Prof. nsg part 1


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Prof. nsg part 1

  1. 1. The ProfessionalPractice of NursingAdministration
  2. 2. BOOKS OF RELATED INTERESTFiesta: The Law and Liability: A Guide for Nurses, 1983,0-471-07879-4Jacobson: Nurses IJnderSlress, 1983, O-47 l-07899-9King: A Theory for Nursing: Systems, Concepts, Process, l98l ,0-471-0779s-XKnapp: Basic Statistics for Nurses, Second Edition, 1985,0-471-87 563-5McFarland: Nursing Leadership and Management: A Contemporarl,Approach, 1984, 0-47 l-09097 -2Parse: Man-Living-Health: A Theory of Nursing, l98l , 0-471-04443-lSchweiger: The Nurse as Manager. 1980, 0-471-04343-5Stevens: Power and InfTuence: A Sourcebookfor Nurses, 1983,0-471-08870-6
  3. 3. The ProfessionalPractice of NursingAdrninistrationLTLLIAN M. STMMS, R.N., Ph.D.Ass o c iate P rofe s so r o/ Nursrngand Heahh GerontologrNursrng Health Services AdministrationSchool o/NunsingThe University of MichiganAnn Arbor, MichiganSYLVIA A. PRICE, R.N., Ph.D.Research AssociateNursing Heahh Services AdministralionSchool o/NursrngThe Universitv of MichiganAnn Arbor, MichigartNAOMI E. BRVTN, R.N., Ph.D.Assrstant ProfessorDepartment of Pttblic Health NunsingCollege o/NursingUniversit.v of Illinois at ChicagoChicago, lllinoisA Wiley Medical PublicationJOHN WILEY & SONSNew York . Chichester . Brisbane . Toronto . Singapore
  4. 4. ContributorsYvonne M. Abdoo, R.N., M.S.N.Assistant Professor of NursingSchool of NursingThe Univcrsity of MichiganAnn Arbor, MichiganGladys Ancrum, R.N., Dr. PH.Professor of NursingDepartment of NursingBloomsburg UniversityBloomsburg, PennsylvaniaJudith A. Bernhardt, R.N, M.S.Associate Activation Administratorand Senior Hospital PlannerThe University of Michigan HospitalsAnn Arbor, MichiganAgnes M. Buback, R.N., M.S.N.Associate Administrator and Director of NursingC.S. Mott Childrens HosPitalHolden Perinatal and Womens HospitalsThe University of Michigan HospitalsAnn Arbor, MichiganCatherine Buchanan, R.N, Ph.D.Management Nursing ConsultantHome Health CareLathrup Village, MichiganMarjorie M. Jackson, R.N., M.S.Associatc Professor of NursingSchool of NursingThe University of MichiganAnn Arbor, Michigan vll
  5. 5. X PREFACEchallenging and gratifying work, with emphasis on the importance ofindividual growth and development through the administrativc expc-rience. In summary, the goals of this book are to:1. Present nursing administration as part of professional nursing prac- tice within the total organization.2. Provide an approach to the practice of nursing administration that integrates the clinical and research climate with nursing education.3. Provide knowledge about the institutional, political, and social con- trols that influence the practice of nursing administration.4. Forecast emerging trends that influence the professional practice of nursing in various settings.5. Provide a conceptual framework for the practice of nursing admin- istration in current and emerging practice settings. Special acknowledgment is given to Andrew Simms, word processoroperator, and Francile Clevenger, typist, for their able assistance in pre-paring the manuscript. Lru-rRN M. Srnrus Svlvn A. Pnlce Naoruu E. EnvlN
  6. 6. ContentsPart IA Frarnework for the Practice of NursingAdrninistation I Professional Nursing Practice 3 2 Nursing Theories and Models 12 3 Management Theories 24 4 The Person in the Role of Nursing Administrator 36Part IIThe Context of Nursing Adrninishation Practice 5 Creating the Environment for Nursing Practice 57 6 The Organization of Nursing Practice 68 7 Organizational Change 85 8 Operationalizing Professional Nursing 94Part IIICurrent and Emerging Challenges 9 Developing Human Potential lO710 Managing Fiscal Resources 120 Agnes M. BubcLck cmd Nancy V. Moranl1 Managing Conflict 140 Gladys Ancrum12 Leadership in Care of the Eldcrly 154 XI
  7. 7. Xii CONTENTSPart tVFacilitating Ilrofessional Nursing Practice13 Decision Making in Clinical Settings 173 Florence M. Johnston14 Facilities Planning 185 ludith A. Bernhqrdt15 Quality Assurance 20416 Effective Communication 22I17 Nursing Research in a Professional Practice Climate 236Part VManaging Human Resources18 Mobilizing Existing Resources 24919 Staffing and Scheduling 264 Yuonne M. Abdoo20 Productivity 281Part VIMoving Beyond ttre Ordinary2l Mentorship and Networks 295 Catherine Buchanan22 Marketing Nursing Services 31023 Current and Emerging Practice Settings 32324 The Comedy of Management 339 Marjorie M. Jackson25 The Nursing Imperative: Integrating Practice, Education, and Research 352Author Index 367Sulrject Index 373
  8. 8. PurtlA Flarneworkfor the Practiceof NrrrsingAdrninistration
  9. 9. PROFESSIONAL NURSING PRACTICE 11 2. Wilenski, H. The professionalization of everyone? American Journal ofSo- ciology, September 1964, 70(2), 137-158. 3. Schien, E.H. Professional Educatiorz. New York: McGraw-Hill, 1972. 4. Kelly, L. Dimensions ofProfessional Nursing,4th ed. New York: Macmillan, r98r. 5. Donabedian, A. Foreword, in M. Phaneuf, The Nursing Audit and Self-regtt- lation in Nursing Practice,2d ed. New York: Appleton-Century-Crofts, 1976. 6. Henderson,Y . Basic Principles of Nursing Care. London: International C<-runcil of Nurses, 1961. 7. American Nurses Association. The Nursing Practice Act: Suggested State Leg- islation. Kansas City, Mo.: American Nurses Association, 1981. 8. Schlotfeldt, R. Nursing in the future.NursingOutlook, May 1981, 29(5),295- 301. 9. American Nurses Association. Nursing: A Social Policy Statemenf. Kansas City, Mo.: American Nurses Associaticln, 1980.10. State of Michigan, 79th Legislature. Enrolled House Bill No. 4O70. Michigan Public Health Code, 1978.I l. Lysaught, J.P. Action in Affimtation: Toward an Unantbiguous Profession of Nursing. New York: McGraw-Hill, 1981.12. D<rnaldson, S. and Crowley, D. The discipline of nursing. Nursing Outlook, February 197 8, 26(2), 1 l 3-120.
  10. 10. qL0 _A _EB4l4sWqB Elg B r H_E_PBAqIICE_ m _N!Bs IN rA DN{INISTBAION_ _which nursing practice can occur. The majority of nurses are employedby health care institutions, and thcir clinical practice must intcrfacewith administrative philosophy and policy. The amount of control thatnurses have over their own practice is related to many factors in thisemployer-employee relationship. Thc following chapters cover inno-vative administrativc approaches and factors that influence nursingpractice on both conccptual and pragmatic levels. A nursing adminis-trator must consider both conceplual and pragmatic levels in order toconstruct a supportive and growth-producing environment for profes-sional nursing practice.SUMMARYIn order for nursing to be a professional practice discipline, nursingmust formulate a theoretical basis for its practice. Nursing theories andmodels provide a conceptual framcwork for the implementation ofnursing practice. The next chapter examines selected nursing theoriesand models.STUDY QUESTIONS1. What docs professionalism involve?2. List at least five essential criteria of a profession.3. Explain why profession is a social concept.4. Why is nursing often referred to as an emcrging prolession?5. Formulate a definition of nursing.6. What are the distinguishing characteristics that differentiate profes- sional and vocational nursing?7. According to the National Commission for the Study of Nursing and Nursing Educations interactive model, there is no singlc focus for nursing practice. Explain.8. Why is the field of nursing considered a professional practice disci- pline rather than an academic onc? Explain.9. Describe the four components of professional nursing practice.REFERENCES 1 . Etzioni, A., ed. The Semi-Profbssions and Their Organiz.ation. Ne.v York: The Free Press, 1969.
  11. 11. l&o_Eqs qq NAL N u&qING PRAgrrcEgiving service, and educating. Furthermorc, somc mcmbers of the prolessionmust engage in enquirl that is not immcdiatelv applicable to currenl clinicalpractice. As a branch o[ knowledge, the discipline cmbodics more than the scienceo[ nursing and requires rescarchcrs uho emplo] a variety of approaches fiomnursings perspective (p. 1 l9).Nursing researchers, clinicians, and educators use information frommany disciplines and need to understand or conduct research in thesefields outside nursing. Professional practice discipiines such as nursing, medicine, and den-tistry are defined by the application of knowledge in relation to thehealth of clients. Alrhough clinical practice is a major thrust of nursing,other components of professional practice must be considcred, includingresearch, education, and administralion. The four components, therefore,are (I ) clinical (application of knorvledCe), (2)research (development ofknowledge), (3) education (transmission of knowlcdge), and (4) admin-istration (utilization of knowledge), as sh<-rwn in Figure 1.2. These com-ponents need to bc articulated and coordinated toward the full attain-ment of a professional practice discipline. The education componentinfluences policy formation by administration, which in turn nurturesresearch-bascd clinical practice. Nursing administrators are responsiblefor nursing practice, research, and cducation as they relate to profes-sional nursing within an institution. Administrative support provides the environmcnt and structure in Administration (utilization of knowledge) Research Professional Education (development ol n ursi ng (transmissron o{ knowledge) practice knowledge) Clinical (application of knowledge) FIGURE 1.2 Four components of professional nursing practice.
  12. 12. 8_e FRAMEWORK FOR THE PRACTICE OF NURSING ADMINISTRATION PATIENT CONDITION gt nra"ara"ntf *( H el 6 lntervention J =(lnstruction IFIGURE l.l Interactive model of an emergent, full profession of nursing. Ep-isodic care is that domain ol nursing practice that is essentially curative andrestorative, generally treating ill patients, and most frequently provided in ahospital setting or other in-patient facility. Distributive care is that domain ofnursing practice that is essentially designed for health maintenance and diseaseprevention, generaliy continuous in nature, seldom acute, and increasingly pro-vided in community or emergent care settings. (From J.P. Lysaught, Action inAffirmation: Toward an Unambiguous Profession of Nursing. New York: McGraw-Hill, 1981, p.44, Figure 3-11.)a mild iilness) and vertically, within a nursing practice (from staff nurseto master clinician). This conceptual scheme also argues for variation in the educationalpattcrning of preparatory and advanced studies to ensure the educationof the variety as well as the number of nurses needed to implement afull range of client services. It provides for a commitment and careerperspective that includes mobility and increments in responsibility, au-thority, and recognit ion. Donaldson and Crowley (12) distinguish betwcen academic andprofessional disciplines. The purposc of academic disciplines is to know(and, for some, to apply that knowledge); therefore, they develop de-scriptive theories. Because the professional disciplincs have an addedcomponent of service to people, their theories are both descriptive andprescriptive in nature. While academic disciplines involve basic and ap-plied research, profcssional disciplines also involve clinical research.Donaldson and Crowley (12) caution that:The discipline, which is a body of knor.rledge, must not be confused with itsassociated practice realm, which embodies the processes of conducting research,
  13. 13. PROFESSIONAL NURSING PRACTICEPROFESSIONAL PRACTICE DISCIPLINESThe legal responsibility and scope of nursing practice are regulated bythe nursing practice acts of each state. For example, according to thcState of Michigan Public Health Code, House Bill No. 4050 (10), thepractice of nursing is "the systemalic application of substantial spe-cialized knowledge and skill derived from the biological, physical, andbehavioral sciences to the care, treatment, counsel, and health teachingof individuals who are experiencing changes in the normal health pr<-r-cesses or who require assistance in the maintenance of health and theprevention or management of illness, injury, or disability". This defi-nition is appropriate for a professional practice discipline such as nurs-ing, It conveys that nursing emphasizes human health and well-being,which are the concerns of nurses and determine the essential nature ofnursing. Lysaught (11) has reported that the National Commission for the Studyof Nursing and Nursing Education prescnts an interactive model ofnursing practice that envisages three dynamic continua that operate inclose relationship to one another and, taken logether, explain thc entiredomain o[ needs for nursing and experlise (see Figure 1.1). One axisclassifies the set of nursing behaviors ranging from the initial assessmentof client condition through intervention, instruction, and assessment ofoutcomes and results. The second axis classifies patient condition: well,unwell, or acutely unwell. The commission emphasizes that the "conceptof maintaining wcllness and limiting illness is as much a part of thefull practice of nursing-or medicine-as is thc treatment of acutc ill-ness." The third axis depicts the environmental setting (e.g., instilution,outpatient setting, clinic, home, or community). This axis contains arcasfor thc cnactment of nursing behaviors classified, for simplicity, in twocategorics: episodic care, which includes curative and restorative carc;and distributive care, which is geared toward health maintenance anddisease prevention and takes place with increasing frequency in com-munity and emergenI carc scltings. In determining proper role lunctions in accordance with client needsand in rclationship to sclecting the optimum environment for care, Ly-saughts interactive modcl focuses on whether the nurses role is indc-pendent or interdepcndent. This conceptual framcwork suggests no sin-glc focus for nursing practice; it argucs for nursing as a variety o[ specificcapacities, rather than a group of simple skills, and for a relocation ofthc patient and his or her necds to an elemental position in the decision-making process rclated to intervention and care. This model argues fornursing as a profession-not just nurses as individuals-to be preparedfor health intervention in a kaleidoscope of situations. There is roomfor a variety of concentrations and spccializations, both horizontally,across the range of client care needs (from acute cardiac care through
  14. 14. A FRAMEWORK FOR THE PRACTICE OF NURSING ADMINISTRATIONcarry out the therapeutic plan as initiated by the physician. She also, as a mem-ber <lf a medical team, helps other members, as they in turn help her, to planand carry out the total program whether it be lor the improvement of health,or the recovery from illness, or support in death. (p.a2) The American NursesAssociation Congress for Nursing Practice hasproposed a definition that attempts to differentiate between professionaland vocational nursing:The practice of nursing means the perfcrrmance for compensation of professionalservices requiring substantial specialized knowledge of the biological, physical,behavioral, psychol<lgical, and sociological sciences and of nursing theory asthe basis of assessment, diagnosis, planning, intervention, and evaluating thepromotion and maintenance of health, the casefinding and management of ill-ness, injury, or infirmity, the restoration of optimum function, or the achievementof a dignified death. Nursing practice influences but is not limited to admin-istration, teaching, counseling, supervision, delegation, and evaluation of practiceand execution <lf the medications and treatments prescribed by any person au-thorized by state law to prescribe. Each registered nurse is directly accountableand responsible to the consumer for the quality of nursing care rendered. The practice of practical (vocational) nursing means the performance forcompensation of technical services requiring basic knowledge of the biological,physical, behavioral, psychological, and sociological sciences and of nursingprocedures. These services are performed under the supervision of a registerednurse and utilize standardized procedures leading to predictable outcomes inthe observation and care of the ill, injured, and infirm, in the maintenance ofhealth, in action to safeguard life and health, and in the administration of med-ications and treatments prescribed by any person authorized by state law toprescribe. (7 , p. 6) Schlotfeldt (8) emphasizes that nurses should search for a conceptualfocus and definition of their profession that permit inclusion of phe-nomena related to human beings seeking optimal health. She belicvesthat a definition is needed that will help to establish nursing as a profes-sion whose practitioners are responsible for the gcneral health of humanbeings. Thus, her definition is, "Nursing is assessing and enhancing thegeneral health status, health assets, and health potentials of humanbeings" (p. 298). This definition is unambiguous; focuses on nursingpractice, education, and research; and conveys nursesknowledge, prac-tice, and scope of accountability. Because it does not encroach upon theresponsibilities of other helping professionals, it is conceptually appro-priate and politically acceptable. Schlotfeldt emphasizes that nursingr.vill become a recognized, learned profession and that nurses will provideessential services that will enhance the health and well-being of oursociety. The nursing profession makes significant contributions to the evolutionof a health-orientcd system of care. Nursing practice has been health-oriented for over a half a century because o[ its focus on individuals aspersons and on the family as the necessary unit of service (9).
  15. 15. lBoiqs, rIqNAr- NURSING PRACTICEan occupation, rather than a profession, such as medicine, theology, andlaw. Writers who present this issue acknowledge that some nurses nowperform expanded roles and functions, while others lack the educationalbasis for such a practice. Therefore, it is often difficult to distinguishamong associate-degree, diploma, and baccalaureate-prepared nurses. Nurses provide services in a variety of settings, such as industry,schools, and public health agencies. Nurses now assume more respon-sibility and accountability for the consequences of their decisions thanin the past. This extension of nursing practice also involves increasedcollaboration with physicians and other health practitioners in the per-formance of their respective roles in the provision of health services, Incollaborative practice, nursing emphasizes psychosocial aspects of healthcare, coordination ofpatient care services, and advocacy ofpatient rights. As an emerging profession, nursing is recognizing the need to formulatea theoretical base for its practice and to articulate that base to others.Research is evolving in the clinical areas to test nursing theories andrelated theories upon which the practice of nursing is based. Similarly,research in the practice of nursing administration provides an empiricalknowledge base for the various functions and responsibilities associatedwith nursing administration. Nursing must initiate and promote re-search to support the organizational restructuring of the delivery ofnursing services, to define nurses roles and responsibilities in interdis-ciplinary endeavors, and to provide a data base for a systematic eval-uation of the impact of nursing. Prolessional roles and functions of nursing are being reexamined. Theprofessional role of the practitioner of nursing has been expanded, lead-ing to a repatterning of nursing education and emphasis on lifelong ca-reer commitment to nursing. This trend has further emphasized the needfor nurses who are creative and possess competencies to function in acollegial relationship with other health care professionals.NURSING PRACTICENursing is concerned with human health and well-being. It involves thedelivery of humanistic care to people in order to promote and maintainhealth, prevent illness, cure illness and restore health, and coordinatehealth care services to increase continuity. Discussing the nature of nursing, Virginia Henderson (6) states:The unique function of the nurse is to assist the individual, sick or well, in theperformance of those activities contributing to health or his recovery (or topeaceful death) that he vuould perform unaided if he had the necessary strength,will, or knowledge. And to do this in such a way as to help him gain independenceas rapidly as possible. This aspect of her w<trk, this part of her function, sheinitiates and conlrols; of this she is master. In addition she helps the patient
  16. 16. 4a IB4ruElyaBE IoB rHE PRACTICE OF NURSING ADMINISTRATIONThis knowledge will enable nursing administrators to develop a con-ceptual framework for their nursing administrative practice.DEFINITION OF A PROFESSIONAND PROFESSIONALISMNursing is an emerging profession and a prolbssional practice discipline.One must have comprehensive understanding of both terms in order topromote the highest level of nursing administrative practice. Manywriters have discussed the history, development, definition, and appli-cation of the concept of a profcssion (1 ,2,3,4). Although these writersexhibit considerable diversity, there is consensus on thc basic premisethat professionalism involves autonomy, mastery of a body of knowledge,and a community of colleagues. The following are essential criteria ofa profession:1. Provides practical services that are vital to human and social wellare2. Possesses a specialized body of knowledge and skills3. Educates its practitioners in institutions of higher education4. Attracts people who emphasize service over personal gain or self- interest and recognize their occupation as a long-term commitment5. Formulates and controls its own policies and activities and has prac- titioncrs who function relatively autonomously in the performance o[ functions and activities6. Has a code of ethics that is usually enforced by colleagues or through licensure examinations7. Has a professional association that promotes and ensures quality of practice It should be noted that profession is a social concept. The authorityfor nursing is based on a social contract that is derived fr<lm a complexsocial base. Donabedian (5) states:There is a "social contract" between society and the professions. Under its terms,society grants the professions authority over functions vital to itself and permitsthem considerable autonomy in the conduct of their own affairs. In rcturn, theprofessions are expected to act responsibly, always mindtul olthe public trust.Self-regulation to assure quality in pcrformance is at the heart of this relation-ship. It is the authentic hallmark of a mature proflession. (p. xiii) Although there is some agreement as to what constilutcs a profcssionalnurse, much variation in opinion remains. One area of diversity involvesthe length and type o[ educational preparation nccessary to qualify forthe status of professional nurse. Another issue is whelher nursing is rcally
  17. 17. ProfessionallNursing Practice The purpose of this chapter is lo present a conceptual framework for professional nursing practice. On completion of this chapter, the reader will be able to: l. List the essential elements of a profession. 2. Formulate a definition of nursing. 3. Differentiate between professional and vocational nursing. 4. Critically analyze the National Commission for the Study of Nursing and Nursing Educations interactive model for nurs- ing practice. 5. Discuss the distinctive features of academic and professional disciplines. 5. Describe the four components of profcssional nursing practicc.Nursing services constitute a core function of the health care deliverysystem, and nursing administrators conduct and control clinical nursingpractice. As health care delivery systems change and as professionalroles are redefined, effective nursing leadership is cssential. Nurses inadministrative positions participatc in policy and decision making, as-sume responsibility for managing nursing service and related activities,and work cooperatively with professionals from other health disciplinesto ensure that quality client-ccntered care is administered. The acqui-sition and allocation of human and physical resources required to meetthe goals of clinical care are facilitated by the nursing administrator.For example, nursing administralors generally influence the largestproportion of the budgets of hospitals and other health care institutionsand make major decisions affccting the quality of patient care. Since the hcalth care industry is a human services endeavor, nursingadministrators must havc a thcoretical grounding in the behavioral sci-ences. It is also essential that they acquire knowledge and understandingof administrative theory and be aware of changing concepts in thc field.
  18. 18. 20 R ppRtvlEwoRK FoR THF, pRACTTcE oF NURSING ADMINISTRATIONgether or maintenance of a proper balance. Levine states that the purposeof conservation is to maintain the unity and integrity of the patient. Thefour conservation principles are: Conservation of energy refers to balancing energy output and energy input to avoid excessive fatigue, i.e., adequate rest, nutrition, and exercise, accurate assessment o[ the patients ability to perform nec- essary activities without producing excessive fatigue.2. Conservation of structural integrity refers to maintaining or restoring the structure of the body, i.e., body defense systems which protect people from loss of body fluids, rapid adaptations ro changes in ex- ternal temperature.3. Conservation of personal integrity refers to maintenance or resto- ration of the individuals sense of identity and self-worth, i.e., respect from the nurses, willingness to permit people to make decisions for themselves whenever possible.4. Conservation of social integrity refers to the acknowledgment of the individual within the context of social life. No individual can rec- ognize his/her wholeness unless it is measured against relationships with others. (pp. 14-18) Like Orems conceptual framework, Levines nursing theory focuseson the individual (patient). The nurse is concerned with the patientsfamily and significant others only as they influence the patients progress. Levines theory depicts nursing as an independent practice profession.Levine does not consider the collaborative relationship of nursing withinthe total health care setting. However, nurses in acute care settings coulduse this model. For example, the theory emphasizes the patients de-pendency (e.g., illness states, limited participation in the planning ofcare). In such settings, the nurse has the major responsibility for as-sessing the patients ability to participate in his or her own care, whichis in direct contrast to Orems conceptual model of nursing.Roys Adaptation ModelSister Callista Roys (12) adaptation model of nursing practice is basedon her philosophy of a human as a biopsychosocial being who, to beunderstood, must be considered as a unit, or whole (p. 11). Human beingsare in constant interaction with their environment. Because they areliving systems, they require matter, cnergy, and information from theenvironment and cope with environmental change through biopsycho-social adaptive mechanisms. Roy has identified four distinct modes of adapting by which a personresponds to change: (1) physiological, (2)self-concept, (3i role function,
  19. 19. NURSING THEORIES AND MODELS 19pensatory system, the nurse and the patient perform care measures orother actions involving manipulative tasks or ambulation. A patient inthe supportive-educative system can or should learn to perform the re-quired self-care measure but cannot do so without assistance. The family, community, and environment are important componentsconsidcred in self-care actions, but the primary focus is on the patient.The goal of nursing action is to involve the patient in his or her ownself-care whenever possible.Levines TheoryMyra Levines theory (11) of nursing is based on the concept of totalpatient care, from which she derives four conservation theories that serveas the basis of her nursing model. Levines theory reflects her definitionof nursing, in which she makes the assumptions that nursing is:l. A human inl.eraction.2. A discipline rooted in the dependency of people and their relationships with other people.3. Based on intervention that supports or promotes the persons ad- justment. (pp. 1*3) The components of Levines theory are as follows:l. The patient is in the predicament of illness.2. The nurse must recognize the patients holistic response, which in- dicates the nature of the adaptation to illness.3. The nurse who participates actively in every patients environment must recognize the organismic response of the patient, make an in- tervention in the patients environment, and evaluate the intervention as therapeutic or supportive. (p. 13) Levines theory makes the basic assumptions that the nurse-patientinteraction is determinedby (1)the conditions in which the patient en-ters the health care setting, (2) the functions of the nurse in the situation,and (3)the responsibilities of the nurse in the situation. The theory implies that the nurse is able to make judgments that willpromote or support the patients adaptation to the situation based onknowledge. The nurse also is expected to possess the skills necessary toimplement these interventions. Levine views a person holistically as requiring structural, personal,and social integrity as well as energy to be in a state of health. If anyone of these elements is disrupted or changed, the person is in a stateof altered health. Nursing interventions are based on the conservationof thesc four elements. Levine dcfines conservation as the keeping to-
  20. 20. 18 _4 JB4I4E!yqB4 rof,fHE!&AqIcE qF NURSTNG ApMrNrsTRATroN Accompl ishes pattents therapeutic self-care Compensates for patients inability to engage in self-care Supports and protects patient Wholly compensatory system Performs some self-care measures for patient Compensates for self-care limitations of patient Assists patient as required Performs some self-care measures Regulates self-care agency Accepts care and assistance from nurse Partly compensatory system Accompl ishes self -care Regulates the exercise and Nurse development of action self-care agency Supportive-education systemFIGURE 2.1 Basic nursing systems. (From D.E. Orem, Nursing: Concepts ofPractice,2d ed. New York: McGraw-Hill, 1980, p.98.)care requisites, three varieties of basic nursing systems are recognized:(.1) wholly compensatory, (2) partly compensatory, and (3) supportive-educative (see Figure 2.1). The nursing system is formed by the nursesselection and use of methods of assisting patients and prescribes par-ticular roles for the nurse and the patient. The r.vholly compensatory nursing system exists when the patient isunable to engage in those self-care actions requiring self-directed and-controlled ambulation to refrain from such activity. In the partly com-
  21. 21. NVSqNG_IUEOBIEIAD M9!EL-S_ I 7 Universal self-care requisites arc universally required by all humanbeings and include (1) maintenance of a sufficient intake of air, water,and food; (2) care related to excrements; (3) balance between activityand rest; (4) balance of solitude and social interaction; (5) preventionof hazards to human life, human functioning, and well-being; and (6,)promotion of normalcy. Orem stresses that self-care related to the needfor normalcy may be directed toward the promotion of integrated humanfunctioning or the protection and care of the body. Developmental self-care requisites are the following:1. Bringing about and maintenance of living conditions that support life processes and promote the processes of development, which refers to human progress toward higher levels of the organization of human strrrctures and maturation during: a. The intrauterine stages of life and process of birth. b. The neonatal stage of life when (1)born at term or prematurely and (2)born with normal birth weight. c. Infancy. d. The developmental stages of childhood, including adolescence and entry into adulthood. e. The developmental stages of adulthood. f. Pregnancy either in childhood or adulthood.2. Provision of care either to prevent the occurrence of deleterious effects of conditions that can affect human development or to mitigate or overcome these effects from conditions such as: a. Educational depreciation. b. Loss of relatives, friends, associates. c. Poor health or disability. d. Terminal illness and impending death (p.a7). Health-deviation self-care requisites exist for persons who are ill; areinjured; have specific forms of pathology, including defects and disa-bilities; and are under medical diagnosis and treatment. Obviouschanges in (1/ human structure (e.g., edematous extremities, tumors),(2) physical functioning (e.g., dyspnea, joint immobility), and (3) habitsof daily living (e.g., sudden mood changes, loss of interest in life) focusa persons attention on himself or herself. When a change in health statusresults in total or almost total dependence on others for the needs tosustain life or well-being, the person moves from the position of self-care agent to that of patient or receiver of care. The role of nursingfocuses on assisting the individual, family, or significant others to meetuniversal self-care demands or develop new methods of providing self-care. On the principle that nurses, patients, or both can act to meet patients
  22. 22. NURSING THEORIES AND N{ODELS 13(1) envision a theory as a systematic abstraction of reality intended toserve a particular purpose. A systematic abstraction is a defined organ-izational pattern derived from reality but not reality itself. Approachesto theory development are themselves organized and patterned, or sys-tematic. The syslematizalion of abstractions requires rigorous thoughtand action. The words and symbols that comprise a theory are labelsassociated with an object, property, or event in the real world. For ex-ample, the word computer represents an abstraction that denotes a realobject. A theory consists of words, such as the label computer, that rep-resent abstractions, such as the mental image of a computer, that denotereality, such as the object computer. Words and other symbols enabletheories to be communicated and understood. Hage (2) states that concepts that refer to classes or categories of phe-nomena may be called nonvuriable. Such concepts are observed in ty-pologies in which classes are clearly defined, based on the presence or absence of the property of interest, for example, a nurse or a patient. General variables are concepts used to order phenomena according to some property or concepts that refer to dimensions of phenomena, for .*u-pl", degree of anxiety or level of mobility. Hage stresses that con- cepts that 1ru.y ol a continuum should be used more frequently than ". nonvariables in conceptualization and theory construction. General variables are not restricted to time and place and lend themselves to more subtle description and ciassilication than do nonvariable concepts. In general, theories are constructed either deductively or inductively. In deductive theory construction, the concepts under study proceed from general to specific. Thus, deductive theory construction begins with general axioms and propositions. Deductive theories are developed through a logical process that relates concepts in general statements so that increasingly specific statements can be deducted from them The process of inductive theory construction proceeds from the spe- cifics of empirical situations to generalizations about the data. This ap- proach is best illustrated in the grounded theory of Glaser and Strauss (:). Tt-r" process involves sequential formulation, testing, and redevel- opment of propositions until a theory is generated that is integrated, consistent with the data, and in a clear form, operationalized for later testing in quantitative research. Simms (a), in referring to the theory of Glaser and Strauss, cites four stages in the constant comparative method they used in formulating the grounded theory:/1/ Comparing incidents applicable to each category, (2) integrating,categoriesand their prolerties, (3) delineating the theory, and (4) writing the theory. Theelements oi theory that are generated by comparative analysis are the conceptualcategories, their conceptuil propertics, and generalized relations among thecategories and their proptrlies. TJevaluate propositiorrs and refine categories and their properties, relevant
  23. 23. I{ursing Theoriesand Models The purpose of this chapter is to introduce the concept of theory and its relationship to nursing administrative practice. On com- pletion of this chapter, the reader will be able to: 1. Define theory. 2. Distinguish between deductive and inductive theory con- struction. 3. Describe the four stages of the constant comparative theory used in formulating grounded theory as depicted by Glaser and Strauss. 4. Briefly discuss Dickoff and James relationship of inductive theory to practice. List the critcria a theory must meet in order to have direct application to practice. 6. Define model. 7. Distinguish among Orems, Levines, and Roys conceptual models of nursing practice. 8. Critically analyze Orems, Levines, and Roys models and their application to nursing practice.Nursing theories and models provide the conceptual framework fornursing practice. In a practice discipline such as nursing, conceptualframeworks are useful in directing the thinking of scholars, in the de-velopment of theories, and in guiding the observation of practitionersas the processes of assessment and intervention are carried out.THEORIESA theory consists of a set of interconnected propositions designed todescribe, explain, and predict an event or phenomenon. Chin and Jacobs12
  24. 24. NURSING THEORIES AND MODELS 235. Wald, F. and Leonard, R. Towards development of nursing practice theory. Nursing Research, April 1964, 13(4), 309-313.6. Dickoff, J., James, P., and Wiedenbach, E. Theory in a practice discipline: part I. Nursing Research, September/October 1968, 17(5),415-434.7. Dickoff, J., James, P., and Wiedenbach, E. Theory in a practice discipline: part IL Nursing Research, November/December 1968, l7(6), 545-554.8. Newman, M. Theory Deuelopment in Nursing. Philadelphia: Davis, 1979.9. Hardy, M. Theories: components, development, evaluation. Nursing Research, March/April 197 4, 23(2), 100-107.10. Orem, D. Nursing: Concepts of Practice,2d ed. New York: McGraw-Hill, 1980.11. Levine, M. Introduction to Clinical Nursing,2d ed. Philadelphia: Davis, 1973.12. Roy, C. Introduction to Nursing: An Adaptation Model. Englewood Cliffs, N.J.: Prentice-HalI, 1976.13. Riehl, J. and Roy, C. Conceptual Models for Nursing Practice,2d ed. New York: Appleton-Century-Crofts, I 980.14. Stevens, B. NursingTheory,: Analysis, Application, Evaluation. Boston: Little, Brown, 1979.
  25. 25. 22 A FRAMEWORK FoR THE PRACTICE oF NURSING ADMINISTRATIONof the individual which occurs by conservation in four areas when adap-tive needs are manifestcd. Roy espouses that nursing is an interpersonilprocess that is initiated by the individuals maladaptation to change inthe environment. The goal of nursing is to assess the adaptation lcveland intervene to promote positive adaptation and integrity. Like nursing theories and models, management science theories and 8models are commonly used in nursing administration. The nursing ad- 9ministrator should select the model that is most congruent with his orher own administrative practice. Chapter 3 addresses the major concepts 10of administration and management theories applicable to nursing ad- 11ministrative practice. 12 13STUDY QUESTIONS l41. Formulate a definition of theory.2. What are the major diflerences between an inductive and a deductive theory?3. List the conditions under which you would use the constant com- parative theory approach in formulating grounded theory as depicted by Glaser and Strauss. Describe how you would formulate a grounded theory for a specific hypothetical situation.4. Explain the rationale for the statement by Dickoff and James that the highest level of theory building is situation-producing theory. Why must nursing theory be at this level?5. Formulate a definition of model.6. Given three models for nursing-Orems, Levines, and Roys-select the one that would be most applicable to your nursing administration practice and explain the rationale for your choice. What are the im- plications for nursing administration in the application of the model to nursing practice?REFERE-NCES 1. Chin, P. and Jacob s, M. Theory and N ursing: A Systematic Approach. St. Louis: Mosby, 1983. 2. Hage, F. Techniques and Problems in Theory Construction irz Sociology. New York: Wiley, 1972. 3. Glaser, B. and Strauss, A.The Discovery of GroundedTheory. Chicago: Aldine, 1967. 4. Simms, L. The grounded theory approach in nursing research. Nursing Re- search, November/December l98l , 20(6), 356-359
  26. 26. NURSING THEORIES AND MODELS 2land, (4) interdependence. Adaptive modes are activated when need ex-cesses or deficits are created within the individual (p. 14) Each adaptive mode is related to underlying needs. For example, thephysiological adaptive mode is related to the need for physiological in-i"g.ity (e-.g., exercisc and rest, nutrition and elimination, fluid and elec-trolytes). Adaptation occurs when thc person maintains his or her in-t"gilty through positive response to need deficits or exccsses. Thep"iron, self-c&cept is determined by his or her interactions rvith others.As external stimuli affect a person, the person adapts according to hisor her self-concept. Role function is the performance of duties relatedto given positions within socicty The wa1 a person performs thesc duticsis constantly responsive to outside stimulation. In relation to others, thcpcrson adapts aCcording to a system of interdependcnce, which includesih" *uyr an individual seeks help, attention, and affection. Changer.vithin and outside the person causes changc in the system (13) The nurse must be able to consider each client as an individual, as- sessing his or her needs and acting accordingly. Roys model encourages the nurse to utilize and become more proficient in the total assessment of the patient through observation, interviews, and the performance of varioui nursing care activities. An understanding of Roys four adaptive modes for responding to change allows the nurse to bring a broad per- spective to thc planning of nursing care based on individual client needs.SUMMARYBarbara Stevens (14) points out that nursing theory takes on significanceonly to the extent that it cxplains and directs nursing practicc. She stalesthat nursing practice is largely controlled bv nursing administration.However, thc nursing administrator and his or hcr staff must select aconceptual modcl or framcwork of nursing that is congruent with thephilosophy, structure, and goals of the nursing department. A prercquisite lo the implementalion of the model is the revision order"l,rpm"n1 of guidelines and standards of nursing practice. A formalcducation program to familiarize staff with the model is also cssential.The philosophies and goals of the nursing departmcnt will need to ber-eexamined to reflect the concepts and tcrminology of the model. A pa-tient-classification system based on the model will need to be dcveloped. Nursing is attempting to formulate a thcoretical basis for its practice.Many nursing scholars have advanccd postulates, theorics, and frame-u,orks as a mcans to achieve this goal. Orem focuses on the individualsself-care needs. Nursing actions are directcd torvard enhancing self-careability and therapcutic sclf-care ability ol individuals. While Levineemphasizes the conservation principles ol encrgy, structural integrity,and personal and social integritl. Thc goal of nursing is the wholeness
  27. 27. 14 R pReunwoRr poR THE pn4!rr!q qI_llqBSrNG ApMrNrsrRATroNqualitative data are drawn from field and documentary sources. Principles un-derlying theoretical or purp<.rsive sampling guide the selection of comparisongroups. . . . The active search for relevant data continues until all critical var-iables and their interrelationships have been saturated and no new relationshipsemerge that suggest more information be collected. After the conceptual categories and properties are established and interre-lationships cvaluated, thc researcher uses the information to lormulate a thcory.Each element is used to crcate an explanation for the problem or phcnomenaunder study as well as questions for lurther research. The generation of theorvmust bc vierved as a process. Concepts and propositions emerge gradually, andthe ultimate generation of theory is dependent upon the data collected through-out the study (pp. 356-357). Theory formulation in the discipline of nursing provides a guide forpractice in the discipline of nursing. Some nursing theoreticians use thedeductive process with selected concepts from fields such as sociology,psychology, and physiology. They start with general concepts and usethese as parameters for analyzing specific nursing situations. Othertheoreticians use the inductive approach to theory building in nursing.Wald and Leonard (5) speculate that theorists begin with practicalnursing experience and develop concepts from their inductive analysisof this experience rather than borrowing concepts that they feel will fit. Dickoff and James (6) describe the relationship of inductive theory topractice. They emphasize that a theory is neither a useless fairytale nora picture of the real. As such, the various kinds of theories can be groupedinto four levels: (1,) factor-isolating theories; (2) factor-relating, or sit-uation-depicting, theories; (3/ situation-relating, or predictive, theories(promoting or inhibiting theories); and (4)situation-producing, or pre-scriptive, theories. In this classification, each higher level presupposesthe existence of theories at the lower level. Dickoff and James (6) statethat "a situation is depicted in terms of factors already isolated; pre-dictive or promoting theories conceive relationships between depictablesituations; and situation-producing theories prescribe in terms of avail-able predictive and promoting theories, and use depicting theories inthe characterization of goal-content" (p. 420). The factor-isolating ther.rry, or naming, must be considered first becauseall scientific theory begins with the naming of factors. The essentialfunction of naming is to facilitate reference to and communication aboutthe factor associated with the name. This theoretical activity is callcdclassifying or the introduction of technical terminology. To neglect fac-tor-isolating theory is particularly detrimental when a theory is self-consciously being developed for the first time, as in nursing. After factors are identified, they should be observed in relationships.This level of theory is situation depicting in that it relates the factorsthat have been identilied. Theories that depict or provide conceptionsof intcrrelations among factors, as opposed to among situations, are cor-relations: the joint presence or absence or range of variation between
  28. 28. NURSING THEORIES AND MODELS 15two factors. Correlations do not imply causation or reference to timesequence; the two factors simply coexist. In theories classified in the third level, are situation relating. Factorsare related in such a way that predictions can be made, since predictivetheory can state relationships only between such situations as are de-pictable, which is dependent upon what factors have been identified.Causal relationships must show the qualities of priority and directionamong the variables. For example, if A causes B, one must show that Aprecedes B; that when A occurs, so does B; that when A increases, Bincreases; and that when A decreases, B decreases. Therefore, situationsmay be connected causally. The highest level of theory is situation-producing theory. This levelexceeds predictive theory by stating not only that A causes B but alsohow to bring about A or how to facilitate As production of B. Dickoff and James (7) contend that to have impact on practice, nursingtheory must be at the highest level: situation-producing theory. Nursesconfronted with hundreds of situations must have a prescription for ac-tion. This prescription is made as a result of situation-producing theory. Newman (8) emphasizes that in order for a theory to have direct ap-plication, it must meet the following criteria:1. The focus is on the life process of man.2. The purpose is understanding the patterns of the life processes which relate to health.3. A total elaboration of the theory contains an action component which facilitates hcalth.These criteria are consistent with the current conceptual models ofnursing, which include prescriplivc-level thcory.MODELSThe relationship belween variables may be depicted by a model. Hardy(9) statcs that an investigator may formalize a theory, identify its pos-tulates, identify or derive its propositions, and then decide that theproblem of relationships is best represented by a model. A model is asimplified representation of a theory, certain complex events, stmctures,or systems. A model is a conceptual representation of a reality situation. Conceptual models provide a framework that directs the work ofscholars in the formulation of theories. Diffcrences among the variousconceptual models of nursing are apparcnt in terms of emphasis, un-derlying assumptions, definition of health and illness, and designationof the goal of nursing.
  29. 29. 16 A FRAMEwoRK FoR THE PRACTICE oF NURSING ADMINISTRATIoN The following conceptual models and thcories of nursing illustratethese differences. The objective of this discussion is to familiarize thenursing adminislrator with selected nursing models and theories cur-rently being used in nursing practice. It is important that nursing ad-ministrators be knowledgeable about differences in emphasis so thatthey may adapt these models to interface with their philosophy of nurs-ing practice within the context of their organizational (practice) setting.CONCEPTUAL MODELS AND THEORIESOF NURSING PRACTICEOrems Conceptual FrameworkDorothea Orem (10) describes nursing as a response of human groupsto one recurring type of incapacity for action to which human beingsare subject, that is, thc incapacity to care for oncself or oncs dependentswhcn action is limited because of health or health care needs. Fromnursings perspective, human beings are viewed as needing continuousself-maintenance and self-regulation through a type of action termedself-care. Self-care is care that is performed by oneself for oneself rvhen one hasreached a state of maturity that enables one to take consistent, effective,and purposeful action (pp. 32-33). Sclf-care involves lhe practice of ac-tivities that people initiate and perform on their own behalf in main-taining life, health, and well-being. Orem stresses that self-care has purpose. It is action that has patternand sequence whcn it is effectively performed, contributes to humanstructural integrity, human functioning, and human dcvelopment. Thepurposes attained through the kinds of actions callcd self-care are re-ferred to as self-care requisites. Orem describes three types of self-carerequisites:1. Universal self-care requisites are common to all human beings during all stages of the life cycle, adjusted to age, developmental state, and environmental and other factors. They are associated with life pro- cesses and with the maintenance of the integrity of human structure and functioning.2. Dcvelopmental self-care requisites are associated with human de- velopmental processes and with conditions and events occurring during various stages of the life cycle (e.g., prematurity, pregnancy) and events that can adversely affect development.3. Hcalth-deviation self-carc rcquisites are associatcd v,ith genctic and c<.rnstilutional delccts and human struclural and funclit-rnal dcviation and with thcir cflccts ancl mcdical diagnosis and treatmcnt (pp. 37- 4l).
  30. 30. Management Theories The purpose of this chapter is to trace the development of the man- agement schools of thought and their application to nursing administration. On completion of rhis chapter, the reader will be able to: 1. Identify the major premises of the classical, behavioral, and management science schools of administration, or manage- ment. 2. Discuss the contribution of the following people to thcir re- spective schools of management: Taylor, Fayol, the Gilbreths, Mayo, and Barnard. 3. Describe the major differences among the classical, behavioral, and management science schools. 4. Discuss the emergence of the systems approach in the study of organizations. 5. Differentiate between open and closed systems. 6. Critically analyze the contingency management approach. 7. Differentiate among theories X, Y , and Z. 8. Critically analyze the qualiry circle approach in relation to participative management. 9. Describe and discuss the incorporation into nursing admin- istration of the concepts of thc management schools, the sys- tcms approach, contingency application, and theory Z.Nursing administrators must be knowledgeable about administrativetheory from the field of management. The following discussion of themajor schools of administration, or management, theory will familiarizenursing administrators with pertinent concepts and principles in thatfield. This knowledge will enhance the incorporation of specific conceptsinto nursing administrative practice. Early in this century, the study and lormulation of theorics of modernmanagement began. Over the years, three major schools of administra-tion, or management, theory have developed: the classical school, thebehavioral school, and the management science school. Concepts from24
  31. 31. MANAGEMENT THIORIE! 25all these schools have been incorporated into the field of nursing admin-istration.SCHOOLS OF ADMINISTRATIVE THEORYClassical SchoolThe classical theory of management emphasizes the functions of a man-ager. The classical writers focus on prescriptive management theory:on how managers should perform their functions. According to thisschool, the function of management is to discover the "one best way"to perform manual tasks. This approach is based on the classical eco-nomic theory that human beings are basically motivated by a desire foreconomic betterment. The classical theorists identify three componentsof the management process: planning, organizing, and controlling. Theclassical school of managernent consists of scientific management, orthe management of uvork, and classical organization theory, or the man-agement of organization. One of the major contributors to the field of scientific managementis Frederick W. Taylor (1), who in 1911 published The Principles of-Sci-entific Managemertr. This work, along with studies conducted before andafter i1s publication, established Taylor as the father of scientific man-agement. In it, he defines guidelines for improving production efficiency.Taylor theorizes that the cause of industrial conflict is the ineflicientuse of scarce resources. Taylors work concentrates on the worker andthe workers tasks. It advocates the scientific selection and training ofrvorkers, the coopcration of management and labor to accomplish workobjectives, and a more equal division of responsibility between managersand workers. Taylors efforts inspired others to continue his work. Frank and LillianGilbreth conducted time and motion studies. Lillian Gilbreth was anindustrial psychologist who received her doctors dcgree in that field in1915. She raised a dozen children and was depicted in the book andmovie Cheaper by the Dozen. The Gilbreths directed their efforts towardrvork arrangements, eliminating unnecessary hand and body motions,and designing the proper tools for optimizing work performance. FrankGilbreth emphasized that in applying principles of scientific manage-ment, one must consider the workers and understand their personalitiesand needs. The Gilbrelhs concluded that it is not the monotony of workthat results in worker dissatisfaction but, rather, managements lack ofinterest in workers. contemporary with the work of Tayior is that of Henri Fayol, of France, uho was .oncerned with principles of organization and the [unctions
  32. 32. 28 A FRAMEWORK FOR THE PRACTICE OF NURSING ADMINISTRATIONmanagement theory that prcceded them. Through the work of the be-havioral scientists, some aspects of the early thcories have bcen modified,whilc others have withstood the test of scientific validation. Whereasthe classical writers overemphasize the technical and structural com-ponents of management, the human relationists overstate the psycho-social aspects.Management Science SchoolThe prop<_rnents of the management science school attempt to apply sci-entific knowledge to the solution of large-scale management problemsin all types of organizations. Management science can be considered anextension o[ scientific management. The primary emphasis of this schoolis on the establishment of normative models of organizational behaviorfor maximizing efficiency. This approach is also referred to as manage-ment science, Operations research, or decision science and is related toindustrial engineering and mathematical economics. Although attempts have been madc to distinguish between operationsresearch and management science, it is very difficult to do. Severalwriters emphasize that the lerm nlanagenlent science is broader thanthe tcrm operations research in that it encompasses such fields as math-ematical economics and the behavioral sciences and is also closely re-lated to the physical sciences and enginecring. Operations research isoperationally oricnted, whilc management science is directed toward the establishment of a broad theory. There is also a close relationship betwcen management science and industrial engineering. Both disci- plines are concerned with the same problems and often use similartcchniques. Kast and Rosenzweig (5) emphasize thaL, although managemcnl sci-ence and opcrations research rcpresent a loose conglomeration of in-terests and approaches, there are key concepts that permeate the field:1. Emphasis on scientific method2. Systcmatic approach to problem solving3. Mathematical model building4. Quantification and utilization of mathematical and statistical pro- cedures5. Concern with economic and technical rathcr than psychosocial as- pects6. Utilization of computers as tools7. Emphasis on the systems approach8. Seeking rational decisi<tns under varying degrecs of uncertainty9. Orientation toward normativc rathcr than descriptive models (p. 87)
  33. 33. MANAGEMENT THEORIES 29General Systems TheoryThe development of general systems theory has provided a basis for theunderstanding and integration of scientific knowledge from a variety ofspecialized fields. Kast and Rosenzweig (5) define a system as "an or-ganized, unitary whole composed of two or more interdependent parts,components, or subsystems and delineated by identifiable boundariesfrom its environment suprasystem" (p. 98). The key concepts of gcneralsystems theory are as follows:1. A system is more than the sum of its parts; it must be viewed as a whole.2. Systems can be considered open or closed. A system is considered open if it exchanges information, energy, or material with its environment; a closed system does not interact with its environ- ment.3. A system has boundaries that separate it from its environment4. Closecl systems are subject to entropy (a tendency to mn down), which incrcases until thc entirc systcm fails. Open systems that receive in- puts from their environment do not cxperience entropy if these inputs arc as great as the energv the s.vslems usc plus their outputs. In open systems, entropy can be arrested or transformed into negative entropy (a process of more complele organization and ability to translorm resources) by importing more from the cnvironment than the systems use and export.5. If an open system is to survive, it must receive enough inputs from its environment to offset its output plus the energy and materials used in the operation of the system. When a system achieves such a balance, it is in a steady state, or a state ol dynamic equilibrium. Thc system remains in dynamic equilibrium through thc inflow of materials, energy, and information.6. If a system is to achieve a steady state, it must have feedback; in- formation concerning the process of the system is fcd back as input into the system. 7. Systems have subsystems and are also part of a suprasystem; they are hierarchical. 8. Closed systems tend toward entropy and disorganization, whereas open systems tend toward increased elaboration, differentiation, and a higher level ol organization. 9. Open systems can achieve desircd results (such as the steady state) in various ways by means of a process called equilfinalitlt Somc results may be achieved with different initial conditi<,rns and in different ways.
  34. 34. A FRAMEWORK FOR THE PRACTICE OF NURSING ADMINISTRATION Organizations should be considered in terms of a general open systemmodel. The internal functioning of an organization must be congruentwith the demands of organizational tasks, technology, external envi-ronment, and the needs of its members if the organization is to be ef-fective. The view of an organization as an open system suggests a differentand more difficult role for the administrative executive than his or herrole in a closed system. The open system interacts with its environmentand moves toward a steady state while maintaining capacity for workand energy transformation. New management must deal with externaluncertainties and ambiguities and must be flexible in order to adapt tonew and changing requirements. For example, the hospital organizationreceives input from its external environment in the form of personnel,financial and material resources, and information; it transforms outputof health care services and rewards into an organization that is sufficicntto maintain employee participation. An early systems theorist was Chester Barnard, who in 1938 wroteThe Functions of the Executive, based on his years of experience as pres-ident of the New Jersey Bell Telephone Company. He focuses on thepsychosocial aspects of organization and management. Barnard (6) con-iid"rr the organization a social system in his definition of a formal or-ganization as a "system of consciously coordinated activities or forcesof t*o or more persons" (p. 73). He defines the functions of the executivein a formal organization as the followinS (1) the maintenance of or- ganizational communication through a scheme of organization coupledwith loyal, responsible, and capable people; (2) the securing of essential services from individuals in the organization; and (3) the formulation and definition of purpose. Katz and Kahn (7) conceptualize the role of the executive or manager as one of a number of organizational subsystems. Such subsystems op- erate together to meet organizational needs and accomplish necessary tasks. Katz and Kahn identify maintenance structures that function to maintain stability and predictability in the organization. The purpose of such structures is to preserve a steady state of equilibrium. Such structures may resuit in a tendency toward organizational rigidity, the preservation of the status quo in absolute terms. Or they may necessitate mediation between task demands and human needs to keep the struc- tures in operation. Such mechanisms for maintaining stability seek to formalize, or institutionalize, all aspects of organizational behavior. The boundary structures of procurement of materials and personnel and product disposal involve transactional exchanges with the envi- ronrlent. These mechanisms concern acquiring control of sources of supply and creating an organizational image idaptlu" structure concerns the survival of the organization. Both the maintenance and adaptive stmctures move in the direction of preser-ving
  35. 35. MANAGEMENT THEORIES 31constancy and predictability in the conditions of organizational life. Katzand Kahn (7) emphasize that the adaptive function can focus either onattaining control over external forces and maintaining predictability inthe operations of the organization or on achieving internal modificationsof organizational structures to meet the needs of a changing world. The managerial system cuts across all the operating structures of pro-duction, maintenance, environmental support, and adaptation. Themanagerial system is the controlling, or decision making, aspect of theorganization. Karz and Kahn (7) further state that "the complexity oforganizational structures implies that the functions of management arealso complex. Three basic management functions can be distinguished:ll) the coordination of substructures, (2) the resolution of conflicts be-tween hierarchical levels, and (3) the coordination of external require-ments with organizational resources and needs" (p. 91).Contingency Management MovementInvestigators who examine the functioning of organizations in relationto the needs of their members and the external forces impinging uponthem emphasize the contingency approach to management. Comparedto the systems approach, contingency views of organizations emphasizemore specific characteristics and patterns of interrelationships amongsubsystems. The contingency, or situational, approach accepts the dy-namics and interrelationships inherent in organizations and in the be-havior of their members. Some theorists make no distinctions betweenopen systems and contingency theory. Others emphasize that the purposeof the contingency approach is to develop specific functional relation-ships between independent environmental and dependent managementvariables. Robbins (8) points out that the contingency movement began by iden-tifying common characteristics that might exist in a variety of situationsand that could make it possible to qualify a theory to the specifics of asituation. If one cannot say, "If X, then Y," possibly one can say, "If X,then Y, but only under the conditions specified in Z." Three components of the contingency approach are the environment,management concepts and techniques, and the interrelationships be-tween them. For example, management concepts and techniques maybc classified as process variables, including planning, organizing, di-recting, communicating, and controlling; quanlitative variables, in-cluding decision making, linear programming, and operations researchmodels; behavioral variables, including learning, behavior modification,motivation, and group dynamics; and systems variables, including gen-eral systems theory, systems design, and management information sys-tems. The contingency approach is designed to relate the environmentto these various management concepts and techniques.
  36. 36. MANAGEMENTTHEORIES 35 6. Barnard, C.I. The Functions of the Executive. Cambridge, Mass.: Harvard University Press, 1938. 7. Katz, D. and Kahn, R. The Social Psychology of Organizations. New York: Wiley, 1978. 8. Robbins, S.The Administrative Process,2d ed. Englewood Cliffs, NJ.: Pren- tice-Hall, 1980. 9. McGregor, D. The H uman Side of Enterprlse. New York: McGraw-Hill, 1960.1 0. Ouchi, W .G . Theory Z. Reading, Mass. : Addison-Wesley , 1982 .
  37. 37. A FRAMEWORK FOR THE PRACTICE OF NURSING ADMINISTRATIONteracting with its environment. The contingency approach to admin-istration emphasizes that there should be a congruence betr.veen the or-ganization and its environment and among its various subsystems. McGregors theories X and Y have helped clarify direction for the fieldof organizational behavior toward a more humanitarian approach. Thephilosophy of a theory Z management approach is that the organizationcan significantly benefit from a management style based on trust andon workersinvolvement in discussions that affect them and their prod-uct. It is important to note that recognizing the contributions of the variousschools of management is more important than identifying the type ofschool, its functions, and principles. Many modern management tech-niques are direct outgrowths of these schoolsvarious approaches.STUDY QUESTIONS1. What is the major premise of each of the three schools of adminis- tration, or management?2. Which of Fayols management principles have influenced nursing administration? Explain.3. What are the major differences between an open and a closed system?4. How is the systems approach applicable to management practiccs in nursing administration?5. What is meant by a contingencv view of organization?6. What assumptions do theory X managers and theory Y managers make about people?7. Select a problem in nursing administrative practice that could be reduced or eliminated by utilizing the theory Z management ap- proach, involving the quality circle process.REFERENCES 1 . Taylor, F .W . The Principles of Scientific Management New York: Harper and Brothers,1911.2. Fayol, H. General and Induslrial Managemenl. London: Sir Isaac Pitman & Sons, 1949.3. Filley, A., House, R., and Kerr, S. Managerial Process and Organizational Behavior. Glenview, Ill.: Scott, Foresman, 1976.4. Donnelly, J., Gibson, J., and Ivancevich, J. Fundamentals of Management. Dallas: Business Publications, Inc., 1975.5. Kast, F. and Rosenzweig, J. Organization and Management: A Systems and Contingency Approach,3d ed. New York: McGraw-Hill, 1979.
  38. 38. MAN AEMINI lFrEqREq 33ues within the organization. Consensual decision making pr<-rvides thedirect benefits of information and value sharing and at the same timcopenly signals the commitment of organizations to those values. One expression of worker participation in a theory Z managementapproach is the quality circle, or Q circle. The Q circle was developedin Japan as a useful method of achieving high quality, improved pro-ductivity, and increased cmployee morale. Quality circles are disciplinedoperations. It is imperative that the staff be knowledgeable regardingthe concept of theory Z. Quality circle training programs must be a partof the total implementation plan. A typical Q circle consists of two to ten employees who are assignedto that circle. Each circles employces form a natural working group inwhich everyones work is related. Workers meet together regularly toidentify a problem and collect data on the type and nature of that prob-lem. At the conclusion of the study period, members analyze the data,develop and try solutions, and evaluate results. If thcse stcps can beundertaken cntirely by members of the circle, they implemcnt thc stepsto correct it. If the problem is more gencral, then members may call forthe formation of a Q circle team to seek out organization-wide solutions.It is important to note that ultimately a solution is identificd and im-plemented. Once solutions are implementcd and, often, a designated period oftime has passed, the circle musl evaluate thc outcome. The results arecompare d with the goals to dctermine the extent to which the identifiedproblem was solved. If thc goal has not been achieved, the circle analyzcswhy. The circle then returns to the solution development phase and for-mulates another solution and a plan for implementation. A formal reportof the circles activities is presentcd to the appropriate group within theorganization. Quality circles have been very effective not only in solvingproblems but also in increasing worker productivity and enhancing jobsatisfaction.SUMMARYThe classical school of management focuses on the structure of formalorganizations, the process of management, and thc functions of a man-ager. The behavioral school emphasizes human relations and th.r sci-cntific approach to the study of human behavior in organizations. Theactivities of the management science school are characterized by an em-phasis on the mathematical modeling of systems. Systcm concepts provide the c<-rnceptual framework for understandingorganizations. General systems theory includes concepts related to thcunderstanding and integration of knowledge lrom a variety of disciplines.Svstetn thcorists generally view an organization as an open systcm in-
  39. 39. 32 A FRAMEWORK FOR THE PRACTICE OF NURSING ADMINISTRATIONTheory X and Theory YDouglas McGregor (9) has written that the vertical division of labor pro-posed by the classical management theorists is based on a set of negativeassumptions many managers have about their employees. He has sug-gested that organizations can achieve their goals more effectively if theyaddress the human needs of organizational members and utilize theirpotential. What McGregor calls theory X is based on traditional auto-cratic assumptions about people, while theory Y is founded on behav-iorally based assumptions about people. Mosl management actions flowdirectly from the particular theory of human behavior managers hold. Theory X refers to an autocratic approach to managing. It assumesthat most people dislike work and will try to avoid it if possible. Ac-cording to this theory, people have little ambition and avoid rcspon-sibility. They are self-centered, indifferent to organizational needs, andresistant to change. Theory Y implies a humanistic and supportive approach to the man-agement of people. It assumes that people are not inherently lazy andindolent but that they may become so as a result of experience. Accordingto theory Y, people exercise self-direction and self-control in the serviceof obiectives. They have potential. They have imagination, ingenuity,and creativity that can be applied to work. McGregor argued that the conventional management approach ig-nored the facts about people because these managers adhere to theoryX and follow an outmoded set of assumptions about their employees.McGregor contends that most people are close to the theory Y set ofassumptions. These managers need to change to a whole new theory ofworking with people: theory Y.Theory ZAdvocates of theory Z suggest that involved workers are the key to in-creased productivity. With the current interest in Japanese theory Zmanagement, the question arises whether such participatory manage-ment techniques can be adapted to American organizations. William Ouchi (10) contends that the Japanese quality edge is theresult of a management style based on trust, subtlety, and worker in-volvement. Trust and subtlety (i.e., relationships between peoplc, de-termining who works best with whom) improve productivity througheffective coordination. The assumption is that if workers ideas are heard,the result is a satisfied, motivated, and productive work force. Consensus,participative decision making, lifetime employment, and a commitmentto organizational goals are facets of this approach. In a theory Z organization, the participative process is one of themechanisms that provides for the dissemination of information and val-
  40. 40. The Person in the Roleof lNursing Adrninistrator The purpose of this chapter is to emphasize the person in the role of nursing administrator by focusing on the importance of thc ad- ministrators personal attributes and leadership skills. On com- pletion of this chapter, the reader will be able to: l. Conceptualize the nursing administrator in professional practice as a leader and administrator. 2. Discuss the Maslow and McClusky concepts of self-actuali- zalion and transcendence as they relate to the nursing ad- ministrator. 3. Relate the concept of leadership to excellence in administra- tion. 4. Articulate the key personal attributes of the successful nursing administrator. 5. Describe personal support systems as important coping mechanisms. 6. Support the importance of time management for the effective administrator.It is a myth that only those who cannot practice, teach and those whocannot teach, aclministrate. True administrators are leaders who lovethe challenge and hard work of creating a climate in which professionalnursing practice can occur. They are catalysts not only for their ownactivitLi but for those of others. Contrary to the beliefs of many nurscs,the excellent nursing administrator must possess the highcst level ofability and the greatest personal skills. Such leaders are not bound bythinking about *hut.unt ot be done. Rather, they see the same puzzlesothers see, but they envision different ways of putting them togcther. There is a leaderihip crisis in nursing, a critical shortage at all levelsof nursing administrators with the political, psychological , and social-u.rug"-"nt skills needed to cope rvith todays changing world (1).36
  41. 41. 38 A FRAMEwoRK FoR rHE PRACTICE oF NUBqIryg A44INI9rB4IIQNhave technical knowledge as well as executive ability. Financial knowl-edge and training in every detail of work were essential skills. Some ofthese early directors may well have been queen bees, but it is unlikelythat they separated themselves from the rest of nursing, since they livedin the hospital they directed and kncw the nursing staff extremely well.THE NURSING ADMINISTRATOR AS A LEADERNursing administrators cannot create a climate for professional practiceunless they are leaders as well as managers. Administration can be car-ried out by nonnurses, but true leadership in a professional practicesetting must be manifested by a nurse with leadership skills. The workof nursing administrators differs from that of other hospital adminis-trators in that nursing involves professionals, or what Drucker (6) calls"knowledge workers." The productivity of knowledge workers requiresthat people be assigned where there is potential for results and not whereknowledge and skill cannot produce results. The utilization of nursingresources according to level of education, experience and, strengths isof critical importance today for all nurses in administrative posts. There are no known ways of training great leaders, and the preparationof leaders in nursing has become the challenge of this decade for schoolsof nursing. Most deans and program directors will claim to be preparingIeaders, but the fact remains that true leaders simply are not emergingfrom nursing graduate programs. According to Zaleznik(7), managers and leaders differ fundamentallyin their world views, perceptions, and personal characteristics:1. Attitudes toward goals: managers tend to adapt impersonal attitudes toward goals; leaders adapt a personal and active attitude toward goals.2. Conception of work: managers act to limit choices as they seek the accomplishment of specific tasks through predetermined combina- tions of people and ideas; leaders work to develop fresh approaches to long-standing problems and to open issues for new options.3. Relation with others: managers prefer to work with people, avoid solitary activity, and relate to people according to the role they play; leaders are more empathetic and are concerned with what events and dccisions mcan to participants.4. Sense of self: managers are once-born personalities and belong to the institutional environment; leaders tend to be twice-born personalities and separate from their environment; they may work in organizations but never belong to them.
  42. 42. THE PERSON IN THE ROLE OF NURSING ADMINISTRATOR 37Nurses are unprepared or unwilling to assume leadership roles. Womenare not socialized to assume leadership roles, nor do existing nursingprograms really address the need to prepare nursing leaders who arecffective administrators. Chaska (2) speaks of the nursing profession asbeing in a "mist" of conflicting views about professionalism and profes-sional practicc. The hospital is the primary area of employment for nurses, with sixty-five percent of all nurscs employed in a hospital setting (3, p.21). Hos-pitals are big business, and most nursing administrators are not preparedio function within a complex corporate structure. It may be possiblethat much of the burnoul experienced by nurses at all levels is due tclthe inability of nurses in leadership roles to function in complcx cor-porate structures. Regardless of the setting for practice-whether hospital, communityhealth agency, or long-term care setting-nursing administrators needto know how to compete effcctively in a businesslike world. Spitzer (3)suggests thal nursing administrators necd to:1. Reverse the tendency toward isolationism and communicate with others outside of nursing as well as within nursing.2. Expand tcamwork skills.3. Understand management concepts and organizational goals.-1. Promote an organizational stn-lcture and environmcnt that encourage involvement of sfaff nurses at all levels rathcr than the practice of creating and maintaining "Queen Bees" (p.2a)The prevalence of the queen bee syndrome interferes with the advance-rnent of professional nursing in any instilutional setting. The quecn bec syndromc has been identified by Halsey (4) as certainantifeminist behaviors of women who successfully secure positions inmanagement and other traditionally male-dominatcd carecr worlds.Queen bees in nursing administration positions are not an advantagero nursing. These individuals have a desire to work independenfly ofurher nurses, iclentify with people oulsidc nursing, align tenaciously withrhe institution, and have little interest in making changes that wouldbenefit nursing. They seek to preserve their own images, demand per-sonal loyalty, and have a strong need to run the entire show at the cx-:ense of other competent women. Thcy are high achievers and excellcntrn their arca of interest, but thcy are not leaders. Early directors of nursing, called superintcndents, did run the wholeshou, in hospitals but not nccessarily at the expense of other nurses.Erickson (5) dcscribes the nursing superintendent as the forerunner ofirodern hospital and nursing administrators. These early dircctors wcreresponsiblc for nursing service and education. They werc expectcd to
  43. 43. rHE PERSON IN rHE ROLE oF NURSING ADI{IN!9rB4IQ& 39 Managers develop through socialization, and leaders develop throughp".ronul mastery. For a leader, self-esteem does not depend solely onpositive attachments and real rewards. Leaders cannot be bought bythe institution. They have visions and dreams that managers may neversee. As nursing seeks to become recognized as a profession, it is increas-ingly important to have visionaries in leadership roles in order to findnew answers to old unresolved questions. Who, then, are leaders? Lundberg (8) says that leaders are people who:l. Know where they are going.2. Know how to get there.3. Have courage and persistence.4. Can be believed.5. Can be trusted not to sell their cause for personal advantage6. Make missions important, exciting, and possible7. Make subordinates feel that their role in the mission is important.8. Make others feel capable of performing their role. Managers, says Drucker (6), are paid to enable people to do the workfor which they are paid. Nursing administrators do not earn their payil they do not create a professional practice climate in which nurses cando their work. Leaders make a difference in the lives of those who workfor them and with them.MASLOW, MCCLUSKY, AND THE NURSINGADMINISTRATORThe able nursing administrator is not only self-motivated but is alsoable to create an environment in which others are motivated. To mo-tivate others requires a strong self-concept and a high place on the ladderof Maslows hierarchy of needs (9). In other words, the able nursing ad-ministrator is one who has reached the stage of self-actualization. Maslows theory of motivation can be applied to almost every aspectof human life, but it has special significance for those who lead andguide others. Maslows theory provides a basis for the higher needs ofpsychological growth. People are initially motivated by basic physio-logical needs. As those needs are satisfied, the individual moves towardthe level of higher needs and becomes motivated by them. This is theheart of Maslows theory. klost previous studies assumed that needscould be isolated and stuc,ied separately. Maslow considered the indi-vidual an integrated whole. The identification of needs for grorvth, de-velopment, and utilization of potential are an important part of self-
  44. 44. 4 iB4l4EMB4 FoR rHE PRACTTCE oF NURSTNG ADI4Ar]€JRATTON GroMh needs (Being values, metaneeds) Self-esteem Esteem of others Love and belongingness Physiological (Air, water, food, shelter, sleep, sex) FIGURE 4.1 Maslows hierarchy of needs. actualization. Maslow has described this need as the "desire to become more and more what one is, to become everything that one is capable of becominC" (9). Figure 4.1 depicts Maslows hierarchy of needs. Maslows hierarchy has been applied to patient needs. It also has significant application for the nurse as a person. Nursing administrators as nurse persons and leaders of other nurse persons have a special need to reach the level of self-actualization. Nurse persons are described by Simms and Lindberg (10) as fully functioning individuals who are comfortable with using theself as well as technical skills in professional practice. This impliei theneed for growth and development of the nurse as a person. Self-actualization is the desire for self-fulfillmcnt, to make actual allones potentialities. Maslow related potential to the concept of growth,and by growth he meant the constant development of talents, capacities,creativity, wisdom, and character. To play a role satisfactorily, a personmust have a self-concept that fits the role. More recently, Howard Mcclusky (11) the university of Michigan, fdelineated educational necds for oldcr persons ranging from survivalthrough maintenance, to growth and beyond. The Mcclusky conceptualframework is readily adaptable to the growth and development of nurs-ing administrators and provides a companion schema to Maslows hi-erarchy. within the framework of ranges of necds, Mcclusky proposed
  45. 45. THE PERSON IN THE ROLE OF NURSING ADMINISTRATOR 49the seeds of a desired change and then rigorously making sure the seedsgrow and multiply.CreativityA distinctly human quality, creativity is not any one thing, but containsthe common elements of all creative thought: divergent thinking, flex-ibility, fluency, and originality. Creativity is the highest order of con-ceptualization and problem solving. By definition, to create is to evolvesomething from ones own thought. True innovation must come fromrvithin. Innovating means not succumbing to the fallacy that there isnot enough time to be creative. It comes from a can-do, rather than acanl-do, philosophy. Creativity sets the excellent administrator, the tme leader, apart fromthe minimum-level performer. Anyone can be taught the four maximsof management: planning, organizing, implementing, and evaluating.One can learn to memorize the rules of delegation and time managementand still not have anything to delegate or any reason to save time. The successful nursing administrator is a creative problem solver. Tobe creative, nursing administrators must free themselves from their ownpremature judgment. They must allow themselves time for theorizingand hypothesizing. Many creative people recognize that they give in- termittent attention to problems of interest; that is, they are aware ofincubation periods when much subconscious activity may be occurring.It is important, therefore, to develop an increased awareness of theproblems to which one would like to direct attention. Functioning cre-atively, one can combine intuition and scientific principles to achievesuperlative problem solving. Such functioning is the highest level ofprofessional skill. Creativity is truly the art of seeing what everyone else is seeing but thinking what no one else has thoughr. The essential problem for teachers of the professions is the difficulty of providing a transition from academic experience to work experience. Many educators struggle over how to teach administrators the qualitiesof a leader. Epstein (25) discusses the "missing factor" in the teaching:leadership skills and the need for leadership are packaged together forstudents without the opportunity to make creative inferences. The com-petency-based movement in education threatens to shroud further thedevelopment of creative leaders. There is a difference between compe-tence and the full functioning of excellence in the practice of adminis-tration. The excellent nursing administrator is a leader who is creative. Crea-tivity can be recognized only if it is observable by others. The outcomesof creativity are recognized in the results of ones labors either as ac-complished, recognizable feats or as changed behavior of fellow workers. The creative leader is in fact an effective teacher, one who influences
  46. 46. 48 a pnanteWg-B4 tqBl4! JBaAIIcE oF NURSING ADMINIWIo-Nmodalities ranging lrom integraged charlrnB to lrue coaborative careplanning and implementation. Nursing administrators must listen toutt th" aiguments against joint practice and still persevere toward es-tablishinf a feasiblelnstitutional or unit model. They must be preparedto face ttre wrath of nurses and physicians alike who are unwilling tocollaborate in a pr<.lfessional, meaninful way Nursing administrators must be willing to meet one to one, in smallgroups oii.r lurg" groups-whatcvcr it takes to nurture discussion andia"triify opposition. All,owing ones ideas to bc thoroughly challengedu.rd q.r"rtioned enables one to verify thosc ideas and to remain in onesgoal without becoming known as a stubborn tyrant. Stubbornness isiot to be confused with courage, for stubbornness implies a closed mind,one that is not willing to test out new ideas It takes courage to work in the midst of negative criticism. It takescourage to meeiwith opponents and try to achieve a meeting f theminds. It also takes courage to face the opposition and maintain presenceof mind and dignity without becoming pompous or resorting to shallow thinking. It tafes" to swim daily with the sharks as well as the friendly-dolphins. It takes courage to maintain composure and not show orr.,, *o.rnds, though some may be deep. Above all, it takes courage to remain clry eyed even when angered to frustration and tears (24).ConvictionA conviction is a strong persuasion and belief, an opinion held withcomplete assurance d"rpii" opposing arguments, a belief stronger thanan impression and less slrong than positive knowledgc. Onc cannot have.o.rr.g" without convictions, and one cannot have convictions withoutstronf inner discipline and high ideals. one who has conviclion about.rursiig icleals is willing to attempt to convert others to the same wayof thin"king ancl to goals that are meaningful to nursing andthe institution. "rtublith With conviction comes the ability to communicate ones opinion. Notonly does one have an opinion, but one is also able to communicatc thatopinion orally and in writing. A lot is written about communication inthe nursing lite.ut.rr", but little is written about having something to communiclate. The nursing administrator must communicate from a base of knowledge an<l experience that reflects understanding of thc is- sues under discussion. The nursing administrator with conviction is a nagger, one who kecps needling away at others in orcler to move toward goals of worth: when others b"elieve-an idea has been dropped, they soon realize they are being bombar4ed from another quartei. Administrators with courage and conviction bring about change and desired internalization of ideas in others without ftrce. Rather, they bring about such results by planting