Overview and Summary: Power to Influence Patient Care: Who Holds the Keys?

In 2007 nurses continue to comprise the largest group of health care professionals in the United States, but our numbers have failed to result in a corresponding ability to shape and direct health care policy in a way that empowers both nurses and health care consumers.

In her 1988 address to the ANA House of Delegates, President Margretta Madden Styles issued this clarion call:

March! There are no bunkers, no sidelines for nursing today. We find ourselves the center of attention. As the government and corporate America fight escalating health care costs, AIDS is wreaking havoc and technology swells unchecked. Underpaid, overworked and overstressed nurses are in the midst of a conflagration. Nursing is in far greater demand than ever before. Remember Scutari. We must organize, unite, go on the offensive.

Her charge to nurses in 1988 is as true today as it was two decades ago; and many of the issues she addressed in that speech have grown, multiplied, and intensified with the passage of time and the aging of both the general population and the nursing workforce. The extensive corporate takeover of health care delivery has brought with it additional challenges for both nursing and the health care system in general. If ever there were a time for 2.9 million nurses (United States Department of Health and Human Resources, 2004) to collectively exert their power to fix both a fractured health care system and a profession in crisis, the time is now.

Despite the need, however, for nurses to assert their power both collectively and individually, many remain largely oblivious to the concept and relevancy of power in their daily lives. This failure to understand and to utilize power appropriately has its roots in many causes, including sexual stereotyping, role socialization, and negative images of power as a coercive or corrupting influence, rather than in what it is: the ability to "do" or to influence outcomes which we all want and need.

The recent experience of Georgia’s Advanced Practice Nurses (APNs) has illustrated what nursing power can accomplish. The Georgia APNs had been fighting a decade-long battle to attain written prescriptive authority – a move blocked at every turn by the overwhelming influence and money of the Medical Association of Georgia (MAG). As the years dragged on, many APNs had simply disengaged from the battle and despaired of ever seeing prescriptive authority in Georgia.

The year 2006, however, turned out differently thanks to a coalition of APNs working together with Georgia Nurses Association; the mobilization of a powerful grassroots lobbying effort; the involvement of the media (and some very helpful editorials regarding the turf-protecting stance of the Medical Association); and the active recruitment of health care consumers in a letter-writing campaign. As the Georgia prescriptive authority bill, SB 480, rapidly morphed in and out of acceptable versions during the legislative session due to the pervasive interference of MAG, nurses overcame one setback after another to save the bill. After rising to each challenge, a palpable sense of their own burgeoning strength grew among APNs, and they took the fight to the very closing hour of the legislative session. The final vote brought to an end Georgia’s infamy as the very last state to grant written prescriptive authority to its APNs. I had been working online during the evening of the closing session, continuing to exhort my colleagues to phone and email their legislators; and I remember my elation when an email from my own state senator suddenly appeared, saying, "SB 480 just this minute passed the Senate!" For many APNs who had not previously given much thought to the potential power of acting in concert with hundreds, if not thousands of other nurses, valuable lessons about power were learned from this experience.

Others, unfortunately, may continue to view past and future disappointing legislative outcomes as a failure on the part of others, including professional organizations, instead of what they really are: the failure of sufficient numbers of APNs to recognize and embrace their own potential power, and to engage fully in the political process. Power gained is never static; and APNs will need those same skills again in 2007 as they go back to the Legislature to undo the highly restrictive "Rules" that the Board of Medical Examiners recently added to SB 480 in a further attempt to gain control over Advanced Nursing Practice in Georgia.

The Introductory Articles in this OJIN topic look at power from different perspectives.

Manojlovich discusses the various concepts and definitions of power, both in nursing and in other settings and disciplines, providing the historical framework in which to study the evolution of power in nursing practice over the years. She compares the positive outcomes of empowerment on nursing status and professional autonomy with the negative impact of nurses’ failing to understand and embrace power. Positive patient outcomes, as well as increased satisfaction for nurses themselves, are inextricably linked to nursing power, as has been repeatedly demonstrated in research on magnet hospitals. Manojlovich further discusses the organizational characteristics which are key contributors to the nurses’ power to influence patient care in the current work setting.

Abood looks at nursing power in the context of political and legislative advocacy in a health care system badly in need of change. This article points out the symbiotic relationship which exists between the practice setting and the legislative arena, and the ways in which political advocacy can enhance nursing practice in the work setting. After outlining the historical perspective of nursing advocacy, Abood defines the sources from which nurses can derive power. Such an understanding, along with knowledge of the policy-making process and the political forces which govern it, is vital to effective nursing advocacy. She provides specific examples of nurses who have identified problems within the health care system, and who were able to bring about needed change by developing and utilizing political skills. Abood makes the very important point that most policy changes require sustained group effort over many months, which should highlight the importance to nurses of their professional organization as the vehicle for such changes.

Ponte describes a partnering project between the Dana Farber/Harvard Cancer Center Nursing Departments and the University of Massachusetts Boston School of Nursing and Health Sciences, which included a unique mentoring project designed to enable doctoral nursing students to develop powerful professional practices. Ponte and her colleagues share how they interviewed 11 nurse leaders to identify how practicing nurses achieve and maintain power in their practices. They present what was learned through these interviews about the properties of a powerful nursing practice and the characteristics of the nurses working in these practices. While the immediate focus of the project was on doctorally prepared nurses, Ponte’s findings have relevance for nurses in all settings who aspire to be powerful professionals.

Hakesley-Brown and Malone provide a more global perspective by comparing similarities and differences between nursing in the UK and in the US. They use a poem to explore clinical power vis à vis the nurse-patient partnership, and describe the various forms of clinical power, including charismatic clinical power. While core values are the same for nurses in both countries, there are significant differences related to educational preparation, private vs. public health care delivery systems, underlying assumptions, and the degree of diversity of the nursing population. Ultimately, the authors believe that the common bond of caring in nursing is a form of empowerment which cuts across all lines of education, delivery systems, and diversity.

All of this topic’s articles provide the opportunity for nurses to reflect on the meaning and importance of power in their own professional lives, and to contemplate how they can develop the skills necessary to practice powerfully for the benefit of themselves, their colleagues, and their patients. In 1985, Dr. Haifdan Mahler, Director General of the World Health Organization, spoke of his vision for nursing, stating:

If the millions of nurses in a thousand different places articulate the same ideas and convictions about primary health care, and come together as one force, then they could act as a powerhouse for change. I believe that such a change is coming, and that nurses around the globe, whose work touches each of us intimately, will greatly help to bring it about (pg. 10).

I believe that as well.

The journal editors invite you to share your response to this OJIN topic either by writing a Letter to the Editor or by submitting a manuscript which will further the discussion of this topic which has been initiated by these introductory articles.

Fran Beall, APRN, BC
E-mail: fbeall@uhs.uga.edu