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Nursing Administration Quarterly:
Health Care Visions For The 21St Century

Nightingale II: Nursing Leaders Re‐Membering Community

Koerner, JoEllen Goertz RN, PhD, FAAN

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Senior Partner, JoEllen Koerner & Associates, Sioux Falls, South Dakota. (Koerner)

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Abstract

As the health care field moves into the 21st century, the discipline is moving into new forms of service and leadership. This article presents a view of nursing leadership from the vantage point of community. Values, beliefs, and the changing roles of nursing leadership in creation of new order are examined along with skills and capacities necessary to accomplish the task at hand.

JUST AS Vatican II redefined the Catholic Church, a silent but profound reemergence of nursing in community heralds the advent of Nightingale II. The discipline is coming of age in a powerful way as nursing returns to its roots with all the wisdom obtained through a century of learning and serving in structured environments and businesses. Nursing is coming into its fullness at a time when the people we are privileged to serve also come to know and own their unique capacity for achieving total well being.

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What Is the Focus of Nursing?

For some, it is the provision of care through the performance of skills and bedside surveillance that provide safe passage through a critical illness event. For others, it is offering information, insight, and support in moments of chronic illness, or health crisis as individuals, families, and groups struggle to redefine total well being beyond the parameters of disease or its absence.

Futuristic nurses hold a broadly encompassing view of nursing's work based on broader definitions of health, thus expanding the social responsibility of the profession. Issues of social justice and the quality of human life at all levels, both nationally and internationally, are coupled with concerns for women's issues, safety, and well-being of children and elderly. Social tolerance, personal individualism, and spiritual freedom are sought in balance with rebuilding of neighborhoods, communities, and families. Futuristic nursing leaders clearly understand the importance of physical, mental, and spiritual balance and harmony. These nurses strive to foster the well being of the individual, family, community, and society; the corporation; the nation-state; and the planet as a whole. Thus, they design and support contemporary healing models that include complementary health care services and capacity building strategies for all citizens.

A foundational belief of the nursing discipline is that humanity must strive to live life in ways that contribute to universal balance and harmony rather than following lifestyles and pursuing goals that create its opposite. The value of simple, natural living versus the waste being generated by world capitalism and consumerism is being woven into care and caring models that honor the environment and focus on long-term sustainable solutions versus short-term gain. These nurses understand that everything and everyone is part of the web of life and thus interconnected. There is a deeply shared knowing that health based on such a broad platform of understanding requires a personal transformative experience with the sacred—nursing is returning “home.”

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What Is Community?

For some, community is a geographic location, a physical landscape marked by boundaries of terrain and culture. Shared space and commitment to the well being of the whole bind this community. For others, it is a group held together by shared values, beliefs, interests, or ideology. Such a community shares a common task (as in a specific class of students in school), a common work (such as an organization), or a common interest (as in a religious institution). Still others define community as a process of becoming: our predecessors, our successors, and our contemporaries, 1 or seven generations out. 2 Finally, others define community as the universe being a unified web of relationships. 3 The definition of community is as diverse as the people who make up its membership; thus, the first task in working with community is to clearly define “what it is.”

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What Is Health?

For some that live in the scientific/ behavioristic paradigm, health is the absence of disease, or balance between body-mind-spirit. A nurse with this definition sees his or her job as one of healing and support through designing a plan of care based on nursing expertise and professional judgment. If the person does not adhere to the plan, the label of noncompliance is affixed.

Still others define health holistically and simultaneously, with little compartmentalization, labeling, or prescriptive methodology. For these nurses health is person-environmental balance, 4 an expansion of conscious awareness, 5 living the values of one's own choosing. 1 In these health models, the individual is viewed as expert on his or her own health, and the work of nursing is to facilitate individual and family efforts toward balance, insight, and authenticity. Thus, the level of involvement of the person in his or her own health planning and healing is determined to a large degree by the values and beliefs of the nurse.

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What Is Leadership?

For some, leadership is invested in an individual who can solve a problem, fill a need, or create something new that is expanding in nature. This kind of leader is sought as “the one who knows,” the one who will impart wisdom and guidance in difficult times. This form of leadership is important when control and specific outcomes are desired quickly. It does not, however, draw on or potentiate the inherent leadership capacity of others within the field.

New forms and models of leadership are emerging as society becomes more proficient in its ability to solve its own problems. Natural leadership 6 uses principles of nature rather than metaphors of mechanics. In this model, leadership is a singular act of building a bridge between what is and what is trying to emerge. The leader in this model is identified as one who has an intuitive capacity to see what is not yet present, and hold the space for others to discover it themselves.

Others see leadership as an innate capacity inherent within each individual through the process of self-reference and self-generation. 7 This perspective sees communities, groups, and organizations as “leaderful.” In essence, the task at hand invites the capacity of those most expert to step forward, offering the leader space to others when the issues fall outside their domain. In this way, leadership is an artful exchange of leadership-followership, where all become part of something more in an exquisite dance of synergy.

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What Is Nursing Leadership in Community?

The impact of economic realities and the business strategies used to address them are affecting the quality of health services in multiple ways. As patients are moved back into the community more acutely ill, resources and services have not yet matured to effectively serve all people. Many people are underserved or unserved as major health systems struggle with the challenges of decreased funding coupled with increasing demand for services and regulation. Thus, while some nurses are remaining in organizations and corporations to provide powerful leadership in the complex world of business, another part of the nursing cohort is moving back into community. Nursing leadership within this setting is focused on establishing a healing web of relationships and services that facilitate the emergence of new order, not only for the people, but also for the profession.

Nursing entrepreneurship is emerging as a new form of leadership in community. Some nurses are leaving guaranteed salaries and benefits for the high-risk world of independent business. In this space the issues of personal and professional performance and accountability are paramount. Moving from employee to entrepreneur mentality is very challenging as expansion of the nurse's mindset to include the businessperson is undertaken. Stepping outside of organizational space with guaranteed salary and benefits, well-defined expectations, and multiple resources demands a new kind of resourcefulness. A person is required to “show up” each day, for that is all that is! And in this space of great risk and unlimited potential, a profound sense of freedom to practice is its own reward!

Futuristic nursing leaders must seek funding sources to support work that is not yet fully understood by primary payer sources. Some are opting to work with self-pay populations alone, while others are crafting exquisite contracts with third-party payers and various provider groups for carve-out service provision. Some are establishing relationships with specific patient populations, providing services and information that minimize disability and chronic disease progression. And still others are working with well populations in an effort to forestall illness through early detection and health management. Models and methods are as varied as the communities being served, while the values of caring, empowerment, and total well being are a constant across the field.

Leaders in community will be identified through the demonstration of skills of capacity building within this broad and ever-changing sphere. These nurses work from a philosophy that believes in the capacity for transformation and change in each person, no matter what his or her life circumstance. Capacity building fosters resilience and healthy human development and meets the basic human needs for caring and connectedness, respect, challenge and structure, meaningful involvement, belonging, and power. Such nurse leaders help create a nurturing environment that meets these basic needs, enabling the community to directly access their innate resilience. 8

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What Skill Sets Are Needed for Such Leaders?

Capacity building is an inside-out process that begins with the nurse's beliefs and values and emanates outward to transform all it touches. Four major capacities are the hallmark of such futuristic leaders.

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Capacity to create negotiated partnerships

Nurse leaders in communities hold exceptional interpersonal capacity, modeling the ability to work with individuals and groups in a way that creates a shared middle ground. Negotiation skills help all involved agree on shared responsibility and accountability. For example, this partnership may name a person or family as the primary care manager with interactive surveillance contracts established that identify accountabilities for all involved. This leader can work effectively with other professionals, payer sources, governmental agencies, and people from all walks of life. His or her ability to be authentic and invite the same from others—without judgment—is basic to this skill.

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Capacity to create new order

The nursing leader in community can see relationships between unrelated parts. The ability to see relevance and fit between things that have not been connected together in the past is a high-level system-capacity function. Such people synthesize information by seeing whole-part relationships, seeing similar patterns in unlikely pairs. They can anticipate outcomes before they manifest, capturing subtle shifts in direction that are easier to influence and change when small than when they become very dense and obvious. Design principles that maximize virtuality, real time, and networks require the inclusion of emerging technology into the creation of new systems. This often requires midcareer leaders to seek a strong relationship with younger information system experts who can cocreate technological-based solutions to service challenges in preparing for a diverse and geographically dispersed population.

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Capacity for fluency and numeracy

We are leaving the era of physical science, where the premium skill was the ability to break things into their smallest component parts and measure them. Although this will still be a valid method of inquiry for the concrete, physical world, we are moving into the era of living systems, where things are constantly changing. Relationship rather than physical form create the essence or quality of the thing; thus, prescriptive solutions are giving way to creating a quality response in the moment. The ability to approach the situation with an open mind and improvise an adequate reaction requires a very different set of skills. It is based on the knowledge that there are multiple ways to address any situation and that the best solution resides within the problem itself. Thus, the creative leader develops fluency of ideas, words, images, and metaphors to use in painting a context of meaning that inspires others to join in the work at hand. Quantity and quality become paradoxical twins as the art of nursing, which creates and manages relationships, becomes as valid and essential as the science of doing and measuring.

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Capacity for moral courage and integrity

In a leadership role, the person is the instrument. The character and courage of the leader determines the intention of the act, which draws forward a resultant set of activities and outcomes that impact large numbers of people. Thus, there is no room for jealousy, anger, victimization, or artificiality. A person's health, well being, and success in life is dependent on his or her capacity for authenticity and integrity. As nursing leaders witness how the business-oriented and profit-motivated structures are affecting the quality of health care in increasingly negative ways, holding the truth about core care issues is difficult to do in isolation. But as a network of expert nurses with a shared mindset and skill set emerge into “leader space,” they become increasingly positioned in society to facilitate the maturation of this broader view of health and total well being.

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What Is Our Collective Future?

The challenge being faced by humanity on the start of this millennium is to create an interdependent world view within a reality moving toward ever-increasing differentiation. As individuals, we are unavoidably set deeply into the context of our family, community, and spiritual beliefs. Our very existence depends on these profound contexts woven into a web of relationships. Rather than creating and leading nursing in one right way, our call as a multicultural and multidimensional profession is to create an integrating process that facilitates health for a community growing increasingly complex and diverse.

In his compelling work, The Eye of Spirit, Ken Wilbur 9 observes:

To understand the whole, it is necessary to understand the parts. To understand the parts, it is necessary to understand the whole. Such is the circle of understanding…we move from part to whole and back again, and in that dance of comprehension…we come alive to meaning, to value, and to vision: the very circle of understanding guides our way, weaving together the pieces, healing the fractures, mending the torn and tortured fragments, lighting the way ahead-this extraordinary movement from part to whole and back again, with healing the hallmark of each and every step, and grace the tender reward.

The call for nursing leadership is to facilitate the creation of new systems that incorporate the greatest number of orienting frameworks from the largest number of fields of human inquiry. Trust in the process and the people emerge from respect for each person's own unique perspective. “I assume that no human mind is capable of 100 percent error.” 9 Integrative leadership does not ask which approach is right or wrong, but rather assumes that each approach is partial and designs processes that fit them together into a greater whole rather than picking some and discarding others. Honoring diversity does not occur when we treat all people equally (which is the greatest form of discrimination against humankind), but rather, when we treat all people uniquely. Respecting and facilitating the life and well being of all—self, family, staff, community, earth—occurs when we honor the uniqueness of each individual, using the richness of diversity as a vehicle toward wholeness. 10 This is the hallmark of leadership for the 21st century.

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REFERENCES

1. R.R. Parse, Nursing Science: Major Paradigms, Theories and Critiques (Philadelphia: W.B. Saunders, 1987).

2. G. Thin Elk, Legends of the Mighty Sioux (Pierre, SD: Workers of the Writers Society, 1988).

3. F. Capra, The Web of Life: A New Scientific Understanding of Living Systems (New York: Anchor Book by Doubleday, 1996).

4. M. Rogers, “Nursing: Science and Art: A Prospective, Nursing Science Quarterly 1 (1988): 99–102.

5. M. Newman, Health As Expanding Consciousness, 2d ed (New York: National League for Nursing, 1994).

6. W. Blank, The 9 Natural Laws of Leadership (New York: American Management Association, 1995).

7. M. Wheatley, Leadership and the New Science (San Francisco: Berrett-Koehler Publishers, 1992).

8. B. Benard and K. Marshall, A Framework for Practice: Tapping Innate Resilience (Minneapolis, MN: National Resilience Resource Center, University of Minnesota, 1997).

9. K. Wilbur, The Eye of Spirit: An Integral Vision for a World Gone Slightly Mad (Boston: Shambhala, 1997).

10. Center for Nursing Leadership, Dimensions of Nursing Leadership (Berkeley, CA: Institute for Healthcare Executives, 1997).

Keywords:

authenticity; co-creation of new order; compassion; entrepreneur

Copyright © 2000 by Aspen Publishers, Inc.

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