This document discusses nurses as leaders and managers for high quality patient care. It begins by outlining 9 learning objectives related to leadership theories, roles and responsibilities, management vs leadership, followership, finances influencing care quality and staffing, ethics, and the Future of Nursing campaign. It then discusses leadership being taught rather than innate, and calls for nursing education to incorporate leadership. Key initiatives like QSEN and the Future of Nursing campaign are also summarized. The roles of formal vs informal leadership and the distinctions between leadership and management are outlined.

1. NURSES AS
LEADERS
AND
MANAGERS
FOR STAFF,
HIGH
QUALITY
PATIENT
CARE

2.  Upon completion of this chapter, the student should be able to:
1. Explain major leadership theories in relation to the Quality and Safety Education
for Nurses (QSEN).
2. Describe roles and responsibilities of leadership.
3. Define management as distinguished from leadership.
4. Discuss the importance of followership in relation to an organization’s mission and
vision.
5. Explain how the hospital’s finances influence safety and quality of patient care.
6. Describe how a budget influences staffing.
7. Discuss the importance of the Code of Ethics for Nurses.
8. Discuss the importance of Emancipatory Knowing in relation to the call for every
nurse to function as a leader.
9. Discuss the four key elements of the Future of Nursing (FON): Campaign for Action
in the context of functioning as a leader at all levels of care.

3.  Leadership is frequently described in terms of personal attributes
such as having confidence and being strong.
 Often, these leadership attributes have been assumed to be a
quality one has been born with or cultivated by how the person
has been raised.
 However, many experts now argue leadership can be taught,
fostered, and refined.
 Many nurse leaders agree with this more contemporary
viewpoint.
 Specifically, they are calling for nursing education that
incorporates leadership content which encourages nurses to
demonstrate leadership at all levels of nursing practice.
 The leadership they advocate would directly and indirectly impact
the safety and quality of patient care.

4.  Nursing has a rich history of leading change.
 Florence Nightingale, Clara Barton, Margaret Sanger, and Hazel Johnson-Brown are but
a few nurses who have advanced nursing and healthcare through their efforts to
facilitate change.
 More recently, leadership has been demonstrated by nursing in response to the Institute
of Medicine’s (IOM) reports, To Err Is Human: Building a Safer Health System (2000)
and Crossing the Quality Chasm (2001), which documented the need to restructure the
healthcare system.
 These reports revealed issues of both safety and quality of care, specifically in the context
of increased complexity within the healthcare system.
 The IOM reports identified many causes of this complexity, including the health status of
patients, technology, as well as economics, politics, and social factors.
 National organizations such as The Joint Commission (TJC) and the Institute for
Healthcare Improvement (IHI) launched programs in response to the IOM findings.
 Similarly, nurse leaders responded to the same IOM findings at local, state, and national
levels with many initiatives; however, two of these initiatives stand out:
1. The QSEN Initiative-Quality and Safety Education for Nurses
2. The FON: Campaign for Action.

5.  The FON: Campaign for Action is another powerful initiative within
nursing.
 In 2008, the Robert Wood Johnson Foundation (RWJF) partnered with
the IOM to launch a specific study investigating the role of nursing in
transforming healthcare.
 Their research discovered much diversity of educational preparation,
underutilization of nursing knowledge and skill, and fragmentation of
purpose within the nursing profession.
 However, they also found great potential.
 In 2011, the IOM published The Future of Nursing: Leading Change,
Advancing Health.
 As a result of this report, the RWJF joined forces with AARP (formerly
known as the American Association of Retired Persons) to create the
FON: Campaign for Action.
 All 50 states now have an Action Coalition Committee aimed at
meeting the eight recommendations of the IOM report.

6.  In this report, eight recommendations were offered to policymakers,
educators, healthcare organizations, and businesses, as follows:
1. Remove scope-of-practice barriers.
2. Expand opportunities for nurses to lead and diffuse collaborative
improvement efforts.
3. Implement nurse residency programs.
4. Increase the proportion of nurses with a baccalaureate degree to 80%
by 2020.
5. Double the number of nurses with a doctorate by 2020.
6. Ensure that nurses engage in lifelong learning.
7. Prepare and enable nurses to lead change to advance health.
8. Build an infrastructure for the collection and analysis of
interprofessional healthcare workforce data

7. Nurses at all levels, from the patient bedside to the
boardroom, are now asked to step into their authentic
power with moral courage to be leaders for change.
As a profession, nursing now realizes all nurses should
function as leaders to heal patients as well as the
healthcare system.
Residency programs for new graduate nurses have
provided some valuable insight for Cultivating leadership
in nursing.
Curtis, de Vries, and Sheerin (2011) discuss factors that
contribute to leadership in nursing including the offering of
educational activities and role modeling as well as the
opportunity to practice leadership skills.

8.  They discuss being open to new ideas and being extroverted as
traits likely to foster leadership.
 Likewise, the role of age and experiences are positive influences.
 Interestingly, they found the most important skill necessary for
leadership involved fostering effective relationships.
 They describe this specific skill as more important than
knowledge surrounding management skill or technical abilities.
 They found that the most important qualities of effective
relationships include effective communication, approachability,
and emotional intelligence.
 Wagner, Cummings, Smith, Olson, Anderson, and Warren (2010),
as cited in Curtis et al. (2011), discovered the organizations that
promoted nurse empowerment resulted in increased “positive
work behaviors and attitudes, including leadership behavior”.

10.  Max Weber (1864–1920) offered a theoretical framework based on
establishing a hierarchy of authority and power that clearly delineated
policies and procedures as a way of standardizing work.
 As institutions grew focused mainly on efficiency and growth, a
dehumanizing quality to administration and leadership developed.
 In response, government organizations enacted regulations to protect
workers.
 With this national shift, unions formed to further ensure safe and fair
working conditions.
 The focus of leadership then evolved further to the individual within
an organization, specifically looking at maximizing their efforts and
strengths.
 With this new focus, a movement toward “human relations” emerged
that continues today.

11.  Many, if not most, contemporary leadership theories are based on the
behavioral sciences, which aim to explain human behavior.
 This perspective of leadership provides organizations with a better
understanding of what influences behavior.
 Having a clear understanding of what an organization wants allows its
leaders improved ability to manage those influences.
 Dinh et al. (2014) conducted a comprehensive literature review of
established and emerging leadership theories that revealed 23
thematic categories and 66 domains or areas of foci.
 Nursing does not espouse a single theory of leadership but, rather,
most often views leadership through the lens of nursing theory,
incorporating and applying relevant leadership theory as appropriate.
 Three commonly referred to theories of leadership that nursing utilizes
include: Chaos, Quantum, and Systems Theories.
 Each of these theories relates and interrelates to each other.

12.  Chaos theory is based on the belief that underneath the seemingly
unpredictable nature of life and/or business, a pattern or order exists.
 While many leadership styles and strategies are based on the belief
that events are predictable and can be controlled, Chaos Theory calls
for leaders to be vigilant (alert) to the dynamic changing nature of
economic, political, and social cues.
 This awareness allows leaders to guide their organization through
disorder.
 By seeking insight from these cues, the leader finds a new pattern of
understanding.
 Through this pattern of understanding, leaders accept the reality of
complexity as well as unpredictability in order to learn to anticipate
needed change and flexibility.
 The leader then translates this understanding for the need for change
and flexibility to the organization in a way that provides relevance,
importance, and direction.

13.  Quantum Theory acknowledges the complexity and chaotic nature of
life.
 This theory is based on quantum physics, which states particles or
matter can exist simultaneously in two different states of being.
 Quantum Theory asks leaders to simultaneously consider the reality of
a situation and the potential or ideal.
 Porter-O’Grady and Malloch (2011) explain that in order to achieve
this requirement, leaders must adopt a whole systems approach versus
an approach of individual parts.
 They explain that every part of a system is part of one comprehensive
system and smaller systems are linked to form larger, more complex
systems.
 This explanation provides the need and benefit of interdependence
(Box 3.1).

15. They continue their explanation that Quantum Theory
requires leaders to focus on outcomes, not the process;
in other words, what a job or work results in rather
than just that someone preformed the work for work’s
sake.
It asks leaders to emerge from all levels of nursing,
independent of educational preparation or position,
learning to adapt to dynamic, unpredictable change in
order to see what is alongside what could be.
In this way, the leader functions for the present but
works toward the future.

16.  Systems Theory espouses the same belief as Quantum Theory
that all parts of a system are vital and interdependent of the
whole.
 Based on General Systems Theory developed by biologist von
Bertalanffy, Systems Theory addresses seven fundamental
elements:
1.Input (resources),
2.Output (product or service),
3.Throughput (planning),
4.Feedback (data on service or product that allow for self-
correction),
5.Control (evaluation),
6.Environment (milieu), and
7.Goals (vision, mission).

17.  Ultimately, to be viable or sustainable, an organization as a
system, must have a clear vision and mission that is
substantiated by feedback and able to adapt to changing
economic, political, and social conditions.
 Dolansky and Moore (2013) argue Systems Theory or thinking
allows nurses to move from a specific focus on individual patient
care to a perspective that sees patient care in the context of the
care of the “system.”
 In this broadened and more global view, the nurse is able to
appreciate and impact safety and quality of care on multiple
levels.
 With this viewpoint, nurses are able to see how various actions
benefit the patient directly and indirectly.
 Their example (Figure 3.2) of how this occurs on a continuum is
poignantly (effective) illustrative.

18. FIGURE 3.2 Example of continuum of systems thinking for quality and safety in
healthcare.

19. Simply put, leadership is the ability to lead or command a
person or group of people.
Anyone who leads and facilitates change by speaking up,
providing education, role modeling, and/or coaching
resulting in changed behavior of an individual or group is a
leader.
More contemporary views of leadership consider the
possibility of success to be a cocreation of a group that
allows for creativity and innovation.
Grossman and Valiga (2016) explain this cocreation and
shared responsibility for success occurs when a group can
appreciate and foster one another’s strengths and
attributes and commit to inspiring each other, as well as to
be self-aware, insightful, and accountable.

20. The qualities of responsibility and accountability share a
sense of fidelity or dependability to others.
Both of these qualities are components of being a leader;
however, each quality is slightly different from the another.
Responsibility is typically a requirement of assigned tasks,
roles, and/or a position (i.e., a staff nurse on a medical
surgical floor is responsible for monitoring vital signs of
her assigned patients).
Accountability speaks to one’s willingness to accept
responsibility for an assignment (i.e., the nurse accepts
accountability for all assignments related to her job).

21. Nursing leaders such as PorterO’Grady and Malloch (2011)
distinguish leadership that simply facilitates change from
that which transforms, explaining, "A transformational
leader creates a new and improved system that allows
individuals to contribute to their fullest potential to deliver
the most effective healthcare possible”.
This model of leadership abdicates sole “control” by the
individual or individuals holding formal, authorized power
in exchange for shared ownership.
In this new model, everyone involved owns responsibility
to identify strengths, weaknesses, and opportunities.

23. Distinct roles and responsibilities are associated with the
various positions within an organization.
These are typically outlined in a job description.
A role is a position or the part the position fulfills within
an organization, such as a CEO or Vice President (VP) of
Nursing.
Depending on the formal position, appropriate
responsibilities will be delegated or assigned.
For a leader, these roles typically involve developing a
vision and facilitating change on a large scale, such as for a
department or institution.

24.  John Gardner (1993), considered one of the experts in the field of
leadership, distinguishes leaders from managers in six respects.
Leaders:
1. Think long term.
2. Influence the organization/unit they lead.
3. Reach out to those impacted by, as well as those impacting their
organization.
4. Focus on facilitating a vision by actualizing values through
motivation and guidance.
5. Exhibit political skill in managing conflict related to multiple
and potentially differing and/or competing priorities.
6. Include measures to always improve how an organization or
institution functions to meet their stated mission and vision.

25.  Gardner (1993) further distinguishes the tasks or responsibility of the leader
to include:
1. First and foremost, that of creating a vision for the group, this vision includes a
detailed plan as well as directions for managing conflict that might arise from
competing goals.
2. The second task of the leader involves affirming the organization or group’s
values, vision, and mission, which might include facilitating agreement
between people or groups with opposing thoughts.
3. The third task of the leader is to motivate the group by fostering ownership,
positivity, and excitement for what has been committed to by the group.
4. Managing priorities and work in order to actualize the group’s vision and
mission is the fourth task of the leader,
5. The fifth task is to facilitate cohesion of mind and purpose.
 This fifth task is accomplished by establishing trust and loyalty among the
members of the group.

26. 6. The sixth task is to accept responsibility for ensuring understanding
of the vision and mission, specifically as it relates to individual roles
and responsibilities of group members.
7. The seventh task of the leader is to serve as a role model: Gardner
explains, the leader serves as the risk taker, the group’s voice as well
as the force that brings the group together and provides positivity
that they can accomplish their goal.
8. The eighth task of the leader involves serving as the advocate for the
group and their vision; the leader speaks as well as acts on behalf of
the group.
9. The last task of leadership that Gardner speaks to is the
responsibility for ensuring the renewing or sustainability of the
group’s mission; this task is accomplished by balancing continuity
with change so that group members do not become complacent or
satisfied with the status quo, the leader helps to maintain
momentum and movement toward accomplishing their goal.

27.  Leadership within an organization can occur both formally and
informally.
 Formal leadership involves specific role responsibility and authority
related to the position one holds.
 This type of leadership is typically based on certain skill, knowledge,
and experience.
 A variety of formal leadership positions exist within healthcare
organizations including nurse executives that might hold positions
such as Chief Nursing Officer (CNO) or Vice presidents (VP) of
Nursing.
 Other positions of leadership include a head nurse or charge leader.
 Effective leadership exemplifies the qualities of trustworthiness,
courage, commitment, and perseverance.

28. In contrast, informal leadership is not explicit or official.
It is based on personal power or credibility (trustiness) in
the eyes of others.
This credibility can come from many sources but typically
evolves from education and/or experience as well as from
personal characteristics such as charisma, certainty, and/or
courage to speak up or take action.
Nurses at all levels, even newly graduated nurses have the
potential for informal leadership and facilitating positive
change by asking question, speaking up when something
doesn’t appear right, and engaging in continuous quality
improvement.

30. Clearly, managers can also be leaders, inspiring and
motivating their subordinates.
The roles and responsibilities of a manager are distinct
and different from that of formal leaders within an
organization.
A manager is someone who is responsible for
controlling all or parts of an organization.
The focus of a manager is getting the work of the
designated group or unit done effectively.

31.  As a nurse manager of a patient care unit, the role and tasks or
responsibilities associated with this position involve the running
of a floor or unit and usually include responsibilities such as the
following:
1. The hiring of nursing staff.
2. Creating, reviewing, and amending policies and procedures.
3. Coordinating orientation of new nurses.
4. Creating staffing schedules.
5. Developing and maintaining a budget.
6. Conducting employee evaluations.
7. Providing for professional development.

32.  While the ultimate goal of nurse managers is safe and high-quality
patient care, most often they do not provide direct patient care
themselves.
 They manage nurses giving the care, coordinate quality improvement
of that care, and help resolve any patient care concerns.
 In this role, nurse managers work closely with nursing and other inter-
professional team members including ancillary (extra) staff and
managers from other units, departments and disciplines.
 This list could include individuals from any department or discipline
within the organization, such as pharmacy, physicians and other
providers, as well as administration.
 Meetings, emails, safety huddles, and other forms of interaction help
the nurse manager to coordinate communication and efforts of the
interprofessional team.

33.  The list of tasks a nurse manager is responsible for directly and
indirectly help ensure that patient care is both safe and of high quality.
 They aim to hire qualified staff, provide adequate staffing to meet their
unit’s needs, allow for sufficient resources, and foster continuous
quality improvement.
 Policies and procedures help to provide clear expectations to relevant
staff.
 Policies and procedures also provide measures of performance,
knowledge, and skill.
 As a working document, periodic review and modifications of policies
should occur.
 This review provides additional opportunity for continuous
improvement.

35.  Not everyone in an organization can be a leader at the same time.
 And good followers are just as important as good leaders, neither exists without
each other.
 A follower is an individual who supports and is guided by another person who
usually functions as a leader.
 A good follower is not blindly led but rather exhibits traits of discernment (ability
to judge well), commitment, and trustworthiness; that is, exhibits similar traits of
a leader.
 A relationship must exist between the leader and the follower that, to be
effective, must be based on mutual trust and shared goals.
 As with effective leadership, effective followership approaches this relationship
as equally responsible partners in accomplishing the vision and mission at hand.
 Ideally, followers know their own strengths and weaknesses as they critically
appraise the leader and group’s ideas, thus providing support and intelligent
advocacy.

36. To be effective leaders, managers, and followers,
effective communication is required.
QSEN emphasizes this importance throughout its
competencies with specific interventions/tools such as
SBAR (situation, background, assessment and
recommendation)and TeamSTEPPS (an evidence-based
set of teamwork tools, aimed at optimizing patient
outcomes by improving communication and teamwork
skills among health care professionals).

37.  Considering the importance of communication to the effective running of any
organization, understanding chain of command is important.
 Chain of command is the order or hierarchy of authority within an
organization typically delineates (describe) flow of communication and
delegation.
 For example, using a chain of command, a staff nurse reports to a charge nurse
who reports to the head nurse, who in turn might report to a Department
Supervisor.
 That person might then report to a senior manager who reports to the Vice
President (VP) of Nursing.
 That VP then typically reports to the CEO who heads the organization.
 The chain of command is important for communication and direction of power.
 In most institutions and organizations, to initiate or suggest change, following
the chain of command is a well-established process.
 For staff nurses, typically the chain of command starts with their head nurse.

38.  Strategic planning and goal setting are based on an organization’s vision and
mission.
 Many resources exist to aid organizations in developing a strategic plan.
 One such resource is the Society for Human Resource Management (SHRM).
 These resources or associations help organizations distinguish between similar but
different terms.
 Access to resources sometimes requires a membership to an organization.
 SHRM is one of those associations; however, membership is free and comes with
many advantages.
 The vision of an organization is a statement that describes its ideal or future state
 The mission describes why an organization or institution exists.
 Based on the vision and mission of an organization, goals are set.
 Based on the set goals, the organization will then develop a strategic plan to
accomplish them.

39. This strategic plan typically includes very specific steps,
clearly stating who will do what with exact timelines
(when).
Specific units within a hospital will set goals and a strategic
plan that flows from the executive level to them.
That is, the unit’s strategic plan helps them to meet the
unit’s goals which support the institution’s goals and
strategic plan.
QSEN as well as the FON call nurses to participate in this
strategic planning on all levels of an organization to affect
change.
This includes sitting on relevant committees and boards
within the healthcare organization as well as within the
community in order to participate equally alongside other

41.  Though nursing is in the business of caring, healthcare is clearly a business that
must be financially solvent to exist.
 As a business, revenue (income) is generated by the care given to patients.
 This revenue pays for the expenditures incurred.
 A budget is an estimate of anticipated earnings and expenses that allows
organizations to plan and function with forethought.
 A budget stems from the organization’s mission and goals.
 While a variety of budgets exist, most hospitals employ both a capital and an
operating budget.
 A capital budget focuses on fixed costs such as land and buildings.
 Operating budget focuses on day-to-day expenses such as linen and clerical items.
 An operating budget typically involves the allocation of resources including those
resources involving staff and needed supplies.
 Nursing units normally function with an operating budget that focuses on salaries
and supplies required for the care the unit provides.

42.  The revenue/income of an organization comes from reimbursement paid for patient care.
 Reimbursements come from insurance companies, governmental agencies, and out-of-
pocket payments made by the patient.
 If a hospital is fortunate to conduct research and/or allow for auxiliary boards, unique and
separate sources of funding or money can augment (increase) what is received in
reimbursements.
 Healthcare reimbursement has been tied to patient care provided in a fee-for-service
model.
 A fee-for-service model of reimbursement pays a provider or institution for each individual
or separate component of care, independent of quality or patient satisfaction.
 Healthcare reimbursement is now based on additional factors such as patient outcomes
(how well did the patient respond to the care provided?) as well as patient satisfaction
measures.
 These additional performance measures alongside decreased reimbursements from many
private and public insurers have tightened hospital’s and organization’s budgets
significantly.

43.  Misuse of finances within the healthcare setting can have dramatic
consequences on individual patients as well as on the institution.
 As professionals responsible for patient care, nurses have a moral obligation
to understand how finances impact their ability to do their jobs safely,
including how budgets affect staffing, which in turn affects patient care.
 Studies show that patient mortality and morbidity is directly affected by
the number of patients assigned to a nurse in a given shift.
 The number of patients assigned to a nurse depends on staffing of the unit.
 Staffing can be centralized where one unit or department is responsible for
determining the needs for all units.
 Staffing can also be decentralized where the individual unit or department
determines its specific staffing needs.
 Typically, staffing needs are expressed in a ratio of nurses to patients,
which can be determined by one or more factors including budget allocation,
beds filled, and patient acuity.

44.  Adequate staffing helps to ensure nurses are able to provide safe and high-
quality care.
 Organizations like the Agency for Healthcare Research and Quality:
Advancing Excellence in Healthcare and Planetree.org provide valuable
tools to nurses and healthcare organizations to use for many aspects of
healthcare, including safe staffing.
 In 2004, California became the first state to mandate minimum nurse–
patient ratios.
 The legal mandate was limited to the following ratios:
 6:1 patient-to-nurse workload in psychiatrics
 5:1 patient-to-nurse in medical–surgical units, telemetry, and oncology
 4:1 in pediatrics
 3:1 in labor and delivery
 2:1 in ICUs

45. Aiken et al. (2010) studied the impact of this
mandate on patient outcomes and found it
significantly improved patient outcomes and nurse
retention.
Ensuring that the competencies of QSEN are
implemented has been shown to save hospitals
money.
For example, cost savings have been demonstrated
with the provision of patient-centered care.

47.  Nurses’ right and authority to practice as nurses are based on an
ethical social contract with society that explicates specific rights
and responsibilities based on education and licensure.
 Within this contract, nursing describes and agrees to the essence
of the profession with clear guidelines for behavior and intention.
 Documented as Nursing’s Social Policy Statement, the
relationship between nursing (and individual nurses within the
profession) and society is explained and spelled out.
 The behaviors expected of nurses are based on autonomy to
function and perform within the scope of nursing practice.
 The autonomy of nurses is in turn based on nursing’s
acknowledgment of public trust as well as nursing’s agreement to
self-regulate and accept legal parameters and regulations.

48.  Within the social contract is a Code of Ethics for Nurses that lists nine
provisions.
 These provisions allow nurses to fulfill the commitment made to their
patients.
 It also guides nurses to effectively serve as leaders in any and all
positions.
 The nine provisions are the following:
1. The nurse practices with compassion and respect for the inherent
dignity, worth, and unique attributes of every person.
2. The nurse’s primary commitment is to the patient, whether an
individual, family group, community, or population.
3. The nurse promotes, advocates for, and protects the rights, health,
and safety of the patient.

49. 4. The nurse has authority, accountability, and
responsibility for nursing practice; the nurse makes
decisions and takes action consistent with the obligation
to promote health and to provide optimal care.
5. The nurse owes the same duties to self as to others,
including the responsibility to promote health and safety,
preserve wholeness of character and integrity, maintain
competence, and continue personal and professional
growth.
6. The nurse, through individual and collective effort,
establishes, maintains, and improves the ethical
environment of the work settings and conditions of
employment that are conducive to safe, quality
healthcare.

50. 7. The nurse, in all roles and settings, advances the
profession through research and scholarly inquiry,
professional standards development, and the generation
of both nursing and health policy.
8. The nurse collaborates with other health professionals
and the public to protect human rights, promote health
diplomacy, and reduce health disparities.
9. The profession of nursing collectively through its
professional organizations must articulate nursing
values, maintain the integrity of the profession, and
integrate principles of social justice into nursing and
health policy

51.  Reimbursing for care prospectively meant providers and hospitals were paid
based on standardized care related to a patient diagnosis.
 Diagnostic-related group formulas (DRGs) were created as a way to control
hospital costs, which represented a way to “capitate” or control costs.
 Some nurse leaders believed it provided an opportunity for nursing to become
more visible.
 Because patients are admitted to the hospital for nursing care, it was hoped
DRGs would emphasize the centrality of nursing.
 Along with this realization, it was thought nursing would also move into a
position of more authority.
 A revered nurse leader Donna Diers (1986) addressed District Four of the New
York State Nurses Association.
 The title of her speech was “To Profess—To Be a Professional.” She began by
explaining the meaning of “to profess,” which infers a dishonesty or insincerity of
beliefs.

52.  Like others, she spoke of the social contract nurses have with their patients and
society.
 She also spoke of nursing’s primacy of caring.
 Diers believed the DRGs were the start of a revolution that offered nurses the
opportunity to step into a place of authentic and deserved authority.
 Nurse’s moral imperative is to care.
 But simply providing care or exerting compassion and concern are not enough.
 Diers and many others throughout nursing’s history have argued caring must be
intelligent and intentional.
 She states: Nursing is not just comfort, care, coordination, collaboration, or just
applied psychology, physiology, sociology, anthropology or diluted medical
science. Nursing is all of those things and more. It requires an effort of
considerable intellectual acuity—which looks to an outsider like intuition—to
thread one’s way through all the knowledge, technique, and tenderness one has
and to come out with the right action to serve the patient’s particular need.
(Diers, 1986, p. 27)

53. Like many of her contemporary counterparts, Diers
acknowledged that the application of caring must extend
from individual patient care to the creation of budgets,
committees, curricula, community efforts, and legislative
work.
What she argued most ardently was nurses’ legitimacy as
professionals would not come from advanced degrees or
credentialing.
Rather, Dier’s proposed, nursing’s professionalism and
authority would be established when nursing’s practice
was professional.
She argued this would only happen if and when nurses
took ownership of the work performed once education
occurred.

54. Suzanne Gordon is another powerful and ardent champion
of nursing and nurses’ need to “own the knowledge of their
work.”
Like Diers, Gordon argues nurses are solely responsible for
how they are viewed in her 2006 landmark book authored
with Bernice Buresch, From Silence to Voice: If nurses
aren’t willing to talk about their work, the results will be
catastrophic for nursing. Nursing, like every other
profession in today’s work, must justify its existence and
compete for resources. If nursing is misunderstood by the
public and those with influence, it will continue to be
disproportionately vulnerable to the budget ax, and new
resources for nursing education and practice will not be
forthcoming at sufficient levels.

55. If nursing’s script continues to emphasize the virtues of
the nurse as a person to the detriment of the knowledge
work that nurses do, then nurses themselves offer a
rationale for limiting resources for nursing.
Focusing on who the nurse is rather than what the
nurses does can be an invitation to seek not the best
and the brightest recruits, but the most virtuous (high
moral), meekest (humble) and self-sacrificing who will
try to do more and more with less and less.

57.  Acknowledging and accepting responsibility for the knowledge required to do the work of
nursing is an important start.
 But knowledge is based on knowing, which speaks to subjective perception and a dynamic
ontology or way of being.
 When knowing is expressed in a way that can be shared, it is considered to be knowledge.
 Knowledge of a discipline, such as nursing, encompasses the body of shared knowledge.
 This process of sharing knowledge within a discipline is vital to the creation of a
community.
 According to Chinn and Kramer (2013), once knowledge moves beyond the individual to the
discipline as a group, “social purposes form, and knowledge development and shared
purposes form a cyclical interrelationship that moves us toward perspective, value-
grounded change or praxis” (p. 4).
 For Chinn and Kramer, praxis (practice) is the outcome of critical thought and reflection of
the art and science of nursing.
 Change occurs with the inclusion of ethics and the therapeutic use of self that ultimately
results in some type of action.

58. This process of thinking and reflection that leads to action
is called Emancipatory Knowing.
As with Chaos and Quantum Theories, Emancipatory
Knowing stems from critical evaluation of economic, social,
and political influences of a reality or status quo (current
status) simultaneously looking at its potential for positive
change.
For Chinn and Kramer, this positive change must involve
alleviating injustice in order to ensure equitable conditions
for individual and groups.
In doing so, individuals and groups are provided the
opportunity to fulfill their potential.

60.  the IOM reports of 2000 and 2001 have led to many initiatives,
including the formation of the FON: Campaign for Action.
 Within this initiative, several organizations joined forces to
support nurses in a unique way.
 The RWJF, AARP, and the AARP Foundation pledged their
support and resources to aid the nursing profession in addressing
the eight recommendations listed earlier.
 While the FON acknowledges the importance of all
recommendations, they identified four specific or key elements to
ensuring all nurses will be prepared to assume a leadership role
within institutions and healthcare as a whole (Box 3.2).

62.  The call to action by multiple nurse leaders and organizations is
clear: Nurses must step into leadership positions at all levels of
practice.
 From advocating for the primary prevention of nosocomial
infections to safer staffing to working on committees to refine
policies ensuring safer and higher quality patient care on units,
in institutions, and on more global levels, nursing can have a
powerful and important role to play.
 Nursing’s social contract requires nursing to engage in a more
global systems thinking that embraces moral courage and the
knowing of its profession.
 By doing so, nursing will step into leadership that influences the
safety and quality of care of patients individually and as a whole.

63. Using your textbook:
read and answer the “Case Studies” and “Critical
thinking”.
Read “EVIDENCE FROM THE LITERATURE” text