Authority can also be personal and as such is defined as power or influence that results from knowledge or expertise.. Authority was, and is, necessary to nursing as it gives status and po
Trang 1Administrative authority is the power or right to give orders or commands, to enforce compliance, to
take action, and to make final decisions For
exam-ple, the dean of a nursing school has authoritative
power from her position As dean, she has the
power to make decisions that have both short- and
long-term consequences and that directly affect
education and student life Similarly, the primary
nurse has more authority in regard to her primary
patients than do other nurses or nursing assistants
Authority can also be personal and as such is defined as power or influence that results from
knowledge or expertise Professional authority is
granted by choice, not position, and applies to
com-petent professionals, whereas administrative
au-thority depends upon job descriptions and place in
the organization
Authority has been a problem for nursing since
at least the Victorian Era, when nurses were first
seen in the aggregate For most of nursing’s modern
history, nurses were kept under the authority of
physicians Reverby (1987a, b) states that nurses
had to limit revelation of the scope of their
knowl-edge and the effectiveness of their care They had
the responsibility for patient care without needed
authority Reverby asserts that nurses are ordered
to care by a society that does not value care Nurses
gained authority through knowledge, feminist
influ-ences on society, and slow increases in the scope of
practice Nurse leaders worked hard to gain the
power of authority Judicious, skilled use of power
and politics in an environment set for change
helped them to change policy with legislation and
regulations to achieve their goals Nursing leaders
fought hard for standardization of nursing
educa-tion, development of knowledge, and
professional-ization
Feminism from the late 19th century to the pres-ent helped achieve increasing professionalization
and improved status As education and
profession-alization grew, so did nursing’s scope of practice
In 1972, New York State passed the first nurse
practice act For the first time, the essential role
of nursing in dealing with human response to
ill-ness or treatment was stated, debated, and
legis-lated (Diers & Molde, 1983) The nurse practice
act conferred authority on nurses and nursing
Authority was, and is, necessary to nursing as it
gives status and power within institutions and
com-munities to mobilize resources to achieve
health-care goals
Expert
Expert power is influence that results from knowl-edge or expertise that is needed by others It is similar to personal authority, but it is gained and affirmed through respect for expertise Expertise can be an indispensable source of power within health-care organizations Such power is granted by choice to a person, not to a position, and applies to competent professionals
Nurses work in dynamic environments where change is rapid and where power and influence often take new forms Expertise brings knowledge and skills to the assessment of problems and issues, which brings about solutions and change Those who are lifelong learners have an important effect
on deliberations and decision making because they understand those changes and can participate fully and find and implement important and creative solutions to situations or problems Those who do not keep their knowledge current fail to earn or retain expert power Continued acquisition of new knowledge and skills is essential to maintain this form of power Expert nurses, nurse practitioners, clinical specialists, and other nurses have power based on their knowledge and expertise Benner (1984) asserts that nurses can use this power source as they become expert practitioners This is
a source of power that nurses can and must use, because they have expertise that policy makers gen-erally lack Such professionals have power to exert successful change Expert power follows the person
as long as the person maintains his skills
Reward
Reward power is the ability to offer rewards, which
is a potent type of power It is the promise or per-ception of money, goods, services, recognition, and other recompense in exchange for some action that benefits the powerful person Behavior is affected in that a person will often honor wishes or demands for the potential (or actual) rewards from the pow-erful person Managers, supervisors, and adminis-trators have access and ability to use this power through their authority to reward people with bonuses, salary increases, promotions, and recogni-tion Appropriate use of reward power is the promo-tion of a nurse who has earned and is qualified for a new position Inappropriate use of rewards is the assignment of a rotating nurse (bypassing others) to the day shift in return for favors or friendship
Trang 2Power to punish is included in the concept of
reward Those who have the capacity to reward also
have the ability to punish In organizations the
per-son with reward power can usually also discipline
and fire employees
Lobbyists often use reward power They educate
legislators and other government officials Lobbyists
bring a high degree of access to and accountability
from elected officials They form coalitions to
influ-ence needed legislation and policy change and
devel-opment The American Nurses Association (ANA)
lobbies for legislation that is important to patient
care and nursing Lobbyists or advocates can have
relationships with legislators where one rewards the
other For example, lobbyists promise monetary
sup-port for reelection campaigns in exchange for
favor-able votes on beneficial legislation Legislators who
are found to participate in this kind of power
bro-kering are prosecuted
Coercion
Coercion is the real or perceived threat of pain or
harm of one person by another Coercive power
may be physical, psychological, social, or economic
and involves the use of force in the form of
penal-ties and rewards to effect change It shows a lack of
respect for the autonomy of others and is seen in
sexual harassment and threats to livelihood Those
who use coercion are interested in their own goals
and are rarely interested in the wants and needs of
subordinates An example is the threat by a
super-visor to fire whistle-blowers (people who speak out
about a wrong) The threat of a state health
com-missioner to implement onerous regulations for
nurse practitioners or visiting nurses if some action
is not done is coercion A volunteer religious group
that demands religious conversion by threatening to
withhold or withdraw education, expertise,
materi-als, or care coerces the people it is there to help
Referent
A leader who is followed based on admiration and
belief has referent power The chair of a committee,
for example, has referent power for those who work
closely with her Referent power is gained through
association with a powerful person or organization
Selection of a powerful person as a mentor and
working on powerful committees are ways to
develop and hold referent power
THE NEED FOR POWER
Nurses are predominantly women and provide the most direct patient care in male-dominated organi-zations Nurses have rarely had significant power in health-care organizations Over the past 15 years, nurse administrators have made progress in gaining recognition at the top levels; some have even made inroads to governance These leaders are all too often terminated, however, which is an all too graphic indication that role acceptance has not been accomplished (Camuñas, 1994a, b, 1998; Carroll, DiVincenti, & Show, 1995; Donnelly, 2006; Kopala, 2001; Sabiston & Laschinger, 1995; Vestal, 1990; Vestal, 1995)
Power commensurate with knowledge and ex-pertise is needed to enable nurses to provide com-petent, humanistic, and affordable care to people; to participate in health-care policy development; to gain leverage proportionate with their numbers; and to ensure that nursing is an attractive career choice for all who want to provide care, influence, and improve nursing, health care, and health policy
WAYS TO ACHIEVE POWER
There are multiple ways to accumulate, or gain, power Some may be more appropriate at higher positions in an organization Skills to achieve and maintain power take time and patience to learn, develop, and refine Methods to acquire power include the following:
■ Broad human networks: the more networks and the more extensive they are, the more power potential
■ Broad information networks: the more diverse types of information controlled, the more power
■ Multiple formal and informal leadership roles: high engagement and visibility bring increased power
■ Ability to assess situations accurately (espe-cially unstructured ones) and to solve prob-lems
■ Authority over others and resources via legiti-mate work organizational roles
■ Vision for the future and creativity
■ Ability to grant services to others, which builds debts
■ Expertise that is sought by others
Trang 3Ways to Increase Expert Power
There are many ways to enhance your power, for
example Professionals, to maintain their
compe-tence and develop their careers, use these tactics:
■ Participate in interdisciplinary conferences to broaden knowledge, develop skills, and build networks
■ Keep knowledge and skills current to maintain and extend power Continuing education offer-ings, books, and journals are effective means
■ Earn higher degrees; education brings expert-ise and enhances credibility
■ Participate actively in professional associations such as the ANA, state nurses associations, and specialty groups to broaden networks, hone expertise, and develop legitimate and ref-erent power
■ Participate in nursing research to develop knowledge and increase expertise
■ Problem-solve with colleagues in nursing and other disciplines to develop expertise and net-works and to polish skills
■ Participate in nursing and interdisciplinary committees to develop and enhance expert, referent, and legitimate power
■ Publish to develop expert power
■ Learn from mentors; be a mentor (Flynn, 1997; Vance & Olson, 1998) to develop exper-tise and connections or referent power
EMPOWERMENT
Empowerment is a sense of having both the ability
and the opportunity to act effectively
Empower-ment is a process or strategy the goal of which is to
change the nature and distribution of power in a
specific context It is a group activity that increases
political and social consciousness, is based on the
need for autonomy, and is accomplished with
con-tinuing cycles of assessment and action Nursing
organizations seek to empower nurses; nurses
endeavor to empower patients to seek and adopt
healthy lifestyles Likewise, nursing managers and
administrators take actions to empower nurses to
achieve effective, rewarding, competent practice
Empowered nurses have three required charac-teristics that enable them to participate in policy
development The first is a raised consciousness of
the social, political, and economic realities of their
situation or environment and society They are
aware of culture and diversity and of gender, race,
and class biases, prejudices, discrimination, and stereotyping that produce the need for policy devel-opment or change Such nurses can evaluate and understand the dynamics of a situation or issue in which they find themselves and can more readily find or help to find remedies
The second quality empowered nurses have is a positive sense of self and self-efficacy regarding their ability to effect, or facilitate, change They value themselves and have voice to articulate and effect change Within an institution, for example, they can identify situations that constrict professional prac-tice, lower quality of care, waste resources, and cause myriad other problems They can also con-tribute to the resolution of problems that affect health at the community, state, and national levels Development of skills that allow active partici-pation in change processes is the third important characteristic Empowered nurses know how to use traditional methods of power and politics in policy making Concrete knowledge and information are necessary, as is understanding interperso-nal communication skills, politics, and power and how to use them (Kuokkanen & Katajisto, 2003; Manojlovich & Laschinger, 2002)
Abuse of Power
Abuse of power is the control of people by some kind
of force It is the use of power for one’s own benefit (individual or group) and can be present in families, organizations, and all levels of domestic and interna-tional government It is always unethical Poor, devel-oping nations around the world are obvious examples Dictators abuse their people often to the point of genocide Industrialized nations engage in unfair trade and often exploit workers.
Abuse of women, children, the elderly, the sick, and innumerable others who cannot assert themselves is not uncommon To combat these types of abuse of power, we use political negotiations to develop policies
to assuage or eliminate the problem We have child protection laws, laws to protect people with disabilities, and laws that prevent emergency patients from being transferred to other health-care organizations when doing
so puts the patient at risk Around the world, abuse of power causes violence, human suffering, and tragedy
on unimaginable scale (Farmer, 2005) Violence can be physical, psychological, or structural (the absence of health care, education, and just law enforcement for the poor, for example) Leaders who enforce structural and societal inequalities abuse power.
Trang 4Power and politics are often discussed together in
the nursing literature The linkage may be due to the
difficulty that arises in attempts to distinguish
them Those with power find it easy to participate
in politics, and those who participate in politics gain
power Both power and politics serve to achieve
goals, and both do so through the ability to use skills
to convince others to serve the power holder’s
pur-poses Power and politics are the means to achieve
health-care goals in a compassionate and humane
way Application of power and politics through
col-laboration, creativity, and empowerment are
effec-tive ways to influence policy
Politics
Politics is the negotiation for, or influencing of,
allo-cation of scarce resources Influence is the act or
power to produce an effect without apparent use of force or direct command Politics is a neutral term and a process Flexibility is perhaps the most impor-tant trait of a good politician
POLITICAL ACTION SPHERES
The process of influencing others, or politics, in order to achieve ends can be seen in relation to four arenas, spheres, or domains These spheres are (a) the workplace, (b) professional organizations, (c) community, and (d) local, state, and federal govern-ments Although the ranges of these domains differ, and the target publics to be influenced differ, the political tactics and strategies are similar These spheres overlap; what happens in one affects the other Ignoring one can jeopardize outcomes in the others The fact that nurses have not consistently paid attention to this has contributed to the fact that the level of influence nurses possess is not
com-Florence Nightingale had a major impact on health-care
policy in the British army, in India, as well as on the
devel-opment of nursing Indeed, her effect on nursing and
health care is still felt today; her book, Notes on Nursing, is
still in print That she was Victorian has special significance.
She gained power and affected policy in ways that were
unheard of for a woman to accomplish Her leadership skills
were formidable.
Nightingale was born into a wealthy, educated, extended family The women especially were social activists
whose thinking was ahead of their time in significant ways.
Women had no public role and received education only
insofar as it would increase marriage possibilities Florence
was a talented, gifted child who was educated by her father.
She learned Latin, Greek, mathematics, and religion; read
English classics; and learned controversial topics such as
poetry, philosophy, science, economics, and political theory.
Her Greek, which is more difficult than Latin, was at the level
where scholars consulted with her (Gill, 2005, p 128) From
her father she learned to excel and to compete with the
men who ruled the British Empire And she nursed people
in her family and on family estates and towns, which taught
her a great deal about caring for the sick.
Nightingale understood when she was in her early 20s that the women she knew had no desire or want of power;
but she did want power “In pursuit of knowledge Florence
was remorseless She was brilliant, she was focused, she was competitive, and she identified learning, correctly, as
an avenue to power” (Gill, 2005 p 129) Nightingale also understood that knowledge would not be enough
“considered how she, a woman of high social status, could use her personal friendships and family alliances to effect larger social goals such as improvement in national health care” (p 177) Her intellectual skills, family connections, and understanding of power and politics enabled her to go to Turkey to improve and reform care for the wounded of the Crimean War She was successful, had tested her abilities, and had gained powerful authority in the highest reaches
of government, including Queen Victoria and Prince Albert Upon her return to England, she was appointed to two commissions to reform public health Nightingale was the
“chief strategist, chief correspondent, chief worker; in other words, the one essential person upon whom the whole male team of experts relied.” The work Nightingale accomplished had significant effect on the army’s support services, public health in England and India, and the development of professional nursing Even without consideration that she was a Victorian woman, her work was enormous Understanding and use of power and politics in development of effective health policy, which
is rare even in the early 21st century, made her a hero for the ages.
chapter star:
Florence Nightingale (1820–1910)
Trang 5mensurate with the numbers of nurses, their
abili-ties, and their responsibilities and contributions
Workplace
Nurses work in organizations with varied
character-istics—private or public; profit, nonprofit, or
char-itable; large, small, or medium; and in large or small
cities, towns, small towns, or rural areas In the
workplace, there are many issues with which nurses
are involved Power and politics may be necessary to
resolve issues Some issues that may be found in
some, or all, workplaces include the following:
■ Mandatory overtime work requirements
■ A nursing clinical ladder program that rewards excellence with promotions and pay incentives
■ Work scheduling length of shift, evening and night rotation, vacation priority
■ A smoking ban in the entire facility; designa-tion of smoking areas
■ Visiting hours in special care units
■ Identification and security procedures
■ Authority to delay discharge from or admis-sion to special care units based on profesadmis-sional nurse assessment
■ Authority to refer patients to a home health-care agency
■ Decisions regarding substitution of unlicensed personnel for RNs to provide care
Politics are part of every organization; nurse
exec-utives have to use politics to administer their areas
of control They have to negotiate with CEOs and
other administrators (their peers) for budgets to
meet organizational goals
Professional Organizations
Professional organizations have been essential to
the “professionalization” of nursing The modern
nursing movement began in 1873 in response to the
changing role of women Pioneers of this movement
worked for a new profession for women and for
bet-ter health for the public (Reverby, 1987a) These
women used political power to open nurse training
schools, organize professional associations, and
par-ticipate in social issues such as women’s suffrage,
public health, and integration (Rogge, 1987) These
leaders sharpened their political expertise in
nurs-ing organizations they created beginnnurs-ing in 1893
Professional organizations have made significant contributions in developing nursing practice They
have set standards of practice, advocated for change
in the scope of practice and passage of nurse prac-tice acts, and advocated for nurses in collective action in the workplace Such organizations have an ever-increasing role in health policy development Fewer than 10% of nurses belong to the ANA, even though it represents the interests of all nurses
in the United States (Foley, 2001) Membership in specialty nursing organizations rarely exceeds 30%
of those eligible to join (Foley, 2001) These organi-zations are essential for advocating for nurses and for humanistic health promotion A strong profes-sional organization needs to be a visible force: a national organization should have national visibil-ity; a local organization should be known locally For example, the ANA works on national issues in Washington, DC; the state nurse associations work
on state-wide issues; and the local districts work on issues in the local community These three levels of the ANA work in concert Organizations can iden-tify issues that concern nursing and health care, bring them to the public, and take a leadership role
in advocating for development of policies that improve health and ensure high-quality nursing care To achieve this, organizations need support of nurses through their membership and through their political acumen
The New York State Nurses Association (NYSNA), for instance, developed and championed the legal definition of professional nursing in New York State The New York State Nurse Practice Act was passed in 1972 and was the first law to define nursing as an independent profession This defini-tion of nursing still stands and has served as the model for nurse practice acts in the other states The ANA is working to influence legislation to deal with overcrowded emergency departments (Trossman, 2006)
Community
Community is most often defined as a geographic area with boundaries, but during the 1960s the idea
of community empowerment grew to define a group with a common good that required coordinated action Power, politics, and policy became attached; community, in this context, is defined as a popula-tion, a neighborhood, a state, a napopula-tion, and the world It can be a nursing organization or an online group An individual is usually a member of more than one community The other three political action spheres exist in the sphere of community For