“American health care is in a state of hyperturbulence characterized by accumulated waves of change in payment systems, delivery systems, technology, professional relations and societal expectations.”1(p131) Shortell and associates go on to say that hospitals will be forced to reconsider their mission and role based on these forces.1 Within this environment of change, nursing is a constant across all healthcare services. Nursing's long-held convictions of a more holistic, collective approach to healthcare needs to be present in the wake of challenge and opposition. If nursing is to remain a player in the redesign of healthcare delivery, the values espoused by the profession should be brought continually to the forefront of organizational decision making.2 Nursing's professional values are articulated in the American Nurses Association's Social Policy Statement,3 Standards of Practice,4 and the Code for Nurses.5 Regardless of the practice setting, these value documents influence nursing activity and the development of nursing as a profession.
The nurse administrator has organizational responsibility for ensuring that professional behavior occurs. Administrators set and maintain the climate of nursing practice within an organization, formalizing and operationalizing the cogent values. It is from these values that priorities will be set, standards will be developed, resources will be allocated, and all facets of work life will be influenced.
Values of the institution are reflected in a mission statement and philosophy. The nurse administrator participates in the development of these documents and uses them to ensure congruence with nursing's goals and objectives. The inclusion of nursing values in organizational or departmental documents demonstrates a commitment to professional values and the development of nursing.
The administrator is a nursing professional dealing with organizational constraints. In the ANA Code, statement number nine (Fig. 1) has particular importance for the nurse administrator because it reflects the responsibilities for conditions of employment and maintaining conditions for high-quality nursing care. The nurse administrator must bring seemingly conflicting values into an ordered relationship so that the whole of the nursing department team functions synergistically to further the mutual goals of the organization, profession, and society.6
The values with which the nursing department is identified will broadly impact all decisions made in, for, and about nursing service. Because of that, the nurse administrator must ensure the formalization of the values in documents that are clearly written, kept current, and readily shared with all levels of employees in the organization.
According to Fry,7 most nurse administrators have learned about values and their role in ethical decision making through their own insight and socialization into the nursing management role. Some nurse executives cited management business courses as having exposed them to moral decision-making concepts. However, Fry stated that there is no research that supports those modes of learning, nor is there evidence that nurse executives are prepared to make the moral decisions required of them. Schmeiding8 asserted that the limited research on the nursing administrative process leaves nurse executives unaware of whether their actions are helpful to nursing staff members.
Brown9 suggested the importance of examining the primary identity that nurse administrators assume—either as nurse or administrator. She wrote that a statement such as, “I am a nurse who happens to be an administrator,” leads the nurse administrator to practice in such a way that the essential values of nursing are highlighted. Conversely, someone who views his/her primary role as administrative, and just happens to be a nurse, will reflect a business orientation. The author proposed that the nurse executive look at both nursing and administration as art. She defined the aesthetic as the perception, appreciation, and philosophy of art. The aesthetic in nursing, according to Brown, has to do with giving form to our values though the art of nursing. Viewed through aesthetics, all nursing becomes an expression of the central values of the profession, and each nursing act contributes to the definition of nursing. The essential nature of the profession can be reflected through the art of nursing administration.
This steadfast focus on values was strongly and clearly stated by Mason et al. in their book, Policy and Politics for Nurses.10 They implore nurse administrators, in their powerful roles as policy makers, to “refuse to silence the values of caring,”10(p9) and recongnizing that value conflicts will exist in all settings, to explore ways of integrating values into decision making and into all aspects of professional life.
Deremo11 reported on the development of a professional model in which the structure supported professional nursing values and facilitated professional nursing behaviors. She noted that the model advanced nursing by linking values to practice.
Kobert and Folan12 saw a departmental philosophy of nursing as helping nurses move toward a future that is consistent with their professional philosophy. They wrote that it is the context within which nursing is viewed in the organization, and should describe the method by which nursing care is delivered. However, the authors noted that the philosophy is more than the sum of these content parts. It involves an exploration of self and nursing's effect in society—an effect that is changing as the new paradigm of healthcare evolves. According to Shortell and associates, this emerging paradigm represents an example of “organization integrity and humility”1(p154) that allows new organizational forms to develop to meet identified community needs.
To assess how the values articulated in the ANA Code for Nurses were reflected in the philosophy of nursing documents of 10 healthcare institutions, a qualitative design was used. A purposive sample was drawn from all acute and long-term care facilities in a large midwestern metropolitan community. The sample institutions (N = 10) ranged in size from 87 to 700 licensed beds and had been in existence for 15 to 115 years. The vice presidents of nursing/patient care in acute care facilities and the director of nursing in long-term care facilities were interviewed using an investigator-designed instrument. The instrument was developed based on an extensive review of literature related to healthcare institutions, nursing service administration, and philosophy of nursing documents.9,13-21 The instrument was divided into three parts: institutional demographics, nursing administrator data, and philosophy of nursing document data.
Content analysis, a qualitative approach, facilitated the comparison of two data sources, specifically, the ANA Code and the nursing philosophies of 10 institutions. A category system using the 11 code statements was designed to quantify thematic data. Sixteen value-focused themes were identified in the eleven code statements (Fig. 1). A binary index was created to systematically record the presence or absence of themes in the institutional philosophies. The number of themes in each philosophy was noted, and the raw numbers and percent of total were determined.
The study was reviewed by the university Institutional Review Board. Nurse administrators were guaranteed anonymity and confidentiality for both themselves and their institutions. Each nurse administrator signed a consent form.
The 10 institutions in the study sample were all nonprofit. One was public, nine were private (3 nondenominational and 6 religiously affiliated). One institution was identified as a rehabilitation facility.
The nurse administrators had been in their current position from 2 weeks to 14 years (average tenure, 4.5 years). They had nursing experience in acute care, mental health, rehabilitation, and teaching. All of the nurse administrators had prior management experience. Each nurse administrator had a masters degree; two were enrolled in doctoral programs.
The influence of family values was the most frequently reported determinant of management style and management values, according to the nurse administrators. The second major influence was significant nursing experiences the administrators had in each phase of their professional career. This finding is similar to that of Redmond,22 who reported that significant others and professional experiences were primary factors in the development of nurse administrators.
Five nursing care delivery systems were used in the 10 organizations:
2. Primary nursing;
3. Differentiated practice;
4. A case management model; and
5. A structure the administrator labeled “multidisciplinary.”
The most frequently reported care delivery system was team nursing, which included unit-based teams and a practice partner concept.
Philosophy of Nursing Document
Analysis of the data from interviews with the nurse administrators revealed that 50% of the philosophy of nursing documents had been last reviewed before or in 1991. The philosophy of nursing review was performed most often by nurses in management positions. At one institution, staff agreement with the values articulated in the philosophy was demonstrated by having the document approved annually by the institution's professional nurse group. At two institutions, staff members were involved in the 1995 revisions. At another institution, recruitment and retention initiatives and the budget were analyzed to see if the values espoused in the philosophy were operationalized. This latter finding concurs with Hagenstad,23 who reported on one instituion's efforts to integrate values into the staff selection process. This institution has a values committee that seeks opportunities to integrate their values into the workplace.
The nurse administrators reported new employee orientation as the most commonly used vehicle for familiarizing staff nurses with the departmental philosophy. Posting copies of the philosophy in each nursing area and providing each staff member with a copy when the philosophy is revised were other strategies mentioned. Three of the nurse administrators stated that they try to reinforce the basic values of their department whenever nurses are gathered for inservices, forums, professional practice committees, or other nursing department events.
The 10 institutional philosophies varied in length from a few sentences to 13 pages. The former reflected 1 code statement and the latter reflected 7 of the 11 code statements. None of the philosophies contained themes reflecting all 11 of the code statements. However, every philosophy spoke to the core of the nurse-patient relationship, the dignity and worth of individual humanness (code statement 1). Eighty percent of the philosophies contained exemplars of code statement 6, which refers to nursing judgment in clinical decision making, including the delegation of activities to other healthcare workers. Code statement 10 (protecting the public) was not reflected in any philosophy and code statement 11 (collaboration to meet the health needs of the public) was reflected in only one philosophy. The thematic phrases identified in the code (Fig. 1) were mirrored in the nursing philosophies and led to easy enumeration.
Three philosophies each reflected 64% (7 of 11) of the 11 code statements. Two philosophies each reflected 9% (1 of 11) of the code statements, and the remainder of the philosophies fell between those two poles (Tables 1 and 2).
Themes identified in code statements 1 (respect for individuals) and 4 (accountability/ responsibility) were reflected most frequently in the philosophies. As in a study by Schank and Weis,18 patient-focused code value statements (code statements 1-6) were evidenced more frequently than those addressing the profession and society at large (code statements 7-11). They found that respondents attached greater importance to the statements of professional issues than to statements of societal issues. In this study, only two nurse administrators spoke about the implications of social issues for nurses in their institutions and involvement in formal political processes.
A surprising finding was that only 30% of the institutions addressed code statement 2, protecting the patient's right to privacy through confidentiality. This finding also mirrored the findings by Schank and Weis,18 who found that the nurse respondents in their study infrequently reported code statement 2. A possible reason for this statement not being included may be that the value is so basic, it is universally assumed and consequently not written. Another possible reason may be that because of the computerization of the healthcare industry, confidentiality has become compromised.
Themes directly referenced in statements during the interview of the nurse executives when discussing their own values and management style were specifically reflected in the philosophy documents. For example, one institution highlighted code statement 1 throughout the nursing philosophy, and the executive made many verbal references to respect for clients and also to respect for the dignity of colleagues. She stressed the importance of ethical and respectful nursing practice and noted that the institution she represents was the first in the metropolitan area to develop an ethics committee. Another institution heavily emphasized professional accountability (code statement 4) in its philosophy, and the nurse administrator explained accountability not only in clinical practice but in professional leadership.
Implications for Nurse Administrators
All of the nurse administrators expressed a personal commitment to professional values. Few have used the written philosophy to establish expectations for staff based on those values; however, this is a relatively new method to use. Nurse administrators do not have expectations for individual nurses to involve themselves in professional and community initiatives outside the institution. Because what is written will be perceived as important, nurses might attend to professional and community responsibilities if they were job expectations.
The nurse administrator provides stability and direction to the nursing service department by maintaining a demonstrated commitment to a consistent value base.24 Nurses in any setting must be helped to identify the progressive relationship of values to philosophy and mission. The beliefs inherent in the written philosophy become the foundation of what and how they practice. The nurse administrator must recognize the personal values of nursing department employees and take the time necessary to get staff input when reviewing foundation documents such as the philosophy. King25 stated that values can guide individual nurses toward satisfaction, fulfillment, and meaning. To attain such fulfillment in professional practice, the individual nurse must work in an environment in which the institutional values are compatible with the nurse's personal values. Reflecting on Gilligan's work,26 King noted that to the extent that women perceive themselves as having no choice, they correspondingly excuse themselves from the responsibility. In our study, 50% of nurse administrators implemented plans for staff involvement in review of the institutional philosophy of nursing in 1995.
Christensen27 reported that the goals of nursing administration can be accomplished through support of nurses in an organization. The nurse administrator demonstrates support of the profession and support of individuals by involving nurses in decision making. Nurse administrators can structure department processes (such as committees) to reinforce how values frame—or define—each issue, how values supply alternatives considered for resolution, and how values direct the reasoning on which a final judgment is made. By tying values to a process of ethical decision making, nurses are empowered professionally and individually in their practice.
The nurse administrator, in facilitating the process of ethical decision making, must maintain the vision of nursing in the organization. As such, the nurse administrator should stimulate creative thinking framed by a clear belief system. Nurse administrators should encourage all employees to contribute as their individual capabilities and talents allow. The nurse administrator must provide, through self and others, the freedom, coaching, and trust needed for growth. The power needed to shape the future of nursing will come from that growth. Clear articulation to the public of nursing's importance in the healthcare system will expand the power and influence of the nursing profession in our society. Within the profession itself, the direction and depth of change and growth will be influenced most greatly by the professional philosophy.28 Currently, professional values are not consistently operationalized in nursing practice.29 Nevertheless, it is the practice of each individual nurse that must give form to the values of the profession. Every nurse has a responsibility to be familiar with the ANA Code for Nurses5 and other seminal documents from the professional organization, such as the Social Policy Statement and the Standards of Practice. In a study by Schank and Weis,18 only 50% of the respondents reported a familiarity with the ANA Code. Familiarity with the code can be encouraged by strategies such as referencing the code in construction of philosophy statements and other facility-specific documents. Documents such as job descriptions and corresponding competency evaluations can reinforce core professional values.
The current choices for professional nurses in how and where nursing is practiced are practically limitless. A well-defined philosophy of nursing can direct nurses in ethically evaluating the choices before them. However, the choices made by each nurse have far-reaching effects. Each nurse must make an honest self-appraisal of the question, “Will I be instrumental in holding nursing to the stated values of our profession?”
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