, 2007).  Reconnecting with the fundamental obligation of the nurse to ensure the safety of the user will need to be reaffirmed in a much more fluid context.  Evidence of efficiency, effectiveness, and efficacy (E3 ) must be present within the practice of each nurse and, furthermore, must give evidence of positive impact, outcome, and value to both user and system (Plost & Nelson, 2007).  In addition, continuity of care can no longer be attained or maintained simply through the action of the nurse and the communication across disciplines.  Continuity is now embedded in the human-technology infrastructure and the interface between practitioner, user, and technology and is essential to build and sustain an effective continuum of care (Gandhi, 2005).  The professional nurse’s commitment to the integration of human dynamics, technology, evidence, and user outcome now forms the core of the clinical priorities of nursing practice (McNamara, 2002; P. Smith, 2004).


It is the end of the medical model as it has been historically configured.  The multifocal nature of healthcare delivery and the complex intersection of roles, relationships, and practices have now overwhelmed the notion of a unilateral locus of control and compartmental decision-making (Thomson, 2007).  It is no secret that the physician is not prepared by role or by disposition to the presence, time, and intensity of activities necessary to the investment required to coordinate, integrate, and facilitate the continuum of interdisciplinary activities necessary to effective patient care (Moanojovich, 2005).  The role of the physician is primarily as interventionist, as clearly delineated both by preparation and performance.  Certainly, new definitions and scripts for the role of the physician must also unfold in this new age for healthcare.  More delineations of the role need yet to be defined in relationship to equilateral clinical partnerships, inclusionary decision-making, and the leadership role of other clinicians in guiding the therapeutic team and clinical activities at different points across the continuum of service (A. Smith, 2004).  All of this will directly impact the role of nursing professionals.


Nurses will continue to be the central focal point in the integration, coordination, and facilitation of clinical relationships and processes across the continuum of care (Barnum, 1994; Tim Porter-O’Grady, 2003).  In accessing these resources, coordinating their activities, facilitating the team’s dynamics, and evaluating the effectiveness and impact of the interaction, nurses will play an accelerating pivotal role.  This will require from the nurse a degree of facility in articulating multiple roles, bridging the activities of other professionals, managing the integration of communication and documentation technology, and ultimately, evaluating impact and effectiveness.  Failure to adequately address this critical emphasis on the evolving role of the nurse will ultimately diminish the value of that role and increase the requisite of the assumption of that role by another (or new) player in the healthcare system.  Indeed, this role is becoming so important to the effectiveness of the system that many of the contemporary failures in the clinical continuum of services can be related to the paucity of coordination, integration, and facilitation of the process (Mittelstaedt, 2005).


Emphasis on the evolution and transformation of nursing practice and practitioner will need to include focus on the following priorities:


1.      Clinical leadership development which leads to leadership roles exemplifying the capacity to incorporate the above circumstances and skills into nursing practice roles and to reflect their exercise in the normative course of rendering care.  Clinical leaders, advanced practice nurses and others which represent the evolution to advanced or expert practice must not only be able to articulate these shifting role characteristics but to exemplify them within the character and content of their own practice.  Leadership in this age increasingly will mean modeling, demonstration, and actualizing the principles, character, and content of these shifting professional practice roles.

2.      Evidence-driven practice approaches represent an entirely different foundation for provider practices and healthcare delivery.  Evidence is not the domain of any single discipline and cannot be successfully undertaken within their unilateral contextual framework.  Evidence-based practice is fundamentally interdisciplinary, requiring the interface of all relevant clinical providers and activities.  It is the congruence and consonance as well as the fusion among the activities of these various stakeholders that, when synthesized, presents evidence of excellence and best practices.  It is in the nurse’s role where these activities converge, and is therefore appropriate to manage and coordinate the processes associated with a sound evidence-based approach in any clinical setting.

3.      Professional nursing practice operates on a continuum of knowledge and practice.  Delineating differentiation in practice and clinical expectations continues to be an important mechanism for distinguishing performance, clarifying expectations, and measuring clinical outcomes.  Clinical advancement programs which differentiate and articulate various categories of practice expectation moving from novice and advancing along stages of enumerated expertise remains the best mechanism for ensuring accountability and establishing the relationship between competence and performance.  While competence, action, and performance expectations are being transformed in this new age for practice, the requisites for delineating outcomes aligned with competence and the maturity of knowledge remains essential to good practice.

4.      Within the context of an advancing socio-technical reality, users are now able to more fully participate in accessing, interpreting, using, and evaluating clinical options in relationship to their health and life choices.  This primary source of access changes the equation of knowledge management and the locus of control between provider and user.  No longer is the user held hostage to the knowledge capacity of the provider without access to resources not controlled by providers.  In addition, provider performance measures, grades, evaluations and interpretations are becoming increasingly refined and useful tools for users to make decisions with regard to provider choices.  For the nurse, this calls for a growing awareness of the nurse’s role in mediating between the various access points, informational constituencies, providers, in a way that affects the accuracy and adequacy of the resources and tools available to the user.  Increasing capability with regard to this role is critical to the nurse’s effective exercise of it and demands from the nurse a level of engagement and capacity to guide user’s access, utility, interpretation, and evaluation of important clinical data in a way that is both meaningful and liable to the user.

9.      In the United States, changing data and demographic realities related to citizens health strongly indicate that for all our interventional science, technology, talent, and applications, the health of the nation is not comparable with other first world nations in almost all the measures of the status of societal health save one, the cost of health care.  When compared with other first world nations, American health indicators generally place the nation in the bottom categories of measure.  One of the ethical characteristics of professions is that they operate in a way that acts in the best interests of a larger community.  If the health of America is to be advanced and the quality of life improved, the commitment of every nursing professional must be broader than the personal quality of good patient care and clinical excellence.  The outcome of the work of the profession should ultimately be an improvement in the health of the larger community.  Nursing certainly plays a major role in addressing national, regional, and local health needs.  Just as clearly in the language and armamentarium of every individual nurse is a requirement that she or he be able to identify work and role with the advancement of health and the improvement of the quality of life in the greater community.  Individual and local practices must be clearly linked with the broader script for healthcare and a direct relationship established between the practices of the individual and the health status of the community.  It is only when this connection is well established will the true value of nursing advocacy be evidenced, not as an exception to the normative work of daily practice, but as evidence of the impact of the work of each practicing nurse on the health status and quality of life of the community and, ultimately, of the nation.


Nurses continually articulate the commitment of the profession and its practitioners to the needs and interests of the patients in the communities nurses serve.  If this is not to remain simply a vacuous statement, empty of evidence, it must be translated into a living presence and verified by a clearly articulated and discernible impact on person and community (McNamara, 2002).  As a nation and a profession we are awash in data which suggests where we are in relationship to the actualization of quality of care in the health status of the American people (Mazurek, Melnyk, & Fineout-Overholt, 2004).  By all measures of comparison on the global stage, with nations comparable to the American standard of living, we simply do not meet the outcomes of the promises we make.  From measures of access, quality, safety, clinical outcome, satisfaction, and cost-benefit, the United States simply does not favorably compare with our international partners (Commonwealth Fund, 2007). 


The truth of this data calls the profession of nursing to reassess its role and function in relationship to users of the healthcare system and nursing services and to reconfigure the professional script in a way that joins with others in, at a minimum, achieving parity with our international partners and, if possible, establishing a new standard of excellence and quality of life (Fottler, Ford, & Heaton, 2002).  If nursing is to fulfill its professional mandate to act in the best interests of the society it serves, the formation of this new script and the performance against its requisites is not an option (Parker, 2005).  It is a new age for health care and for the nursing profession.  It is early in its formation.  The opportunity to write the new script and the transformative impact of living it presents an exceptional potential and opportunity for improving health and advancing the quality of human life.  Will we do this work?  Urgency is critical; time is of the essence.





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*Based on discussions of: Global Nursing Exchange Leadership Discussion Group


Rhonda Anderson, PhD

Carol Bradley, MSN

Barbara Brewer, PhD

Vicki Buchda, MS

Jayne Felgen, MSN

Elaine Goehner, PhD

Ann Kobs, MS

Terry Pickering, BS

Tim Porter-O’Grady, DM, EdD

Marilyn Rantz, PhD

Catherin Robinson-Walker, MBA

Pamela Thompson, MSN

Beth Ulrich, EdD


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