leadership, nurses, patients, power, quality care, transformationIn a recent anthology (Agabi, 2000), there is a poem called ‘R & B.’ Although a number of interpretations might be applied to this acronym, in this instance, it is cleverly used as a cipher for the colours red and blue. These are utilised as a vehicle to describe a relationship between two people who could appear to be antagonistic towards each other

‘You’re the red rag to my raging bull
You see red when I sing the blues’

The poem develops by stripping away the complex layers that make up this nuanced relationship that, ultimately, works exceedingly well

‘You say we were a mismatched couple
but I’m reminiscing too.
I remember how we made the colour purple
And my eyes are red from missing you.’

This idea of two colours/people, mixing together to produce the colour purple is a useful metaphor. It can be utilised for effectively unpacking and understanding the symbiosis achieved by the blending of the patient/nurse relationship. This relationship has the potential to forge a powerful force for quality on the anvil of global changing health care needs and health care delivery.

This article will examine the way that the existing patient/nurse dyad is the result of clinical, political, and organisational power paradigm shifts over time. Using this exploration of the history of nursing in the UK as a contextual framework, the commentary will then consider the way that nurses have contributed to the emancipation of patients, and vice versa, in the quality endeavour, using various bases of power. This will be expanded to compare and contrast United Kingdom (UK) and United States (US) scenarios, using the themes of (a) education, ( b) the NHS/the US health care systems, and (c) issues of diversity, in terms of both the development and the significance of the patient/nurse partnerships as a power base for quality. The conclusion will include a transatlantic vision for the future in terms of the consolidation of the patient/nurse transaction to achieve, not only the common goal of negotiated, competent, and compassionate care, but also as a continuing force for quality at strategic and operational levels.

History of Nursing Power from the UK Perspective

Historically, there has been a number of shifting power paradigms in relation to patients and nurses. These have been much influenced by the economic, political, and social structures in which they took place. Black (2005) attributes the transformation of UK hospitals in the nineteenth century to "…medical advances, nursing reform and improvement in buildings" (p. 1394). Conversely, Dean et al. (1980) illustrate how some areas of the development of nursing in nineteenth century England were influenced by the need by the politicians of the day to exercise social control by managing the sick poor.

Understanding our history is an important facet to understanding the shifting power base of patients and nurses.

Williams (1980) provides further insights into the socio-political imperatives that shifted nursing from a largely unskilled, low-paid job to that of a more respected, contributing role in society. She sees the major shapers of this development as the increase in medical interventions, the health care needs of the rich, and the requirement of a burgeoning industrial, capitalist economy for a healthy workforce.

Understanding our history is an important facet to understanding the shifting power base of patients and nurses. The rights and responsibilities of both constituencies become enmeshed with the socio-political infrastructures of the period. In the UK, social class, access to education, gender, franchise rights, and economic status have all been important elements in the power brokering equation for these two groups.

Nearly 20 years ago, Clay (1987) wrote that:

Nursing is a remarkably insular profession, which has taken little heed of the great social, political and economic forces that have shaped and surrounded its practice….We are sometimes guilty of not taking time to lift our heads from the bedside to look at what is happening around us (p. 1).

More recently, Black (2005) reappraised nursing from a historical perspective and concluded that nurses made a major contribution to nineteenth century health care delivery. He makes powerful arguments, with supporting evidence, that not only is the contemporary UK patient public losing faith in hospital care, but that today’s nurses, as in the nineteenth century, have the potential and are the key to:

• replicating a transformation of hospitals similar to the nineteenth century change
• improving the hospital environment
• reducing the need for hospital care
• improving the hospital environment, in addition to also reducing the need for hospital care

Some progress has been made in relation to this last point. On November 9, 2006, the Chief Executive of the English National Health Service (NHS) wrote to every Member of Parliament to inform them that the NHS was developing a new model of care with fewer patients being treated in hospitals "...and more in local clinics and hi-tech specialist centres. This would require fewer beds in hospitals" (Cavel, 2006, p. 12). Black (2005) points out that the nursing contributions to the transformation of health care can only be achieved if doctors, managers, and politicians recognise and respect the contributions that nurses can make and there are enhanced opportunities and improved leadership opportunities available.

...nursing contributions to the transformation of health care can only be achieved if doctors, managers, and politicians recognise and respect the contributions that nurses can make...

Perry (1991) asserted that, in the past, nurses had increased their knowledge by observing a variety of pathologies and interventions from the perspective of the sick poor. Doctors, however, were more associated with the care of the rich; and thus the status of the two occupations became derived from the social class of those receiving care. This resulted in nurses having a more subordinate position in the health care hierarchy. In recent times, this relationship has changed dramatically as a consequence of increased education for both patients and nurses. Mackay (1993) believed that this potential narrowing of the relative educational gap between doctors and nurses could result in negative attitudes towards, and some discomfort about, graduate nurses by medical colleagues.

The adage that knowledge is power is becoming more of a lived reality for both patients and nurses in a UK health care system, which has previously been grounded in paternalism (the father/child analogy to describe superior/inferior relationships) and biomedical reductionism (the artificial distillation of health issues to fit a biological/medical model without taking into account psychosocial factors for a more holistic approach).

...there is no way to deliver quality care in highly complex, frequently chaotic, organizational environments without power.

This article describes power as a force towards achieving goals (Marquis & Huston, 1996). For example, education is often identified as powerful; it is the movement of one’s mind from one point to a different point that captures the educative experience. Both nurses and patients are often averse to identifying themselves as powerful. Nevertheless, there is no way to deliver quality care in highly complex, frequently chaotic, organisational environments without power.

Nursing is the process of accompanying someone on a journey of recovery, end of life, or the promotion and maintenance of health; and yet, regardless of the journey’s destination, living each moment to the highest quality. At times, when the patient does not have the power to see his/her way forward due to lack of physical, psychological, or emotional capacity, the nurse leads in the direction of healing. At other times, it is the patient who leads. With healing as a destination, with power as the fuel, the possibilities for creative leadership by both the nurse and the patient are infinite.

Using Nursing’s Power Base to Move from Vision to Reality

Without power, there is no action.

A vision is a picture, an image of the destination, the goal one is trying to achieve. The antecedent for visioning is dreaming. Dreaming requires time, practice, and permission from one’s self to think illogically and irrationally (Malone, 1991). It requires power to move the dream from vision to reality. This can only be accomplished by sharing it with others and transforming the vision as others buy into it and joint ownership occurs. A vision without action is a hallucination (Malone, 1996). Without power, there is no action. The concept of power is multidimensional and complex. The following power perspectives have been selected for their relevance to the professional practice of nursing and the therapeutic relationship between nurses and patients. These power perspectives are clinical power, which has several forms: (a) informational, (b) legitimate, (c) charismatic, and (d) extended (French & Raven, 1960), political power, and organisational power, each of which will be described below.

Clinical Power

Clinical power is at the core of the nursing profession and of individual nurses. Patients are an essential part of, and make an important contribution to, this clinical power base. Without patients, there is no clinical power. Without patients, nurses would have no clinical power, which is created by the interdependence of nurses and patients. It takes power to shape and massage an organisational system, such as a hospital, and extract the best care for our patients (Malone, 1996).

Informational Clinical Power

Informational clinical power is multi-directional and generated through listening, reviewing, examining, discovering, intervening, and being together with the patient.

Nurses share more information (and vice versa) with patients than any other provider group.

Nurses share more information (and vice versa) with patients than any other provider group. Nurses are alongside patients twenty four hours, seven days a week, offering an integrated, holistic approach that extends to families, colleagues, significant others, and communities. Consequently, nurses are endowed with information that, when shared between all the stakeholders, becomes a powerful tool in the healing process. Managing informational power means sharing across traditional boundaries, frequently redefining the boundaries in the process.

Legitimate Clinical Power

Legitimate clinical power is based on one’s position and/or credentials. The most significant legitimate clinical power that all nurses in the UK have is their Nursing and Midwifery Council (NMC) registration. The NMC affirms every nurse’s power and authority to provide safe, competent care to the people of the UK. This is every patient’s right. This is currently under threat with the recent Department of Health’s (DH) Foster Non-Medical Regulation Report (DH, 2006). This recommends a diminished role for the NMC in its monitoring and disciplinary activities. The Royal College of Nursing (RCN) and the NMC are speaking out in opposition to any steps that constrain nursing’s ability for self-regulation.

...legitimate power emanates from an accepted ethical framework...in which patients' rights are enshrined.

From a patient perspective, legitimate power emanates from an accepted ethical framework (incorporated in most professional codes of conduct) in which patients’ rights are enshrined. The first public document which acknowledged a more knowledgeable and autonomous public in the UK was the Patient’s Charter (DH, 1991). Additionally, professional bodies such as the RCN have also always been at the forefront of spelling out protocols for patient’s rights in areas such as health care research (RCN, 2005a). Over the last two decades there has been a burgeoning of patient pressure groups, often related to specific conditions, such as the Stroke Association. Nurses are often active in these groups, particularly if they are related to their practice specialisms. The public and the professionals also involve themselves in raising money for such enterprises as Cancer Research. This has particular resonance if they, or family members, are affected by the condition. For instance, the daughter of one of the authors recently ran a half marathon for Cancer Research, designating her effort on her sweatshirt ‘For her Mum’!

Charismatic Clinical Power

Charismatic clinical power is related to the power to inspire others (Weber, 1947).

For charismatic power, the nurse must present an element of joy or passion for the profession, for the act of caring and healing.

Charisma is characterised by confidence and enthusiasm, confidence in one’s self and in the other (patient, colleague, family member). For charismatic power, the nurse must present an element of joy or passion for the profession, for the act of caring and healing (Malone, 1996). This joy and passion are contagious and can infect an entire team with the confidence and assurance that they can manage a healing environment. Brown’s research (1989) highlighted the importance of ward sisters in providing positive role models and acting as culture bearers for the ward team in the delivery of high quality patient-centred care. It is also important to acknowledge that patients and their families have huge potential for inspiring nurses and others in the way that they manage life-changing (or even life-limiting) situations.

Extended or Referential Clinical Power

Extended or referential clinical power is built on the premise that providing quality care is not a solo endeavour. If the nurse is the only health provider, the caring is accomplished with the collaboration, cooperation, and support of the patient, family, and community.

...nurses are frequently unaware of their power as they move through their work...

Extended power addresses the challenges of shift work and working in multidisciplinary teams. It emphasises the need to effectively communicate with others, affirming their involvement and acknowledging the nurses’ limited capacity and need for rest and rejuvenation.

All of these versions of power have the potential to liberate both patients and nurses. They underpin the nurse clinician’s ability to provide quality care to patients in a variety of settings, ranging from hospital to community. Yet nurses are frequently unaware of their power as they move through their work, 24 hours a day, 7 days a week, and 365 days a year. It is critical for nurses to be able to identify their power in order for them to manage it and apply it in collaboration with the patient and other health care providers. Yet power must also move beyond the clinical frame and extend to the political and organisational arenas.

Political Power

Nursing must have an opportunity to shape policies...[or they] are continually working at a disadvantage, waiting for others to make policy decisions that nurses are then expected to implement.

Political power refers to the ability to shape and influence policy and the processes, including people, for developing and implementing the policy. Nursing must have an opportunity to shape policies that determine the quality of care, and the quality of life to which patients, people, and communities are entitled. Without this opportunity, nurses are continually working at a disadvantage, waiting for others to make policy decisions that nurses are then expected to implement, regardless of the consequences. This not only undermines the patient/nurse relationship, but also is key to the diminished morale among nurses. The RCN mission statement states, "The RCN represents nurses and nursing, promotes excellence in practice and shapes health policy" (RCN, 2003, p.2). This pro-active mission is reflective of the determination by UK nurses to be involved in decision making early in policy development through think tanks, government task forces and commissions, and any other power shaping groups.

Organisational Power

Organisational power is demonstrated by an astute appreciation of systems, boundaries, tasks, transactions, and organisational life.

...nursing's arena for action has to stretch beyond the clinical setting and into the boardrooms of decision makers and policy shapers.

This knowledge can be translated into the transformation of organisations. Barker (1991) suggests that nurses can design work environments that satisfy the needs of both patients and staff, thus enhancing the quality of care. This is the use of organisational power. But nursing’s arena for action has to stretch beyond the clinical setting and into the boardrooms of decision makers and policy shapers. One exemplar for the use of organisational power is the strategic positioning of nurses on boards where executive policies and decisions affect a wide range of staff and patients (Hennessey, 2000). Nurses are also beginning to venture into social enterprise businesses, such as that led by a nurse and a therapist who will run community nursing and therapy services for a Primary Care Trust

Clinical, political, and organisational power are essential for nursing as a predominately female profession in a predominately male health leadership culture.

in the South of England. The added bonus in this example is that each of the 600 staff will receive share certificates for this not-for-profit company (Staff hold shares, 2006). The RCN has a long tradition for supporting nurse entrepreneurs.

Hennessy (2000) also offers a useful synopsis of the organisational empowerment of patients, which began with the previously mentioned publication of the Patient’s Charter (DH, 1991). This was accompanied by the statutory inclusion of lay members on Trust Boards and Purchasing Authorities. Greater emphasis has been placed on managing patient complaints, patient choice, and the development of patient/health professional partnerships. Hennessy (2000) points out, "There are excellent opportunities for nurses to take up the baton here and truly attempt to provide care in partnership with their patients.…There are opportunities at the present time for nurses to be very influential" (p. 114).

Clinical, political, and organisational power are essential for nursing as a predominantly female profession in a predominantly male health care leadership culture. An awareness and capacity to effectively utilise power does not eliminate the need for emotional intelligence.

...emotional intelligence [is]...another frequently undervalued and perhaps underdeveloped source of power for nurses.

In caring for patients, it is a critical component of providing a healing process framed within a healing environment. Grossman (2001) suggests that emotional intelligence, an interpersonal skill, is the difference between outstanding and mediocre leaders. This represents another frequently undervalued and perhaps underdeveloped source of power for nurses.

The effective use of the clinical, political, and organisational power base as the infrastucture for a sensitive patient/nurse relationship has the potential for not only realising the richness and regality of ‘…the colour purple’- the metaphor mentioned in the introduction. It also has infinite possibilities for producing the magnificence of the whole rainbow spectrum of the power dynamic when patient and nurses work together. This, in turn, can become a power house for change in influencing the dynamics of health care in the interests of the major stakeholders who matter most – the patients.

Similarities and Dissimilarities between the UK and the US

In reviewing these different types of power, the question may arise as to the similarities and differences along the power dimension between UK and US nurses. Overall, the same values underpin nursing on both sides of the Atlantic Ocean. These values include: listening, caring, respect, inclusiveness, and equality. Vance (2000) describes the universal power of nursing: passion – what we believe in; presence – who we are; practice – what we know and do; and partnerships – how we connect with others. The passion, along with the presence, can be linked to charismatic power as discussed earlier, while presence can be associated with charisma, but extends to clinical power. The power of partnerships is more aligned with referential or extended power. These are common power attributes of nurses in both the UK and the US.

Overall, the same values underpin nursing on both sides of the Atlantic Ocean.

In contrast, the differences between the patient populations are found in the types of health care systems they have experienced throughout their lives. For example, the UK population’s expectations are higher in the area of free service at the point of delivery; while US patients are accustomed to a fee for service and payment for ongoing care, with no expectations of a universal system free to all citizens. At the same time, US and UK patients are similar in feeling vulnerable and exposed when ill and reliant on the heath system for healing. In the UK, the patient population has a tendency to be more dependent on the system because it is free. At the same time, patients also have higher expectations. In the US, patients are expected to self finance their health care usually by a health care insurance plan. The differences between the two groups of nurses along the different dimensions of power is embedded in the systems of (a) education, (b) the NHS/the US health system, and (c) issues of diversity. Each of these differences will be discussed below.

Education

Hennessy (2000) charts the development of the UK Project 2000, university- based diploma level education (normally three years in length but equivalent to the first two years of a three year undergraduate degree programme), for all nurses from 1989. This included the introduction of education-led supernumerary status (where the student is not included in the official workforce ratios), compared to the previous service led apprenticeship mode of training. There were already 5% of all pre-registration (leading to accreditation as a first level nurse) programmes at degree level at that time. To date, England is the only country, out of the four in the UK, that does not offer an all-graduate (an undergraduate, degree-level preparation) entry to nursing. The Chief Nursing Officer (CNO) for England has recently indicated that there is a strong consensus to move to an all-graduate entry to nursing, as well as a need for a more holistic approach to the pre-registration nursing branch programmes (Time is right, 2006).

Branch programmes are currently divided into four clinical areas, i.e., adult, mental health, paediatric, and learning disability. These different branches inevitably create a level of separatism among nurses, but simultaneously create an army of specialists at post-registration level who have a significant commitment and passion for their area of specialty. This exclusive process, at times, serves as a disincentive for nurses to use the power of unity. By separating into branches at an early stage in their career, there is less likelihood of coordinating and utilising the total power of the UK nursing profession.

Compared to the US system of preparing a generalist nurse first before specialisation, the UK model offers a less flexible route for nurses to move from one branch to another. This lack of flexibility may also contribute to fewer nurses being prepared at masters’ and doctoral levels in the UK than in the US. In the US, specialisation, advanced practice, is acquired at masters’ level (Gillis & Mundinger, 1998). The opportunities for certification and other acknowledgements of advanced specialist work are also available through advanced, higher degree education.

Issues related to power are taught and experienced during graduate studies in both the UK and the US Systems theories and change-agent strategies are often part of the curriculum (Brown, 1995). It is at post-graduate level that one is introduced to transacting across boundaries, transforming systems, and using one’s political skills in negotiating with willing and unwilling significant others. In the US, the fact that, in order to be certified as an Advanced Practice Nurse (APN), an advanced (graduate level) degree is considered baseline. This gives US nurses an edge in effectively using power to engineer and coordinate policies and strategies for populations as well as for individuals. Over 10 years ago, the then UK regulatory body, the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC), published a position statement on advanced practice (UKCC, 1994). This statement included ideas around:

• adjusting the boundaries of professional practice, i.e., increased responsibility and accountability
• developing new roles, i.e., nurse led clinics
• advancing clinical practice, research, and education, i.e., developing, disseminating, and utilising evidence-based clinical practice through research and education
• determining health need, i.e., being able to assess health care needs of individuals, groups and populations from the available evidence
• contributing to health policy and management, i.e., participating in both the strategic development and the operational delivery of health care at local, regional, and national levels

The Council members, at that time, were not prepared to specify a particular qualification for fear of stifling innovation and progress! However, they did go so far as to suggest that "…such levels of study are likely to be at the academic level associated with a Master’s Degree" (UKCC, 1994, p. 20). Brown (1997) notes that this was the first time ever that it had been officially acknowledged that "…some of those professional colleagues who remain in [clinical] practice would benefit from, and contribute to, postgraduate level work" (p. 8). As Davies (1995) pointed out, promotion in the UK, and by implication, extra qualifications, usually involved a move away from the interface with patients into such areas as education, management, and research. In the past, such nurses in the UK have been criticised for adding ‘alphabets’ after their names (Devlin, 1987).

Yet the passion and commitment that is achieved in the UK branch system of nursing education is remarkable. It instantly creates an army of specialists who are devoted to their area of caring. As more of these nurses become prepared at an advanced degree level, there will be an increasing number of nurse leaders using their power to position and shape policies and practice at the highest level of the systems, both governmental and health care. There is early evidence of this in the increasing number of nurses who are undertaking both the Clinical and Political Leadership Programmes at the RCN. Additionally, there has been an exponential increase in the number of UK nurses presenting research findings at the RCN’s Research Society’s International Conference and also submitting applications for the Nursing Standard Nurse of the Year Awards. All of these activities demonstrate ordinary UK nurses are engaging in quite extraordinary endeavours at both local and national levels.

For both countries, changes in education will be required to ensure that all the potential elements of power that result from the patient/nurse dyad are realised. Lindeman (1995) summarise this as a move from:

• individual, autonomous functioning to interdisciplinary models
• episodic to care over the continuum
• provider-centred care to partnership with consumers
• technology as an optional tool to technology as a foundation for practice

These changes in education will form a platform for more effective use of power by nurses on both sides of the Atlantic. In the UK, there have already been developments towards achieving this kind of framework as required by the NMC’s Standards of Proficiency for Pre-Registration Nursing Education (NMC, 2004) which includes the following standards:

1. Provide a rationale for the nursing care delivered which takes account of social, cultural, spiritual, legal, political, and economic influences
2. Demonstrate sound clinical judgment across a range of differing professional and care delivery contexts
3. Demonstrate knowledge of effective inter-professional working practices which respect and utilise the contribution of members of the health and social care team
4. Enhance the professional development and safe practice of others through peer support, leadership, supervision, and teaching (NMC, 2004, p. 5).

Similar developments are taking place in the US as evidenced by Gebbie and Qureshi’s (2006) excellent overview of the US nursing profession’s response to the challenges of emergency situations. Sommers (2006) extends this perspective as a global phenomenon by focussing on injury as "...significant health problem for the world’s population.…" as a major concern for culturally relevant nursing scholarship (p. 319). Considerable progress has already been made in the US in relation to the establishment of specialist and advanced practice roles and the post-graduate development of such practitioners (Brown, 1998). In the UK, recent evidence (Gleeson, 2006) suggests that nurses are becoming highly sophisticated users of information technology to support high quality care delivery.

The NHS and US Health System

The NHS began in 1948 and is generally viewed as a national treasure. Created after World War II, it represents more than just the delivery of health care for all, free at the point of delivery; it also represents social justice as a core principle in the UK health care. More than 350,000 nurses deliver services to in excess of one million patients per day. The NHS is the third largest organisation in the world following behind the Chinese Army. It is the largest employer in Europe. It was created, and is managed centrally, by the government, which is striving to decentralise the management and policy making to local level as quickly as possible. It is a system in constant change, one which is much influenced by the political imperatives of the day. Even with the chaos of change, nurses and other health providers take a reactive approach to government decisions and then frequently revolt against those decisions. This mode of behaviour on the part of health care professionals is detrimental to the effective use of power and is often described by government officials as the whining and moaning of the professions. This description is particularly disabling to a predominantly female nursing profession.

To return to the RCN’s mission statement, as described above in discussing organisational power, the powerful phrase ‘shapes health policy’ speaks to a proactive mode of behaviour that has the potential to transform the image of nursing as well as the reality of nursing’s use of power. As the NHS continues to reform at, sometimes breakneck speed, the need for the strategic use of power by nurses is essential. The new structure of the NHS is based on local commissioning, which includes local organisations working closely with local authorities, within the framework of national, political imperatives. The desired outcome is for a locally negotiated health, social care, and well-being strategy (Hodders et al., 2005). This completely fits with nursing’s belief system of transforming the NHS from an illness system to a health system. However, nurses are frequently excluded from the policy decision- making process. Since policy centres on better expenditure control, greater productivity, and efficiency, nurses are not considered primary players in this strategic work. Yet it is nurses, with their patient partners, who have the experience of safeguarding the deeply rooted moral imperatives of the NHS, which are to maintain universal access to care and equitable distribution of resources (Hennessey, 2000). Through strategic leadership and the use of power from a patient-centred approach, nurses must become essential in helping to create this new NHS that continues to maintain core values.

The US system of health care is fragmented, private, and highly competitive. It is a system where bridges of collaboration and cooperation are frequently built only around economic gain, rather that national political imperatives as in the NHS. Interestingly, however, this market-oriented system has pushed the rapid consolidation of health-care providers, i.e., hospitals, professional groups, and other health care delivery assets, into integrated systems of care. Some of the integrated systems incorporate the old health insurance entity along with providers to create comprehensive systems of care. Overall, the US system can be described as more integrated, intensively managed, evidence-based, and community-oriented, with both an emphasis on information/communication technology and on the psychosocial/behavioural dimensions of health care (O’Neill, 1998). This description is a recipe in need of the nursing profession. Nurses coordinate and facilitate the integration of services, manage patient services, are evidence and community-based, and emphasise information technology and psychosocial/behavioural care which illustrate the efficacy and level of patient (consumer) response, and satisfaction with health care interventions. To address these issues, another one million nurses are required for the US health market by the end of this decade.

While US nurses fight for inclusion in the board room and other policy-shaping venues, their political strategies and vehicles have been more fully developed over a longer period of time than their UK counterparts. Having to challenge health care systems built on profit models, or at best, cost containment principles, US nurses have developed into strong, assertive advocates for patients and consumers. Without the basic value of health care free for all, US nurses have within their professional and trade union bodies articulated and implemented strategies for working with government at both local, state, and national levels. With a greater emphasis on advanced education, many nurses in the US are educationally, as well as clinically, prepared to work as colleagues and leaders in health teams. Career opportunities are more plentiful in the US than in the UK. With a centralised system of care and few top nursing posts available, the UK does not offer the range and extent of career growth that is possible in the US. For example, posts such as the CNO for England and the General Secretary of the RCN are few and far between in the UK. The reality is that there are too few opportunities for the vast numbers of excellent nurses throughout England.

Whilst the emancipation of both nurses and patients in the US would appear to be well-advanced along the clinical, political, and organisational power continuum, the power position of nurses and patients in the UK is making great strides forward in a health care system that is currently free at the point of delivery. The two differing health care systems of the UK and the US are important variables in considering the emancipation and power base of nurses and patients in both countries.

Diversity: A Race Issue

Finally, on the issue of diversity in the UK and the US, there are more opportunities for nurses of colour in the US than in the UK. At one count, there were only five black Directors of Nursing throughout England, out of a total of 425. This difference in opportunity relates to the historical background of the two countries. Jim Crow laws in the US that required separate-but-equal education for blacks and whites produced historically black colleges where nurses were educated to be meaningful participants and leaders in the health care of the nation. Vestiges of slavery resulted in predominantly white universities seriously implementing strategies to recruit and retain students who could progress, not without challenges, into the mainstream of health care.

Nurses in the US and UK still struggle with their invisibility and questions from the dominant culture concerning their legitimate power to be a nurse.

This lack of an infrastructure to support the development of black leadership throughout the UK is a barrier to black nurses excelling within the new and old NHS. Many black nurses came to the UK in the fifties to rescue the staffing dilemma of the newly established NHS. These nurses were treated with disregard and that legacy extends into the 21^st century. Recent UK statistics show that, generally, it will take 45 years to close the employment prospects gap between white and black job seekers in the UK (Branigan, 2006).

Despite these pessimistic observations, some attention has begun at the strategic level to progress the promotion of a more diverse and representative nurse leadership in the NHS (DH, 2002). Mensah (2006) graphically describes her positive experience of the NHS leader initiative when she recently undertook the DH ‘Breaking Through’ programme. In addition, the RCN has been particularly active in supporting the diversity and the political/clinical leadership agenda on a number of fronts (Large et al., 2005; RCN, 2002a; 2002b; 2005b).

In both of these wealthy, democratic countries, racism is alive and well. Nurses in the US and UK still struggle with their invisibility and questions from the dominant culture concerning their legitimate power to be a nurse.

A Transatlantic Vision for the Future Vision for the Future

Nurses must use the power within their reach and stretch for the power that seems slightly removed.

The family of nursing cuts across education, health care systems, and diversity to bind nurses together with the same belief in quality patient care for all. Nurses must use the power within their reach and stretch for the power that seems slightly removed. With the patient as a partner, the power of nursing is essential to the future well-being of nations throughout the world.

Perhaps Colin Marshall, former Chief Executive of British Airways, should have the last word:

What is the essential element any successful leader absolutely must have? I think it can be reduced to one word and a rather simple one at that: caring. I cannot claim that caring leadership is terribly clever or even terribly new. I can only promise that within my experience it works better than anything else (Ritchie & Goldsmith, 1987, pp. 172-173.

Nurses and patients have a great collective knowledge about caring. Knowledge is power. Combining the two will enable us to realise the dream of a powerful force for quality.

Authors

Roswyn Hakesley-Brown, MPhil, RN
E-mail: ros@hector.demon.co.uk

Roswyn Hakesley-Brown is an experienced educator and author. She is also a past President of the Royal College of Nursing in the UK. In this role, she initiated and led the Presidential Task Force for Nurse Education. A major recommendation of this task force was that graduate preparation for nurses at the point of registration be expanded to all of the four countries of the United Kingdom (UK). This is currently being considered by the CNO for England. As chair of the UK Task Force for Refugee Nurses, Roswyn is also the leading advocate for refugee nurses. In this role she is required to think and act strategically in a politically sensitive area. This necessitates engaging with and influencing multiple stakeholders at regulatory, political, and operational levels. She is currently the project lead for the first refugee nurses project in Wales where she is privileged to work face-to-face with refugee nurses. Her guide for refugee nurses, funded by the Department of Health, was published in 2006.

Beverly Malone, PhD, RN, FAAN
E-mail: maloneb@NLN.ORG

Beverly Malone is the General Secretary at the Royal College of Nursing in the UK. Prior to this position, Beverly served as the Deputy Assistant Secretary for Health in the Clinton Administration, the highest position any nurse has held in the government at this time. She has also served two terms as President of the American Nurses Association. Beverly has worked closely with the governments of both the US and the UK, meeting regularly with Tony Blair, Prime Minister. These positions have all involved the use of strategic power and the knowledge, confidence, and skills gained from working with patients.

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