The Image of Male Nurses and NursingLeadership Mobilitynuf_2.docx

The Image of Male Nurses and Nursing
Leadership Mobilitynuf_206 22..28
Timothy B. McMurry, EdD, MSN, RN
Timothy B. McMurry, EdD, MSN, RN, is Associate Director for
Patient Care Services/Nurse Executive, El Paso VA Health
Care System, El Paso, TX.
Keywords
Gender, discrimination, male
nurses, gender advantages, glass
ceiling, sexism, stereotype,
nontraditional
Correspondence
[email protected], with a
copy to the Editor:
[email protected]
Research consistently reveals that white men maintain an
advantage over
other status groups such as women in positions of authority
pertaining to
human capital. This paper examines male underrepresentation in
the
nursing profession, including difficulties such as discrimination
and
advantages for them determined by their gender. The literature
suggests
that men are given fair, if not preferential, treatment in hiring
and
promotion decisions, are accepted by supervisors and
colleagues, and are

well integrated into the workplace subculture.
The gender segregation of the U.S. labor-force is one of
the most perplexing and tenacious problems in our
society even though the proportion of men and
women in the labor force is approaching parity,
particularly for younger cohorts of workers (U.S.
Department of Labor, 2009). However, women are still
generally confined to predominantly single-sex occu-
pations. Forty percent of these women would have to
change their occupational categories to achieve equal
representation in all job categories (Reskin & Roos,
1999). This figure underestimates the true degree of
sex segregation. It is extremely rare to find specific
jobs where equal numbers of men and women are
engaged in the same activities in the same industries
(Bielby & Baron, 2003). Most studies of sex segrega-
tion in the workforce have focused on women’s
experiences in male-dominated occupations. Both
researchers and advocates for social change have
focused on the barriers faced by women who try to
integrate predominantly male fields. Few have looked
at the “flip-side” of occupational gender segregation:
the exclusion of men from predominantly female
occupations. But the fact is that men are less likely to
enter female-typed occupations than women are to
enter male-dominated jobs (Jacobs, 1989). Reskin and
Roos (1999), for example, were able to identify 33
occupations in which representation increased by
more than nine percentage points between 1985 and
1995; however, only three of these occupations had
increased male presence as radically (Porter-O’Grady,
1995).
This paper will examine male underrepresentation

in the nursing profession, including difficulties such as
discrimination and also advantages for them deter-
mined by their gender. Scholars interested in sex
workplace inequality have developed a varied and rich
literature documenting the discrepancies in access to
positions of authority. Research consistently reveals
that white men maintain an advantage over other
status groups such as women in positions of authority
pertaining to human capital (Porter-O’Grady, 1995).
To adequately review the relevant literature and
discussions regarding men in nursing, the discussion
will include both social science and nursing research.
Although each respective body of literature tends to
overlap and underscore the other, their focuses differ
significantly. Social science discourse tends to evaluate
larger social structures and processes, while the
nursing literature utilizes a microstructural approach
by concentrating on the paucity of men in nursing and
how best to recruit and retain men into the profession.
Although some male nurses have made anecdotal
assertions that male nurses encounter difficulties
maneuvering successfully through the profession,
social science research does not support these asser-
tions (MacKintosh, 1997).
Disagreement between the two bodies of research is
most noticeable in the following two metaphors used
AN INDEPENDENT VOICE FOR NURSING
22
© 2011 Wiley Periodicals, Inc.
Nursing Forum Volume 46, No. 1, January-March 2011

to describe differing perceptions of the professional
experiences of male nurses. The first example used by
male nurses to describe their experiences in nursing
has included the depiction of a “concrete ceiling”
barring men from leadership roles in nursing (Porter-
O’Grady, 1995). Yet, the metaphor used by prominent
social scientists characterizes the movement of men
within professional nursing as a “glass escalator” car-
rying men to top leadership positions in the field (Wil-
liams, 1992).
While nurses generally discount or ignore gender
relations in health care, social science researchers
assert that male nurses use a number of strategies to
establish and maintain masculine spaces within the
nursing profession, and by carrying the privilege of
their gender into nursing, men tend to monopolize
positions of power in the nursing profession (Simpson,
2004).
Historical Evolution
The purpose of this review is to provide a historical
overview of how nursing became a predominantly
feminine endeavor, including how masculine honor
codes in medicine and science assured gender-
segregated career paths of medicine and nursing in
health care. Caring work and the intersections of
gender, race, class, and religion will also be reviewed
with an overview of current understanding about how
male nurses negotiate masculinity in the predomi-
nantly female occupation of nursing.
Until Nightingale’s reformation of nursing, males
performed many nursing tasks (Burns, 1998). Reli-

gious orders played a particularly hardy role in defin-
ing nursing as a career for men during the Middle
Ages. Detailed records of the monastic movement pre-
served the history of male caregivers as evidenced by
the Saint Antonines, an order founded in 1095 to care
for mentally ill persons, and the Knights of Lazarus,
founded in 1490 to care for persons with leprosy
(MacKintosh, 1997). Historical documents demon-
strate that males also doubled as soldiers and caregiv-
ers for the sick and wounded during wars, from the
Crusades, the U.S. Civil War, World War 1, through
modern day conflicts including the present war in Iraq
(Boivin, 2005). In many Islamic countries, where
women are not well integrated into the workforce,
men primarily function in the role of a nurse (Burns,
1998).
Modern discourse, however, focuses almost entirely
on the study of a predominantly female occupation
built upon the essentialist philosophical assumption
that the caring role performed by nurses is an inher-
ently feminine one. Although men have had a place in
nursing as evidenced by records maintained by reli-
gious orders, the military, and labor-intensive indus-
tries such as mining, the numbers and roles for male
nurses have declined. In the mid-nineteenth century,
Florence Nightingale introduced training reforms for
nursing that marked the profession as a secular
nursing sisterhood which allowed little to no oppor-
tunity for male participation in nursing. What
emerged was the reproduction of the wider Victorian
class structure, based on preconceived notions of the
division of labor between the sexes and between
women of different classes (MacKintosh, 1997).

Based on the essentialist view that women are bio-
logically endowed with a nurturing, caring nature,
Nightingale secured a place for nursing as an accept-
able career for white, elite Victorian women. Nightin-
gale firmly believed that nursing was a natural
extension of virtuous womanhood. Concurrently,
men came to be viewed as “clumsy” and inadequate or
incapable of caring adequately for persons experienc-
ing sickness or an injury (Burns, 1998). Meanwhile,
under a structure of patriarchal capitalism, which was
advanced during the Nightingale era, the work of men
became elevated and women’s caring work was deval-
ued and subsequently relegated outside the domain of
work that was considered worthy or masculine
(Padavic & Reskin, 2002).
Williams’ (1989) discussion of the changing status
of males in nursing during and after World War II
revealed the American military to be virtually an all
male domain until World War II, when a surge of
women enlistments moved into the war effort.
Women especially made headway into the military
ranks by filling nursing and secretarial positions, thus
freeing men for combat roles. Williams demonstrated
that the military’s vision and preference for nurses
included only “young, single, white, females” and
served to perpetuate and reproduce an ideology
excluding men as nurses. Arguably, even if men had
been allowed into the military as nurses, few would
have accepted military nursing assignments with so
few benefits. Although the Navy did allow admission
of a small number of male nurses, they were not
granted entry into the Nurse Corps nor were these
male caregivers called nurses.
The military did not stand alone in perpetuating the

essentialist vision of gender bias in nursing. Even the
premiere U.S. nursing organization, the American
T. B. McMurry The Image of Male Nurses and Nursing
Leadership Mobility
23
Nurses Association (ANA), inadvertently endorsed the
essentialist ideology through its efforts to increase
male nurses in the military. The ANA lobbied to
change the military’s policies to permit men into the
Army and Navy Nurse Corps and to train men in the
Cadet Nurse Corps, a federally funded all-expenses-
paid training program for young nurses. However, the
argument used by the ANA reinforced gendered ste-
reotypes by calling for strong men to work in special-
ties such as urology, psychiatry, supervision, and
teaching (Williams, 1989).
Simply adding more women into the military ranks
did not automatically result in reduction of dichoto-
mous labeling of what was deemed appropriate work
for men and women in the military. Military men
often depicted female military nurses by using either
virgin or pin-up girl imagery. Williams (1989) pro-
vided a cogent explanation for this phenomenon. She
believed the mere presence of women was particularly
threatening to men and their since of good order and
discipline. If women performed tasks previously con-
sidered “masculine,” women’s participation devalued
the activity because the masculine goal of separation

from feminine identification had been challenged
(Williams, 1989). Likewise, male military leaders’ pre-
conceived notion that nursing could only be per-
formed by females precluded allowance for a separate
category for men. According to Williams, to place men
in a female role (nursing) would have threatened the
bastion of masculinity for which the military stood.
The military, although a traditional historical site for
male nurses throughout the world, became pro-
foundly disconnected from the profession in the
United States. Just as the essentialist ideology
espoused by the military served to disconnect men
from nursing, masculine honor codes deepened this
disconnection in both the military and civilian
domains.
Masculinity and Nursing
A number of authors characterize men who engage
in traditionally female professions as challengers of
cultural norms. According to Williams (1992), male
nurses configure their labor practices in nursing, uti-
lizing a number of strategies to overcome being ste-
reotyped as culturally deviant. She examined the issue
of male underrepresentation in predominantly female
professions (including nursing) by systematically
exploring barriers to men’s entry into women’s pro-
fessions; the support men receive from their supervi-
sors, colleagues, and clients; and the reactions they
encounter from those outside their profession (Will-
iams, 1992).
Many of the men in Williams’ study perceived their
numerical minority as an advantage in hiring and
promotion. In some facilities, however, policies actu-

ally barred men from certain jobs such as in birthing
and women’s surgery units, especially in private
Catholic hospitals (Williams, 1992). Other facilities
have used more latent tactics to exclude men from
women’s and children’s healthcare settings (Cude &
Winfrey, 2007), while some men described being
encouraged, even tracked into areas within the pro-
fession deemed more legitimate for men. For example,
“A nurse interested in family and child health said he
was dissuaded from entering in favor of adult nursing”
(Williams, 1992). Such tracking, Williams contends,
directs men to become upwardly mobile because jobs
in specialty areas are more prestigious, better paying,
and legitimize masculinity.
The effect of tracking results in the opposite of the
“glass ceiling” effect reported by women in male-
dominated professions. Women often experience
invisible barriers to advancement in male-dominated
professions. In contrast to the “glass ceiling” experi-
enced by women in gender atypical professions, many
of the men Williams interviewed seemed to encounter
a “glass escalator” effect of invisible pressures to move
up, but the upward mobility is excluded from the
Nurse Executive role since men are not usually
capable of working in female health-specific areas
(Williams, 1992).
Throughout the twentieth and twenty-first centu-
ries, the nursing occupations have been identified as
“women’s work” even though prior to the Civil War,
were more likely to be employed in this line of work.
These percentages have not changed substantially in
decades. In fact, since 1975, nursing has been the only
female-dominated profession experiencing noticeable
changes in sex composition, with the proportion

increasing to 80% between 1975 and 2000 (Reskin,
2002). Even so, men continue to be a tiny minority of
all nurses. Although there are many possible reasons
for the continuing preponderance of women in these
fields, the focus of this paper is female-oriented gender
discrimination within nursing management.
Researchers examining the integration of women
into “male fields” have identified discrimination as a
major barrier to women (Reskin & Hartmann, 2004).
This discrimination has taken the form of laws or
institutionalized rules prohibiting the hiring or promo-
The Image of Male Nurses and Nursing Leadership Mobility T.
B. McMurry
24
tion of women into certain job specialties. Discrimina-
tion can also be “informal,” as when women
encounter sexual harassment, sabotage, or other
forms of hostility from their male coworkers resulting
in a poisoned work environment (Reskin & Hart-
mann, 2004). Women in nontraditional occupations
also report feeling stigmatized by clients when their
work puts them in contact with the public. In particu-
lar, women in engineering and blue-collar occupations
encounter gender-based stereotypes about their com-
petence, which undermine their work performance
(Epstein, 1998). Each of these forms of discrimination
—legal, informal, and cultural—contributes to
women’s underrepresentation in predominantly male

occupations. The assumption in much of this literature
is that any member of a token group in a work setting
will probably experience similar discriminatory treat-
ment. Kanter (1977), who is best known for articulat-
ing this perspective in her theory of tokenism, argues
that when any group represents less than 15% of an
organization, its members will be subject to predict-
able forms of discrimination. Likewise, Jacobs (1989)
argues that in some ways, males in female-dominated
occupations experience the same difficulties that
women in male-dominated occupations face and
Reskin (2002) contends that any dominant group in
an occupation will use their power to maintain a privi-
leged position. However, the few studies that have
considered men’s experience in gender-atypical occu-
pations suggest that men may not face discrimination
or prejudice when they integrate predominantly
female occupations. Zimmer (2001) and Martin
(1988) both contend that the effects of sexism can
outweigh the effects of tokenism when men enter
nontraditional occupations.
Discrimination in Hiring
In several cases, the more the specialty was occu-
pied by women, the greater the apparent preference
for males. For example, when asked if he encoun-
tered any problem getting a job in pediatrics, a Mas-
sachusetts nurse said “no,” because he overheard
managers and supervisors within Pediatrics that they
think it is a pleasant change since their specialty is so
female dominated (Williams, 1993). However, there
were some exceptions to this preference in the most
female-dominated nursing specialties. In some cases,
formal policies actually barred men from certain jobs.
This was the case in a rural Texas school district,

which refused to hire male nurses for grades K-6
(Porter-O’Grady, 1995). Other nurses reported being
excluded from positions in obstetrics and gynecology
wards, a policy encountered more frequently in
private Catholic hospitals. But often, the pressures
keeping men out of certain specialties were subtler
than this. Some described being “tracked” into prac-
tice areas considered more legitimate for male nurses.
For example, another Texas man described how he
was pushed into administration and management,
even though he professed to be disinterested. A nurse
who was interested in pursuing graduate study in
family and child health in Boston said he was dis-
suaded from entering the program specialty in favor
of a concentration in “adult nursing.” This tracking
may bar men from the most female-oriented special-
ties within the nursing profession. But these situa-
tions may lead to male nurses effectively being
“kicked upstairs” in the process (Williams, 1992). The
specialties considered more legitimate practice areas
for male nurses also tend to be the most prestigious
and better paying ones. Researchers have reported
that many women encounter a “glass ceiling” in their
efforts to scale organizational and professional hierar-
chies. That is, they are constrained by invisible barri-
ers to promotion in their careers, caused mainly by
sexist attitudes in the highest positions (Freeman,
1990). In contrast to the “glass ceiling,” many others
seem to encounter a “glass escalator.” Despite their
intentions, they face invisible pressures to move up in
their professions. As if on a moving escalator, they
must work to stay in place. The glass escalator does
not operate at all levels. In particular, nursing aca-
demia reported gender-based discrimination at the
highest appointments when two male nursing profes-

sors reported they felt their chances of promotion
to deanships were nil because their universities
viewed the position of nursing dean as a guaranteed
female appointment in an otherwise heavily male-
dominated administration so that the university
could claim equal opportunity by having a female
dean within the university system (Williams, 1993).
Of course, men’s motivations also play a role in
their advancement to higher professional positions. I
do not mean to suggest that all male nurses resent
the informal tracking they experience. For many,
leaving the most female-identified areas of their
profession helped them resolve internal conflicts
involving their masculinity. Many men may also
have career ambitions of their own and take advan-
tage of these practices whether consciously or
unconsciously.
Leadership Mobility
25
It appears that women are generally eager to see
men enter “their” occupations. Indeed, several male
nurses noted that their female colleagues had facili-
tated their careers in various ways, including mentor-
ship in college. However, women often resent the
apparent ease with which men advance within tradi-
tional female professions, sensing that men receive
preferential treatment, which closes off advancement

opportunities for women (Tracey & Nicholl, 2007).
But this ambivalence does not seem to translate into
the poisoned work environment described by many
women who work in male-dominated occupations.
Among males, there are very few accounts of sexual
harassment. However, women do treat their male col-
leagues differently on occasion. It is not uncommon in
nursing for male nurses to be called upon to help
catheterize male patients, or to lift especially heavy
patients. Furthermore, women’s special treatment
sometimes enhanced rather than poisoned the men’s
work environments. One male nurse stated he felt
more comfortable working with women than men
because “I think it has some thing to do with control.
Maybe it’s that women will let me take control more
than men will” (Williams, 1993).
Several men reported that their female colleagues
often cast them into leadership roles. Although not all
favored this distinction, it did enhance their authority
and control in the workplace. In subtle (and not too
subtle) ways, differential treatment contributes to the
“glass escalator” experience in nontraditional profes-
sions (Williams, 1992).
Discrimination From Outsiders
The most compelling evidence of discrimination
against men in the nursing profession is related to
their dealings with the public. Male nurses are often
sterotyped as overly feminized males. Men’s move-
ment into traditional female jobs is also perceived by
the “outside world” as a step down in status, while
women who enter traditional male professions are
thought to have taken a step up in social status. This
particular form of discrimination may be most signifi-

cant in explaining why men are underrepresented in
these professions. Men who otherwise might show
interest in and aptitudes for such careers are probably
discouraged from pursuing them because of the nega-
tive popular stereotypes associated with the men who
work in them. This is a crucial difference from the
experience of women in nontraditional professions:
“My daughter, the physician,” resonates far more
favorably in most people’s ears than “My son, the
nurse.” Popular prejudices can be damaging to self-
esteem and probably push some men out of these
professions altogether. Yet, ironically, they sometimes
contribute to the “glass escalator” effect previously
described.
The negative stereotypes about men who do
“women’s work” can push men out of specific bedside
nursing jobs and channel men into more gender
“legitimate” practice areas. Instead of being a source of
discrimination, these prejudices can add to the “glass
escalator effect,” thereby perpetuating gender dis-
crimination for women.
Conclusion
Both men and women who work in nontraditional
occupations encounter discrimination, but the forms
and consequences of this discrimination are very dif-
ferent. The interviews suggest that unlike “nontradi-
tional” women workers, most of the discrimination
and prejudice facing men in female professions ema-
nates from outside those professions. The literature
suggests that men are given fair, if not preferential,
treatment in hiring and promotion decisions, are
accepted by supervisors and colleagues, and are well

integrated into the workplace subculture. Indeed,
subtle mechanisms seem to enhance men’s position
in the nursing profession, a phenomenon referred to
as the “glass escalator effect” (Williams, 1993). The
data lend strong support for Zimmer’s (2001) critique
of “gender neutral theory” in the study of occupa-
tional segregation. Zimmer argued that women’s
occupational inequality is more a consequence of
sexist beliefs and practices embedded in the labor
force than the effect of numerical underrepresenta-
tion per se.
The minority status of men in nursing often results
in advantages that promote rather than hinder their
careers. This translates into an advantage in spite of
their numerical rarity, which is a much different expe-
rience than that of women entering male-dominant
professions. Benefits to men in nursing are associated
with the desire for personal and professional power
and with stereotypes about masculine traits. This sug-
gests that token status itself does not diminish men’s
occupational success. Men take their gender privilege
with them when they enter predominantly female
occupations.
These stereotypes are initially emphasized in the
family and reinforced by the power differences and
B. McMurry
26

patriarchal structure that continue to characterize the
healthcare industry. These advantages translate into
preference in hiring and promotion. Strategies that
capitalize on increasing men’s awareness of these
benefits may be employed to increase the number of
men in nursing. This hidden gendered process creates
a structure which may encourage the overrepresen-
tation of males in the higher levels and a possible
explanation of their underrepresentation at lower
levels of nursing. It would appear that for men, the
tradition and favor of career developments and pat-
terns are clearly established. For women, however, it
seems that the traditional approach to career
advancement requires continued scrutiny. Consider-
ation should now be given to the development of
career structures which reflect not only the tradi-
tional male career developments and patterns but
also include the diversity of women’s experiences,
which, unlike male experiences, are gained both in
the organizational workplace and in the home.
Developments should also take account that women
place varying degrees of emphasis on the two
domains of home and work at different points in their
lives. It should also be recognized that men are more
likely to view work as a means to an end, whereas
women are more likely to see work as leading to
personal growth and fulfillment subsequently requir-
ing new and innovative considerations for evaluating,
management development, and promotion consider-
ations within the higher ranks of the nursing profes-
sion (Tracey & Nicholl, 2007).
Historically, the inclusion of men into nursing has
been fraught with difficulties since the era of Flo-
rence Nightingale. Although men represent a small,

but growing, minority in the profession of nursing
today, this does not appear to represent a career
liability in the same way minority status does for
women in male-dominated fields. Although sex role
stereotyping has hindered the recruitment efforts of
many, obstacles to entry into practice are superseded
by a quest for personal and professional power
among men that facilitates professional career
advancement in nursing. One perspective on men’s
advantages in nursing may be viewed from within
the context of gender socialization as etiologic to
men’s desire for power. A discussion of the evidence
suggests that there is a relationship between
increased desire for and attainment of power by men
in nursing as compared to their female colleagues.
An examination of the benefits that accrue to men in
nursing may have implications for further research
on the impact of gender and underlying themes of
discrimination unknowingly perpetuated by social
expectations of the male role and the nursing
profession.
Visit the Nursing Forum blog at http://www.
respond2articles.com/NF/ to create, comment on, or
participate in a discussion.
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B. McMurry
28
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MEDSURG Nursing—September/October 2009—Vol. 18/No. 5
273
Colonel John S. Murr a y, PhD, RN,
CPNP, CS, FAAN, is Director of
Education, Training & Research, Joint
Task Force National Capital Region
Medical, Bethesda, MD; and Pre s i d e n t
of the Federal Nurses Association.
Note: The views expressed in this art i-
cle are those of the author and do not
reflect the official policy or position of
the United States Air Force, Depart m e n t
of Defense, or the U.S. govern m e n t .
John S. Murray
Workplace Bullying in Nursing:
A Problem That Can’t Be Ignored
C
a rol is a new nurse working on a medical-surgical unit. She is
an outstand-
ing nurse — very thorough, attentive to the needs of her
patients, and
c o n s i d e red to be a team player by her co-workers. One day,
she is asked by
her supervisor to document she had provided care to patients
not assigned
to her. Carol declined. In the weeks that followed, Caro l ’s
supervisor contin-

ually belittled her in front of other staff and patients, told her
she should
have chosen another profession, spoke to her in a condescending
manner,
used demeaning language, or just completely ignored her. After
months of
continually being bullied, feeling depressed, suffering from loss
of sleep and
appetite, and not knowing where to turn for help, Carol resigned
her position
and went to work at another hospital.
What Is Workplace Bullying?
Workplace bullying, a serious issue affecting the nursing
profession, is
defined as any type of repetitive abuse in which the victim of
the bullying
behavior suffers verbal abuse, threats, humiliating or
intimidating behaviors,
or behaviors by the perpetrator that interf e re with his or her
job perf o rm-
ance and are meant to place at risk the health and safety of the
victim (Center
for American Nurses, 2007; Felblinger, 2008; Longo &
Sherman, 2007; Murr a y,
2008a). Often workplace bullying involves abuse or misuse of
power and
authority within an organization.

Bullying behaviors create feelings of defenselessness in the
victim and
significantly demoralize his or her right to dignity in the
workplace
( D e p a rtment of Labor and Industries, 2006; Longo &
Sherman, 2007). This
silent epidemic in nursing usually is driven by the perpetrator’s
need to be
in complete control of an individual, re g a rdless of the pain
and suff e r i n g
inflicted on the victim. The bully meticulously plans who will
be targ e t e d ,
when the victim will be abused, and how this abusive behavior
will be per-
petuated. Furt h e rm o re, the bully strategically plans to
involve other employ-
ees in the bullying behaviors, either voluntarily or by coercing
them into the
abusive behavior. Ve ry frequently these minions cooperate out
of fear of
being the next victim (Griffin, 2004; Murr a y, 2008a).
Why Individuals Bully
Nurses may bully others for a number of reasons. The basis
most often
is solely the need for the bully to be in control of all aspects of
the work envi-
ronment. The perpetrator of the bullying behavior also may have
a person-
ality flaw, such as being shortsighted; stubborn to the extreme
of psycho-
pathic tendencies, such as trying to be repulsively charming;
have an exag-
gerated sense of self; and lack the ability to be remorseful or
feel guilt over

the harm inflicted upon others (Anderson, 2002; Felblinger,
2008; Murr a y,
2 0 0 8 a ) .
Bullying behaviors also exist because of a white wall of silence
that often
p rotects the bully (Murr a y, 2007). In some cases, senior
managers ingratiate
these behaviors and often protect the bully instead of the
victims (Longo &
S h e rman, 2007). This unrelenting bullying behavior in the
workplace will con-
tinue unless health care organizations implement zero-tolerance
policies and
Workplace bullying is a seri -
ous problem affecting nursing.
Abusive workplaces result in
lack of job satisfaction, poor
retention, and adverse patient
outcomes. The purpose of this
a rticle is to present the history
of this problem in nursing and
o ffer potential solutions.
274 MEDSURG Nursing—September/October 2009—Vol.
18/No. 5
legislation is passed making work-

place abuse illegal (American
Association of Critical-Care Nurses
[AACN], 2004; Center for American
Nurses, 2007; Longo & Sherm a n ,
2007; Murr a y, 2008b; Ramos, 2006).
Tell Tale Signs of Wo r k p l a c e
B u l l y i n g
The following examples will
help nurses determine if they are
being bullied (Felblinger, 2008;
Longo & Sherman, 2007; Murr a y,
2 0 0 8 a ; ) :
• Despite a nurse’s attempt to
l e a rn a new pro c e d u re or com-
plete a task, the supervisor is
never pleased.
• A nurse is called to unplanned
meetings with the superv i s o r
(and perhaps others who are
witness or participants) where
only further degradation oc-
c u r s .
• The workplace bully continual-
ly undermines and torments a
nurse who is trying simply to do
his or her job.
• Despite having expertise and a
h i s t o ry of excellence in the are a
of practice, a nurse is accused
of being incompetent.

• No matter how many times a
nurse asks for help, and the sen-
ior leader tells the nurse action
will be taken, the bully contin-
ues to interf e re with the nurse’s
job perf o rmance.
• The bully screams or yells at
the nurse in front of others to
make him or her look bad.
• Colleagues are told to stop
interacting with a nurse at work
and in social settings.
• A nurse constantly feels
s t ressed and fearful waiting for
additional negative events.
• When a nurse asks an org a n i z a-
tional leader for help, he or she
is told to “get a tougher skin” or
“work out your diff e re n c e s . ”
• Co-workers and senior leaders
s h a re the nurse’s concern that
the bully is a problem but they
take no action to address the
c o n c e rn in the workplace.
Consequences of Wo r k p l a c e
B u l l y i n g
One of the most profound con-
sequences of workplace bullying is

the emotional pain suff e red by vic-
tims, which also has a secondary
e ffect on co-workers who witness
the bullying as well as families who
recognize the impact on the bullied
loved one. Victims suffer significant
a n x i e t y, depression, and feelings of
isolation (Murr a y, 2008a). Other
consequences include being labeled
as a troublemaker; fearing loss of
c a reer advancement opport u n i t i e s
or job loss, experiencing psychoso-
matic symptoms, such as nerv o u s
tension, headaches, eating disor-
ders, sleep disturbances; and onset
of chronic illness. Symptoms of bul-
lying can persist over extended peri-
ods of time. Furt h e rm o re, victims
may develop symptoms of post-
traumatic stress disord e r. These
wide-ranging consequences can
have long-term detrimental eff e c t s
on victims, including problems with
self-esteem, re c u rrent nightmare s ,
and depression (Felblinger, 2008).
Impact of Bullying on Health
C a re Org a n i z a t i o n s
Bullying in the workplace is a
v e ry serious matter that continues
to escalate in health care org a n i z a-
tions. Although little is written on
the topic of workplace bullying as it
relates to nursing, literature indi-

cates hostility significantly decre a s-
es morale as well as job satisfaction
( G reene 2002; Murr a y, 2008a). If
abuse is permitted to continue
unabated, workplace rights advo-
cates expect the financial burden on
health care institutions to be
u n p recedented. Bullying in the
workplace can cost over $4 billion
yearly (Murr a y, 2008a). It also has
become a major contributor to the
i n c reasing rate of work dissatisfac-
tion, absences from work, lost pro-
d u c t i v i t y, and work-related injuries
in health care institutions
( F e l b l i n g e r, 2008; Longo & Sherm a n ,
2007; Murr a y, 2008a).
Health care leaders can addre s s
workplace bullying by following the
F o rces of Magnetism developed by
the American Nurses Cre d e n t i a l i n g
Center (ANCC, 2008), which de-
scribe characteristics that exempli-
fy excellence in nursing. For exam-
ple, nursing leaders should be well-
i n f o rmed risk takers who support
s t a ff in providing safe, high-quality
patient care. Magnet® leaders are in
a key position to advocate for nurs-
es who are bullied in the workplace
because they realize the potential
impact on patient care delivery.
Magnet hospitals also encourage a
p a rticipative management style that

accepts feedback from nurses at all
levels of the organization. In fact,
Magnet leaders promote and value
nurse input re g a rding concern s .
Having these values throughout an
o rganization creates the conditions
for nurses to re p o rt workplace bul-
lying without fear of reprisal or
becoming the next victim of the
b u l l y. Nurses in Magnet hospitals
also have available consultants and
re s o u rces to address their concern s
related to workplace abuses. These
may include experts from pro f e s-
sional nursing organizations experi-
enced in workplace advocacy or
persons from other health care
o rganizations in the community
who have had success in addre s s i n g
workplace bullying. Nurses are a
critical influence on org a n i z a t i o n -
wide processes and policies, espe-
cially as they relate to workplace
bullying. Using the Forces of
Magnetism can help nurses addre s s
this escalating professional work-
place issue (ANCC, 2008; Murr a y,
2007; Murr a y, 2008a).
How Nurses Can Pro t e c t
Themselves
Nurses can help themselves
and others when confronted with
bullying in the workplace. Although
they may appear to be straightfor-

w a rd, these strategies can be diff i-
cult to accomplish if nurses do not
have support (Longo & Sherm a n ,
2007; Murr a y, 2007; Thomas, 2003).
• A nurse first must re c o g n i z e
when bullying exists. Fre q u e n t-
l y, an individual is told that he
or she is not being bullied.
H o w e v e r, the victim is aware of
being targeted and knows the
bully is planning systematically
to continue the harassment and
i n t e rf e re with the victim’s work.
• A nurse should seek behavioral
health services when needed.
Workplace bullying is a tre m e n-
dously overwhelming experi-
e n c e .
• A nurse must be aware of the
e ffect of the bullying on person-
al health and remain alert to
signs and symptoms, such as
a n x i e t y, loss of sleep, and eating
d i s o rd e r s .
MEDSURG Nursing—September/October 2009—Vol. 18/No. 5
275
• A nurse should know his or her
rights. State and federal pro f e s-
sional organizations might be

able to assist a victim of work-
place bullying (e.g., American
Nurses Association, state nurs-
ing associations, the Depart-
ment of Justice).
• A nurse must be knowledgeable
of workplace policies and pro-
c e d u res related to bullying and
h a r a s s m e n t .
• A victim should document all
incidents of bullying, including
date, time, site of occurre n c e ,
and witnesses.
• A nurse should be pre p a red for
the possibility that instead of
a d d ressing the problem, senior
leaders within the org a n i z a t i o n
will not stop the bullying as
they protect personal interests.
• Legal assistance may be needed
when all other avenues to
a d d ress the problem have
f a i l e d .
What Nursing Co-Workers Can
and Should Do
Nurses also can take a number
of steps to look out for each other
(Johnson, Martin, Markle-Elder,
2007; Longo & Sherman, 2007;
M u rr a y, 2007; Thomas, 2003):

• When bullying is occurring, a
nurse should call for help imme-
d i a t e l y. Operating room nurses
have a method of calling a “Code
Pink” to signal co-workers that
workplace abuse is occurr i n g .
Colleagues who can be re l e a s e d
f rom patient care areas go to the
location of the code and stare
silently at the individual bullying
the nurse. This technique gets
the bully to re t reat from the chal-
lenge or recognize the abusive
behavior has been re v e a l e d .
• A nurse should provide support
to a co-worker immediately fol-
lowing an attack, determ i n i n g
what should be done for the vic-
t i m .
• The bullying incident should be
b rought immediately to the
attention of the manager.
• S t a ff should not side with the
b u l l y. Doing so may bring tempo-
r a ry protection but at a huge
ethical cost. An observer should
have the integrity to do the right
thing and not encourage bully-
i n g .
• S t a ff should offer to attend
meetings as witnesses when the

bullied co-worker is asked to
meet with the bully.
• S t a ff should agree to support
the bullied co-worker by pro v i d-
ing written statements, docu-
mentation, and/or sworn testi-
mony at legal pro c e e d i n g s .
I m p roving Protections for
N u r s e s
Silence unfortunately often al-
lows bullying to continue in the
workplace (Murr a y, 2007). Per-
petrators often have a longstanding
h i s t o ry of committing similar abus-
es at other institutions in which
they were employed. Instead of
a p p ropriate and effective action
being taken to address the unac-
ceptable behaviors, they may get
moved from one organization to
a n o t h e r. Often it is difficult to term i-
nate their employment because
they may be educators with tenure
and many institutions choose not to
take the necessary steps to stop the
bullying from taking place. The cul-
t u re of academic institutions also
must play a critical role in addre s s-
ing unethical behaviors of health
c a re professionals (Whitehead &
Novak, 2003). The nursing Code of
E t h i c s mandates that unethical
behaviors such as workplace bully-

ing be re p o rted through appro p r i-
ate channels within health care
o rganizations and, if needed, to out-
side agencies (e.g. state nurses
association, professional nursing
o rganizations) with re s p o n s i b i l i t y
for safe workplace enviro n m e n t s
( M u rr a y, 2007; Murr a y, 2008a).
To date, most attempts to cur-
tail workplace bullying have ad-
d ressed only minimally its destru c-
tive effect on nursing (Murr a y,
2008a). Legislation is needed to
make it a crime for individuals to
abuse nurses. The Federal Nurses
Association, a constituent member
of the American Nurses Association
(ANA), has been involved in legisla-
tive initiatives that propose critical
p rotections for nurses who identify
workplace bullying. Legislation
such as the Paul Revere Freedom to
Wa rn Act would offer protections to
nurses who draw attention to
w rongdoing in the workplace
( M u rr a y, 2008b).
Nursing Implications
In January 2009, new Joint
Commission standards addre s s i n g
hostile behavior in the workplace
went into effect. These standard s
re q u i re health care institutions to
have in place codes of conduct,

mechanisms to encourage staff to
re p o rt disruptive behavior, and a
p rocess for disciplining off e n d e r s
who exhibit hostile behavior (Joint
Commission, 2008). In addition,
n u r s i n g ’s Code of Ethics m a n d a t e s
re p o rting of unethical behaviors in
the workplace (ANA, 2001).
A d d ressing workplace abuse,
harassment, and bullying of nurses
in the workplace is long overd u e
( M u rr a y, 2008a). Nurses should
demand to work in enviro n m e n t s
f ree from abuse where a model of
ethical behavior is adopted and sup-
p o rted (Center for American
Nurses, 2007). Health care org a n i z a-
tions must adopt and support fully
z e ro tolerance policies which re c o g-
nize abuse in the workplace will not
be tolerated (Murr a y, 2008a; AACN,
2004). Ongoing educational pro-
grams are needed to help nurses
recognize the signs and symptoms
of violence in the work setting as
well as actions that will pre v e n t
abuse from occurring and stop any
abuse that is taking place (Center
for American Nurses, 2007). A safe,
anonymous mechanism for re p o rt-
ing workplace bullying also is criti-
cal (Murr a y, 2007). Nurses have a
right to practice, learn, teach, and
conduct re s e a rch in settings that
a re safe and healthy. Stronger laws

a re needed to protect whistleblow-
ers from retaliation for re p o rt i n g
unethical behaviors in the work-
place. Nurses must play a leading
role in taking political action
( M u rr a y, 2007; Murr a y, 2008b).
F i n a l l y, re s e a rch must be conducted
for full exploration of factors con-
tributing to this escalating pro b l e m
(Center for American Nurses, 2007).
I n t e rvention re s e a rch aimed at
reducing mistreatment is essential,
as are studies aimed at testing the
e ffectiveness of these interv e n t i o n s
(Center for American Nurses, 2007;
F e l b l i n g e r, 2008).
C o n c l u s i o n
Health care leaders have a
responsibility to employees and the
public to provide work enviro n-
276 MEDSURG Nursing—September/October 2009—Vol.
18/No. 5
ments that are free from abuse and
harassment. When workplace bully-
ing has been identified as a pro b-
lem, senior leaders must take swift,
a p p ropriate action to ensure the
abuse stops, the perpetrator is held
accountable, and steps are taken to
e n s u re bullying does not occur

again. Policies and pro c e d u res must
be implemented and enforced to
e n s u re nurses feel safe to re p o rt
incidents of bullying.
In 2006, the ANA adopted prin-
ciples related to nursing practice
and the promotion of healthy work
e n v i ronments for all nurses (ANA,
2006). In its resolution, ANA aff i rm e d
all nurses have the right to work in
e n v i ronments free of abusive behav-
i o r, such as bullying, hostility, abuse
of authority, and reprisal for identify-
ing abuse in the workplace. Nurses
have a responsibility to avoid bully-
ing, promptly re p o rt incidents of
abuse, and most import a n t l y, pro-
mote dignity in the workplace for all
health care professionals (ANA,
2008; Murr a y, 2008a).
R e fe r e n c e s
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( A AC N ) . ( 2 0 0 4 ) . Zero tolerance for abu s e.
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nu r s e s. R e t ri eved March 18, 2008, from
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l e n c e / A N A R e s o u r c e s / Wo rk p l a c e A bu s e a
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Anderson, C. ( 2 0 0 2 ) . Wo rkplace violence: A r e
some nurses more vulnera bl e ? Issues in
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Center for American Nurses. ( 2 0 0 7 ) . Bullying in
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/ S a fe t y / R e s e a r c h / F i l e s / B u l l y i n g . p d f
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the wo rkplace and nu r s e s ’ s h a m e
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F e a t u r e
The power and politics of
collaboration in nurse practitioner
role development
Judith Burgess and Mary Ellen Purkis
University of Victoria, Victoria, BC, Canada

Accepted for publication 15 April 2010
BURGESS J and PURKIS ME. Nursing Inquiry 2010; 17: 297–
308
The power and politics of collaboration in nurse practitioner
role development
This health services study employed participatory action
research to engage nurse practitioners (NPs) from two health
authori-
ties in British Columbia, Canada, to examine the research
question: How does collaboration advance NP role integration
within
primary health-care? The inquiry was significant and timely
because the NP role was recently introduced into the province,
sup-
ported by passage of legislation and regulation and introduction
of graduate education programs. In separate and concurrent
inquiry groups, the NPs discussed their practice patterns, role
development progress and understanding of collaboration and
role integration. The inquiry revealed the political nature of the
NP role and the extent to which NPs relied on collaborative
relations at all levels of the health system to advance role
integration. Given that NP role development is still at an early
stage in
this province, as well as other provinces in Canada, this study
provides important insights into the power and politics of role

development, and offers direction for future role advancement.
Key words: collaboration, nurse practitioner, politics, role
development.
Nurse practitioner (NP) role development in British
Columbia (BC) is part of a Canada-wide nursing strategy to
formalize the NP role and ensure its sustainability (Canadian
Nurses Association (CNA) 2003). Official sanction of NPs is
significant because the NP role is intended to catalyze a team
approach in primary health-care (PHC), and thereby
increase access to primary clinical care, as well as extend ser-
vice availability of preventive screening and early detection
of disease, wellness and health promotion, health education
and counselling, outreach to vulnerable populations, and
community engagement (DiCenso et al. 2007).
A health services dissertation study was undertaken in
2008, at a relatively early stage of NP role development, to
investigate the research question ‘How does collaboration
advance NP role integration within PHC?’ A participatory
action research (PAR) approach was employed to engage

NPs from two BC health authorities in group dialog. The
inquiry groups uncovered tensions related to role develop-
ment and thus certain taken-for-granted assumptions were
exposed (McIntyre and McDonald 2010). At the provincial
level, government officials assumed that with NP legisla-
tion and regulation in place, the six regional health
authorities responsible for service delivery, would be set to
implement NP roles; yet there were many uncertainties to
resolve in the regions regarding deployment decisions and
policies. Health authority leaders assumed there was readi-
ness for NP roles to be implemented into PHC sites; yet
settings lacked technical and procedural infrastructure,
and managers and team members were often unprepared
to welcome and support the new NP. And finally, NP
graduates assumed their role would be focused on
direct client care, yet there was a political side to NP role
development and the new NPs were ill-equipped for the
strategic leadership required to navigate the complexities

of role development.
However, the inquiry groups also highlighted the
resilience of NPs to rise above the tensions, cultivate
Correspondence: Dr Judith Burgess, RN, PhD, University of
Victoria, Victoria, BC,
Canada V8W 2Y2. E-mail: <[email protected]>
� 2010 Blackwell Publishing Ltd
Nursing Inquiry 2010; 17(4): 297–308
collaborative community and collegial partnerships, and
develop strategic capacity, and in so doing the NPs were
better able to address the power and politics of role develop-
ment. In this paper, we provide a brief history of the NP role
from a Canadian and BC perspective; we outline the PAR
methodology used in the inquiry; and we report on study
findings particular to the effects of collaboration on NP role
integration. Discussion of the tensions and challenges of
NP role development raises particular concerns about
the lack of resources and supports for NPs, and about the

incongruence between role expectations and health system
realities. The troubles of NP role development in many ways
mirror the tribulations of PHC renewal and to this extent
NPs continue to suffer, because their practice is counter to
the neo-liberal view of health-care.
CONTEXTUAL BACKGROUND OF NP ROLE
DEVELOPMENT
The NP role in Canada has a discontinuous history, in which
lack of legislation, regulation, remuneration mechanisms,
and public-policy support has hindered role development
progress (DiCenso et al. 2007; McIntyre and McDonald
2010). NP pioneers date back to the 1970s, with initiation of
early educational programs to prepare NPs for deployment in
northern nursing stations. NPs later moved into urban area
practice, mostly into community health centers, and secured
local physician oversight for delegated authority of advanced
medical acts. Despite the lack of official sanction, the small
cadre of NP pioneers survived by ‘flying under the radar’ and

keeping a low profile in the politics of health-care; instead
their strategy was to gain the confidence and respect of
patients, colleagues, and local communities (Draye and
Brown 2000; Fairman 2002; Brown and Draye 2003).
In recent years, the federal and provincial governments’
focus on PHC renewal, coupled with the limited numbers of
and access to family physicians, has compelled more formal
support for NP role development (Romanow 2002). Leader-
ship from the CNA has played a significant part in shaping
policies for successful role introduction (CNA 2003, 2006,
2008a). As well, the Canadian Nurse Practitioner Initiative
funded by Health Canada and sponsored by the CNA,
provided role development guidance including this role
description:
NPs are experienced registered nurses with additional educa-
tion who possess and demonstrate the competencies
required for NP registration or licensure in a province or ter-
ritory. Using an evidence-based holistic approach that
emphasizes health promotion and partnership development,
NPs complement, rather than replace other healthcare pro-

viders. NPs, as advanced practice nurses, blend their in-depth
knowledge of nursing theory and practice, with their legal
authority and autonomy to order and interpret diagnostic
tests, prescribe pharmaceuticals, medical devices and other
therapies, and perform procedures. (CNA 2006, iii)
Introduction of the NP role has now occurred in all
Canadian provinces and territories (NPCanada.ca). Most
provinces have legislated provision for title protection of the
NP role, and have mandated nursing regulatory bodies to
regulate NPs and set standards, conditions, and limitations
for practice (Canadian Institute for Health Information and
CNA 2005). While educational programs still vary, most have
adopted or are moving toward graduate level designation.
The majority of NPs licensed in Canada practice in PHC set-
tings, although payment issues are still a significant barrier
to advancing the NP role. The issue of funding is con-
strained by provincial-regional politics. The funds for pri-
mary care services are generally accessed through provincial
fee-for-service mechanisms; however, these funds are
restricted for physician payment, and regulators have been

reluctant to allow payment access for NPs. Instead NP fund-
ing is expected to be covered by health regions or health
organizations; however, health regions are not particularly
compelled to use their strained budgets for NP primary care
services, when such services can be covered by provincial
physician coffers. These politics of jurisdictional responsibil-
ity leave NPs without a sound funding mechanism and this is
a critical issue to resolve to ensure NP sustainability.
Development of the NP role in BC began with and bene-
fitted from a stakeholder consultation and a provincial-based
study (College of Registered Nurses of BC (CRNBC) 2005;
MacDonald et al. 2005; Schreiber et al. 2005). Government
funding was subsequently provided for NP graduate level
education programs, and in 2005 the NP role was officially
launched with legislation that amended the BC Health
Professions Act and gave regulatory authority to the CRNBC
(BC Ministry of Health Services 2005). Three-year start-up
budgets to initiate NP roles were later allocated to health

authority regions responsible for healthcare delivery; how-
ever, these funds have now been expended, and an ongoing
NP funding mechanism is uncertain.
Despite the systematic approach used at the BC provincial
level to prepare legislation and regulation for effective NP
role introduction, there was limited time and direction given to
the six health regions for role implementation, and conse-
quently the regions gave little guidance to programs at the
practice level to ensure NP role integration. However, the
issues of implementation and integration were not to be
unexpected. A number of barriers beyond the introductory
stage had been reported by leaders of early adopter provinces,
298 � 2010 Blackwell Publishing Ltd
J Burgess and ME Purkis
such as Ontario. Barriers to implementation and integration
include failure to clarify role function and set appropriate
goals, ineffective utilization of NPs, insufficient funding

mechanisms, inadequate collaborative team relations, and
limited evidence to guide role development and evaluation
(DiCenso and Paech 2003; Bryant-Lukosius et al. 2004;
Jones and Way 2004; DiCenso and Matthews 2005; DiCenso
et al. 2007). These early lessons indicate the complexity of NP
role development with respect to identified stages of intro-
duction, implementation, integration and sustainability, and
highlight the extent to which the NP role is enmeshed in
dynamic and interdependent health system politics (Begun,
Zimmerman, and Dooley 2003; Burgess 2009). Research is
thus helpful to gain insight into these complexities and to
provide recommendations for future success.
METHODOLOGY
Participatory action research offered a dynamic and empow-
ering methodology to bring NPs together, in order to coun-
ter the inequities of knowledge, power, and resources,
address theoretical and practical interests of participants,
and create collective capacity (Burgess 2006; Reason 2006).

Hall’s (2001) definition of PAR, which highlights three
dimensions of social investigation, education, and action,
served to direct the inquiry method. These dimensions also
provided three-point criteria to validate the quality and
integrity of the inquiry (Bradbury and Reason 2001). The
social investigation or participatory stage of the inquiry
encouraged participants to share stories, engage in critical
and collective reflection, and become co-authors and co-con-
structors of their everyday work life (Reason and Bradbury
2001). The educative or informative stage elicited the formu-
lation of meaning, where new knowledge was generated and
theorizing took place to advance practice (Bradbury and
Reason 2003). The action or transformative stage of PAR
uncovered power relations and political processes, and
helped to mobilize the NP collectives (McTaggart 1991).
Thus, PAR supported the NPs to critically reflect on the
taken-for-granted assumptions of the social world, interpret
the meaning of cultural, historical and social conditions, and

mobilize actions to effect individual and social transform-
ations (Kemmis and McTaggart 2005; Kincheloe and
McLaren 2005). The reflexive participatory process empow-
ered the NPs ‘to investigate reality in order to change it and
to change reality in order to investigate it’ (Kemmis and
McTaggart 2005, 567).
Participant recruitment took place in two BC health
authorities. As health authorities (HAs) had only 10–12 NP
employees at the time of recruitment, participant numbers
were limited. Ethics approval was required separately from
each HA, and was thus obtained from the joint review board
of the University and one HA, and from the review board
of the second HA. Approval from the chief of professional
practice of each region was acquired for NPs to have employ-
ment release time for the inquiry. A strategic sampling
approach was used (Mason 2002), whereby an invitation to
the introductory research meetings was prepared by the
researcher, and e-mailed out by each HA to their employed

NPs. The introductory meetings, in which the research ques-
tions were outlined, consent forms reviewed, and inquiry
meeting dates and locations set, resulted in recruitment of
11 of 12 NPs employed in one HA and 6 of 12 employed in
the other HA. The variance in HA recruitment rates was later
attributed to the different approaches used by the HAs to
cultivate a collective grounding and presence for their
NPs. Each HA had organized a NP community of practice to
support role development; however, recruitment was more
successful in the HA with a well established community of
practice, and less so in the HA that had a newly formed
community of practice. Demographics specific to the HAs
and NP participants were unreported in the study to protect
anonymity of those involved.
The inquiry data sessions in each HA were held in
conjunction with the NP community of practice meetings;
five data sessions and two action meetings were held in
each HA. The inquiry produced a combined total of

22 hours of audio-taped data. For each inquiry session,
questions were prepared to journey participants through a
group dialog. The participatory stage of the inquiry
included developing community of inquiry principles, shar-
ing journal articles for grounding of group knowledge, clar-
ifying roles and responsibilities, and fostering informal
interactions and trusting relations. The informative stage
focused on inquiry discussion of everyday practice patterns
of NPs, the ups and downs of role development progress,
and factors that contributed to collaboration and NP role
integration. The transformative stage unfolded as two
action strategies taken up within each inquiry group. The
first action strategy, particularly relevant to this paper, was
to invite the respective HA leaders responsible for NP
implementation to an audio-taped data session to discuss
organizational planning of the NP role. A second action
strategy was to host a research action day, in which a
researcher with evaluation expertise helped to design a

research template for NPs to initiate inquiry and analysis
within their own practice settings.
Following each data session, the audio-tapes were tran-
scribed and preliminary analysis undertaken. QSR NVivo 7
electronic software was used to index data into initial codes
� 2010 Blackwell Publishing Ltd 299
Power and politics
(free nodes), create sub-themes (tree nodes), formulate
themes, and make conceptual correlations (Mason 2002).
Data analysis took the form of constant comparative analysis,
drawn from analytic techniques of grounded theory,
which supports examination of plausible interrelationships
(Schwandt 2001; Charmaz 2005). Yet the intention was not
to produce a grounded theory result, but instead correlate
and extend knowledge development between and across the
two HAs (Charmaz 2005; Coghlan 2002; Eaves 2001; Strauss
and Corbin 1998). The emergent codes, sub-themes, and

themes were continually shaped and re-shaped as stronger
associations were cataloged. Sub-theme analysis and thematic
interpretations were translated into written text and power
point presentations, and taken back to NP inquiry meetings
for further discussion and analysis. HA data sets were initially
kept separate to compare results and then later integrated to
capture common themes and findings. Inquiry participants
received and commented on dissertation chapters as they
were drafted. The final dissertation was released to NPs and
health leaders; dissemination strategies and the co-authoring
of publications are underway.
The promise of PAR was realized by the findings and out-
comes of the study. The inquiry opened up communicative
space for NPs to investigate their experiences and foster more
democratic relations (Reason and Bradbury 2001). The NPs
determined that collaboration was foundational to their
everyday practice and to the advancement and integration of
their roles. Analysis of NP stories created shared learning, and

this educational process helped to theorize the NP world, and
reconstitute their collective understanding (Reason 2006).
The NPs revealed the value of their communities of practice
for fostering informative learning, inquiry and knowledge
development. By exploring the meaning of role integration,
NPs articulated steps forward, and gained confidence to
engage in actions to co-construct their sustainability (Burgess
2009). NPs came to realize the significance of cultivating stra-
tegic capacity and collaborative alliances; thus the emergent
nature of PAR created potential for enduring consequences
as part of the transformative stage of the study (Bradbury and
Reason 2001). The findings section outlines the extent to
which the NPs relied on collaborative relations at all levels of
the health system to advance role integration and in so doing
engaged in the power and politics of role development.
FINDINGS
Collaboration advances role integration
Nurse practitioners portrayed themselves as being a nurse

first and practitioner second. As nurses, the NPs were
grounded in disciplinary values, theories, and knowledge.
As practitioners they integrated advanced competencies
and skills into everyday practice. The NPs discussed collab-
oration as foundational to the ethics of practice. This is
consistent with NP policy documents that guide practice,
such as the CNA (2008a) Advanced Nursing Practice
Framework and the CRNBC core competencies (Registered
Nurses Association of British Columbia 2003). Collabora-
tion was viewed by the NPs as both a philosophy and a
practice. As a philosophy, collaboration denoted NP com-
mitment to egalitarian power relations, whereby all team
members were valued for their unique and significant con-
tributions to decision-making. As a practice, collaboration
signified the enactment of this philosophy, in which NPs
fostered and modeled the sharing of knowledge and exper-
tise. The NPs discussed how they utilized a full range of
people and resources in the provision of complex client

care. Collaboration was considered by the inquiry partici-
pants to be central to advancing role integration. One NP
commented:
When I think about being a new NP, I think about how do I
collaborate with other people? What does the cohesiveness
of our team look like in order for me to enact my role? How
can I work with a community to identify needs so I can tar-
get myself as a resource to help meet those needs ... And
how do I build relationships and partnerships within the sys-
tem that are going to help me enact this role.
The NPs cultivated collaborative relations with clients, col-
leagues, and healthcare leaders to address concerns of role
autonomy and role clarity, extend holistic client-centered
care and team capacity, and create strategic alliances to pro-
mote innovation and system change. These characteristics
of role autonomy, role clarity, holistic client-centered care,
team capacity, and strategic alliance were determined to be
indicators of NP role integration, and thus potentially useful
for evaluating the progress of role integration.
Collaboration facilitates NP autonomy for role
enactment

Nurse practitioner commitment to collaboration facilitated
role autonomy. The intention of legislation and regulation
in BC was to provide NPs with extended scope of practice to
allow for increased autonomy and flexibility, and facilitate
safe and responsive health-care (CRNBC 2005). The issue of
autonomy is discussed by MacDonald (2002) with respect to
profession-based scope and professional-based discretion.
Profession-based scope refers to structural factors, such as
legislation, that enables self-government and self-regulation;
while professional-based discretion refers to individual fac-
tors, in which professionals engage in personal agency to
control their practice and decision-making.
However, the inquiry found the dynamics of autonomy
to be more complex than this. The NPs also required the
understanding and endorsement of policy and program

leaders within their health organizations. For instance, a
few of the NPs experienced an undercurrent tension of
being likened and compared to a physician style of practice,
and scheduled accordingly, which limited their role flexibil-
ity and constrained role development. One NP com-
mented,
I think we have to do everything we can to hang on to that
thing that we call time, and not sacrifice it by seeing 20 or
30 patients a day … we need to step back and say, ‘how is
that meeting my goals and objectives for my client popula-
tion?’ … We have to be really careful that we don’t become
assimilated into the existing [primary care] system.
Yet other NPs reported cultivating collaborative relations
with program leaders and colleagues in order to enhance
role understanding; this in-turn extended NP autonomy and
enabled them to design their roles in response to assessed
client and community needs. An NP stated:
I feel, for the first time in my work life, I don’t have some-
one overseeing my moment-to-moment interactions in
the day. And I feel that I’m a grown up and I’m a good
time manager, and I don’t need someone telling me how
I should do it. So, I’m grateful for that [autonomy].
The NP discussions of their everyday work and practice

patterns revealed that the design of their roles had emerged
with much diversity; each role and site was different and the
notion of a uniform NP role seemed a paradoxical idea.
Collaboration fostered NP autonomy to explore new practice
approaches, cultivate new partnerships, and be responsive to
clients and communities. And NP autonomy enabled NPs to
construct innovative collaborations to advance PHC practice.
In this way, collaboration and autonomy had reciprocal
effects, in which the NPs were enabled to more fully enact
their roles. The idea of reciprocal effects adds to Way, Jones,
and Busing’s (2000) conclusions that collaboration and
autonomy are complementary.
Collaboration fosters role clarity
Collaboration helped NPs to bridge the professions of nurs-
ing and medicine. NPs reflexively discovered and articu-
lated how the NP role was distinctly different from other
roles, such as that of a registered nurse or of a physician.
The literature refers to the importance of establishing pro-

fessional identity and role clarity to ensure effective utiliza-
tion of NPs (Bryant-Lukosius et al. 2004; Pauly et al. 2004;
Bailey, Jones, and Way 2006). NPs employed various com-
munication strategies, from informal interactions to formal
presentations, in order to clarify scope of practice and
negotiate role overlap with other health providers. One NP
commented:
I think about collaboration as being the how we do our
interaction – so collaboration is all about mutual respect, we
have an understanding about how we are going to make the
decisions … it really comes down to good patient care.
As respect and trust developed by way of collaboration with
clients, colleagues, and managers, NPs gained recognition
for their knowledge, skills, and unique contributions, and
role acceptance was cultivated. This acceptance enabled NPs
to develop their role as multi-faceted, and thus carry out
complex client and community assessments, apply evidence-
based guidelines, prescribe and provide treatment for a
wide-range of health conditions, and initiate health promo-

tion and prevention programs, all with the aim of improving
population health.
The inquiry also revealed that collaboration with clients
was key to establishing role clarity. NPs were very much
aligned with clients and communities, and this enhanced
role clarity and public awareness of the NP role. Clients,
knowledgeable, empowered, and confident in their health-
care, were reportedly better able to determine when the NP
was the right practitioner to address their health concerns.
NP–client interactions thus helped clients to gain power in
decision-making about their health-care by sharing empow-
ering information, advocating for improved care, and link-
ing clients to various community resources. An NP
commented:
As the leader in my visit and as client-centered, I’m always
going back to the client and affirming with them – is this
what’s going to work for you? Or does this idea work for
you? And that’s how I involve them and make it client-cen-
tered … Sometimes I do say we’re partners in this, or it’s a
team effort – we’re both going to have to work at this.
Role clarity is an important step in gaining acceptance of

clients, collegial partners, organization leaders and the gen-
eral public; in turn acceptance of the NP role upholds incre-
mental deployment of NPs and thus improves access to PHC
(CNA 2006; Keith and Askin 2008). Access to care is particu-
larly significant for our most marginalized populations who
are often underserved by PHC. The NP’s alignment with cli-
ents and communities is a finding that supports Browne and
Tarlier’s (2008) argument for examining the NP role from a
critical social justice perspective.
Power and politics
Collaboration enhances holistic client-centered
care
Nurse practitioners countered the tensions of role develop-
ment by developing strong collaborative partnerships with
their clients and communities. This was a strategy within their
control, and fit with a fundamental belief that clients were

partners in care. Clients as partners signified the dual exper-
tise of clients and NPs combining their respective knowledge,
where NPs applied theory and practice to client care, and cli-
ents contributed the personal lived experience of managing
a health condition. The aim of this partnership was to pro-
vide holistic client-centered care. NPs drew upon a nursing
philosophy and integrated this with advanced clinical educa-
tion to extend their ability to provide holistic care. For
instance, an NP described a home visit to a frail senior, where
she carried out a full assessment using various geriatric mea-
surements, identified the diagnostics needed, collected a
urine culture, faxed a prescription to pharmacy, liaised with
the physician, and made a referral to community care, all in
one visit. A holistic approach is consistent with findings from
a study by Gould, Johnstone, and Wasylkiw (2007), in which
NP practice was noted to be clearly different than that of
medical care. Keith and Askin (2008), in a discussion paper
of factors influencing effective collaboration, also recognized

the holistic client centered care approach of the NP role.
Nurse practitioners discussed and conveyed practice
patterns that demonstrated how they integrated advanced
clinical practice with health promotion and preventive
education. One NP reported:
NPs focus their practice to particular client health condi-
tions, populations, etc. I think the whole concept of wellness
and health promotion is something that’s really important
in what we do, because we bring that into every client
encounter.
Nurse practitioners also developed their roles in unique
ways and in diverse settings so as to improve health access
for marginalized and underserved populations. By being sen-
sitive to cultural and local differences NPs fostered mutual
respect and trust and cultivated client confidence in health-
care. NPs shared power and engaged clients as active partici-
pants and decision-makers in their own health-care. Another
NP reflected:
Well-rounded provision of care for that patient, it shifts
power, it shifts knowledge, it shifts language, and so the
patient does start to take on a lot more power as a benefit of

the NP role.
The NP commitment to social justice and social deter-
minants of health is consistent with the view taken up by
Browne and Tarlier (2008). The aim of increasing health-
care accessibility and redressing health gaps was considered
a value-added contribution of the NP role.
Collaboration generates team capacity
All NP participants reported either being in a team, or part
of an extended team network. Some NPs described team
experiences as effective and satisfying, while others reported
team difficulties. Collaborative teams embodied a sense of
team spirit; they were full of life and there was energy, laugh-
ter, noise, and a general sense of well-being. On the other
hand, teams in struggle were depicted as quiet, sullen, pri-
vate, and tense. The ‘dance of teamwork’ was somewhat elu-
sive for NPs to describe, yet it was a very tangible experience.
An NP commented:
When you feel you’re actually being cared for as a person
it’s amazing how that plays into how you work … there’s

some quality, some sort of sensibility. Some sort of feeling of
connectedness that isn’t created, isn’t manufactured … And
it’s a safe environment; its the climate, its culture.
Teams with a common vision and client-centered focus
seemed to fare better. Hiring well and having effective team
leadership was important to sustain a collaborative milieu.
Good team leaders were able to manage administrative
duties well and make tough decisions; yet also be altruistic,
draw on team member expertise, and generate capacity for
shared leadership. The NPs as advanced practice nurses con-
tributed to modeling this kind of leadership, and willingly
shared and exchanged knowledge, and mentored others.
One of the NPs stated,
I’ve always worked in a collaborative environment; I’ve
always been part of a team. Even though I’m out doing my
thing I’m always connecting with social workers, nutrition-
ists, other nurses, physicians … I don’t know what it’s like to
not work that way.
Although NPs conveyed a natural comfort in collaborating,
attaining effective collaboration required continual educa-
tion of colleagues about their capabilities. Being a pioneer

in this new role created a lot of unexpected work and emo-
tions, and at times eroded NP self-confidence. One NP
described feeling hurt and uncertain when colleagues did
not utilize her as a resource:
So, when you actually do reach out to someone to get an
answer, or some support, or collaborate, and they’re not will-
ing, it feels hurtful. It feels like grade 9 all over again when
you were the girl that no one wanted to hang out with.
The challenges of NP–physician collaboration are reinforced
by Keith and Askin (2008) who identified a number of
influencing factors, such as communication, competition,
funding, liability, and scopes of practice. However, for the
most part, the NPs in the inquiry expressed enthusiasm
about the culture of collaboration that was developing within
their teams, and spoke of the increased capacity of their
teams to provide quality care and engage in innovations.
This sense of team spirit and capacity is referred to by Jones

and Way (2004) as synergy, in their characterization of team
collaboration, and is noted to be a defining feature of effec-
tive interprofessional teams.
Collaboration promotes strategic alliances
Collaborative alliances between the NPs and HA leaders also
served to advance the NP role. NPs relied on the HA leaders
to help remedy start-up problems, develop needed infrastruc-
ture and policies, and negotiate additional resources, such as
gaining access to diagnostics, electronic health records, deci-
sion-making tools, and data tracking. However, the NPs also
expressed a sense of power inequity with HA leaders and at
times had to tread softly in addressing their issues and inter-
ests. Nonetheless HA leaders were a link to the power struc-
ture of the organization and could help NPs develop
strategic capacity. A strategic alliance between NPs and HA
leaders fostered development of NP communities of practice,
and through this collective interaction, NPs formed a provin-
cial association. The BCNPA is now the provincial ‘go to’

group for strategic and political action. One NP commented:
We have to think systems, and at the provincial level too; we
have to think beyond our practice. If we are all working
together with our strengths, if we can somehow get synergy
happening … I think the community of practice is a really
important place for us to start strategizing as a group.
From the perspective of HA leaders, the alliance with
NPs was important for advancing PHC renewal efforts. NPs
had capacity to generate health innovations, and as change
agents could catalyze and actualize a population-focused
vision for PHC. Pogue (2007) similarly discussed the trans-
formational effects of the NP role in health system change.
HA leaders made an early strategic decision to delineate the
NP role for PHC. NPs were located one by one into PHC set-
tings, where there was physician support, and gradual
inroads were made to procure other physician sponsors. This
incremental strategy was anticipated as a way to shift the
medical profession toward a more interprofessional perspec-
tive. HA leaders saw the NP role as highly political and were
prepared to invest extra time and effort to role development.

However, in return they needed NPs to be strategic and to
steward the PHC cause well. One HA leader stated:
I honestly have to say our priority is rural PHC, and it will be
more so in the future … NPs, in our view, are a key piece of
the solution to the challenges we have around access, conti-
nuity, coordination of care … the role needs to be out there
at the interface with the population to improve health in
populations, and communities … The NP role is much
more than a resource; it’s a whole different philosophical
orientation and way of providing care.
However, some NPs said they lacked the political savvy to
be effective change agents and requested strategic mentor-
ship from the HA leaders. The meetings, in which HA lead-
ers participated with the NPs in data collection, were very
informative for both parties. The HA leaders expressed their
expectations of NPs to be strategic leaders in their local com-
munities for enhancement of PHC initiatives, and also to
become a strategic collective at regional and provincial lev-
els, so as to contribute to PHC renewal efforts, and advance
the NP role development agenda. The inquiry highlighted
the collaborative and reciprocal relationship needed

between HA leaders and the NPs, in order to move forward
in PHC, and to secure the NP role and sustain it in the long
term. This reciprocal relationship was a salient finding of
the inquiry, and is not well articulated as an issue in the
literature.
DISCUSSION
This participatory inquiry revealed the inherent capacity of
NPs to champion collaborative relations at all levels of
the health system and thereby foster role development. The
stories of NP participants offer illustrations of collaboration
with organization leaders, site managers, clients and commu-
nities, other practitioners and professions, and provincial
and national stakeholders. In cultivating collaborative rela-
tions and partners, the NPs facilitated their own autonomy,
fostered role clarity, enhanced holistic client care, generated
team capacity, and promoted strategic alliances, all of which
have served to advance NP role integration.
Of course the advances with respect to role autonomy

and clarity did not occur in isolation from the structuring
environment within which the role was established. BC legis-
lation in 2005 provided NPs with title protection and a
clearly articulated (although contentious and debated)
scope of practice that defined some limits for role autonomy.
Through the legislative process the former BC nursing asso-
ciation was restructured to become the College of Registered
Nurses of BC. The CRNBC was given the authority to regu-
late nurses and NPs, while maintaining their historical man-
date to protect the public. The legislative changes did,
however, require an explicit relinquishing of any advocacy
Power and politics
function for registrants (Cartmel 2009). This left NPs with-
out official, professional representation to assist them in
addressing the significant and challenging issues of role
development. NPs countered this lack of representation by

forming collaborative relations with health leader cham-
pions, most often from their own employment context, in
order to mediate early start-up concerns and ensure auton-
omy to fully enact their roles. Health leader champions also
provided NPs with a certain amount of strategic mentoring.
The initiation of NP communities of practice was a good
example of this mentoring partnership, in which NPs were
supported to manage their concerns and challenges as a col-
lective. NPs subsequently formed a provincial association,
which was an important collective strategy to re-build the
advocacy function that was no longer available from the pro-
vincial nursing body. The challenges of NP role develop-
ment are well documented in the literature (DiCenso and
Paech 2003; Bryant-Lukosius et al. 2004; Jones and Way
2004; DiCenso and Matthews 2005); and although prov-
inces ⁄ territories have made legislative and regulatory provi-
sions, the discontinuous history of NPs signifies a caution to
not be overly complacent, and instead, take up a vigilance to
make certain that the necessary supports and resources are

provided for NP sustainability.
Despite the structuring effects of legislative authority, the
inquiry uncovered that NPs still needed to engage in efforts
to clarify and articulate their role as separate and different
from that of primary care physicians. NPs clearly stated they
were not physician replacements, yet they expressed con-
cerns of being compared to physicians and measured
according to physician parameters. The current lack of meas-
urements in relation to NP practice standards and the
absence of infrastructure to support the NP role were noted
as real cause for concern. NP role expectations identified
through the inquiry included efforts to improve access to
health-care, extend clinical and complex care, address social
issues of clients and communities, assess community needs
and design responsive programs, enhance public and com-
munity engagement, champion teamwork and intersectoral
collaboration, steward the cause of PHC, and be a strategic
agent for health-care policy change. The inquiry revealed

the tall order placed on NPs to deliver PHC, and the disjunc-
ture between NP role expectations and available resources.
NPs have only elementary tools, measures, and infrastructure
to draw upon in the provision of PHC to clients and commu-
nities. As well, NPs have only a young association to advocate
on their behalf. Their experience stands in significant con-
trast with primary care physicians, who are well resourced by
provincial funding, have access to numerous quality assur-
ance initiatives, and are supported by a strong association
and infrastructure. The study identified that NPs require sig-
nificant resources and endorsement from system and organ-
ization leaders, in order to address the current inequities
and strengthen NP capacity to meet the obligations and
opportunities of this multifaceted role. NPs and healthcare
leaders need to collaboratively and strategically determine
and shape the fundamentals necessary for NPs to effectively
practice. This view is consistent with the CNPI report (CNA
2006) that outlined numerous resource recommendations

to ensure role integration and sustainability.
The inquiry revealed that NPs are uniquely situated to be
leaders of holistic client and community care. They are also
constructing diverse and responsive roles to improve popula-
tion health and address underserved and marginalized com-
munities. Browne and Tarlier’s (2008) paper discusses the
NP role from a critical social justice perspective. They argue
that NPs must demonstrate practice that reaches beyond
physician functions of illness care to mitigate healthcare
inequities. Health inequities, they contend, arise out of neo-
liberal political agendas and policies that emphasize individ-
ual responsibility and self-reliance, yet neo-liberalism does
not account for effects of gender, ethnicity and socioeco-
nomic status. It is important to recognize that momentum
for NP role development has emerged within this neo-liberal
political context. The accompanying politico-economic cli-
mate buttresses expectations for a less expensive physician
‘replacement’, while demanding comparable service deliv-

ery. The NPs who contributed to this study occupied a space
in which, on a moment-to-moment basis, they experienced
themselves as not measuring up to their physician mentors
while, at the same time, they attempted to fulfill their own
ambitions of developing a unique and comprehensive PHC
role. The conflicts inherent in their occupational stance
seriously undermined NPs capacity to effectively address
health inequities and social justice. This was particularly evi-
dent for NPs working in and with marginalized or impover-
ished communities, such as First Nations communities or
homeless street populations. In these settings, NPs practiced
in a very different fashion from the typical fee-for-service or
profit-oriented walk-in clinics. Their client-centered commit-
ment to increasing access, improving care, and addressing
social inequities flew up against an ideological neo-liberal
perspective of health-care. For instance, the delivery of
culturally responsive services to underserved communities
required a much more holistic approach than that of con-

ventional primary care, in which structured clinical offices,
time constrained appointment processes, and preconceived
outcomes, such as compliance of blood sugar levels for per-
sons living with diabetes, served as a proxy for quality patient
care. So, while the inquiry reinforced the NP role as multi-
faceted and consistent with the aims of PHC as a population-
focused service, it also demonstrated the significant barriers
faced by NPs in their ambitions to offer holistic client and
community care, in an effort to advance the social justice
agenda and actualize a broader and more principle-based
vision of PHC.
The NP inquiry brought to light how collaboration is
foundational to NP practice, yet collaboration is influenced
and cultivated by a broad context of healthcare culture.
Keith and Askin (2008) reported collaboration optimized

the NP role and improved PHC team delivery. NP role devel-
opment is integral to advancement of PHC, and although
both have suffered from a discontinuous history, together
the political forces of NP role development and PHC
renewal have potential for synergistic effects. The World
Health Organization (1978) on the 30th anniversary of the
Declaration of Alma Ata has called attention to the need for
further clarification of PHC, as a community-based full-ser-
vice approach that emphasizes social justice, equity, and soli-
darity. The NP role is particularly suited to advance PHC
and its associated principles, demonstrate a full-service
approach, champion team collaboration, and influence col-
laborative healthcare culture. In this view, the NP role is sig-
nificant to all populations and must not be confined to, or
worse pigeonholed for, underserved populations or remote
regions where physicians choose not to practice. Instead, the
NP role must be championed as a complementary function
with suitable funding mechanisms put in place, in order to

truly realize the breadth and comprehensiveness of PHC.
Thus, the inquiry uncovered the importance of the NP role
to steward the cause of PHC. However, to do so, NPs must
extend the political nature of their role, gain strategic
capacity, and become a strong collective voice in PHC
renewal efforts.
The credibility of an inquiry is enhanced by managing
the unexpected and weighing in the limitations of the study
(Bradbury and Reason 2001; Reason 2006). Indeed, a few
unexpected occurrences may have affected the quality of the
study. The ethics review process required indirect recruit-
ment of NPs to minimize the possibility of researcher coer-
cion, yet PAR relies on relational engagement. One HA was
particularly proactive in helping to recruit NPs, while the
other was less so. As a result the inquiry groups were not
equally represented, which may have compromised the qual-
ity of comparative analysis (Brydon-Miller and Greenwood
2006). When the inquiry began, a number of NPs were still

practicing under temporary registration, and preoccupied
with preparing for final written and oral exams. The newness
of the role and the NP’s focus on the ‘here and now’ made
it difficult for them to envision what role integration 5 years
ahead would look like. As well, the NPs had little reflective
experience about the politics of role integration, and were
somewhat unprepared for this dialog, so the depth of discus-
sion may have been limited. For most participants, this was a
first experience as co-researchers unsure of site manager
support for their involvement in the study, they expressed
concern about taking time away from practice and thus
declined participation in data coding and analysis. The NPs
full involvement as co-researchers was compromised by these
circumstances and may have caused limitations to the quality
of analysis (Reason and Bradbury 2001). Finally, the study
was relevant to the NP role in PHC and specific to BC health-
care politics and context. BC legislation, regulation, and edu-
cation have afforded NPs a high degree of autonomy and a

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