Chapter 9 Cultural Diversity in Health Care This chapter focuses on the importance of cultural considerations for patients and staff. Although it does not address comprehensive details about any specific culture, it does provide guidelines for actively incorporating cultural aspects into the roles of leading and managing. Diverse workforces are discussed, as well as how to capitalize on their diverse traits and how to support differences to work more efficiently. The chapter presents concepts and principles of transculturalism, describes techniques for managing a culturally diverse workforce, emphasizes the importance of respecting different lifestyles, and discusses the effects of diversity on staff performance. Scenarios and exercises to promote an appreciation of cultural richness are also included. Learning Outcomes • Describe common characteristics of any culture. • Evaluate the use of concepts and principles of acculturation, culture, cultural diversity, and cultural sensitivity in leading and managing situations. • Analyze differences between cross-cultural, transcultural, multicultural, and intracultural concepts and cultural marginality. • Evaluate individual and societal factors involved with cultural diversity. • Value the contributions a diverse workforce can make to the care of people. Key Terms acculturation cross-culturalism cultural competence cultural diversity cultural imposition cultural marginality cultural sensitivity culture ethnicity ethnocentrism multiculturalism transculturalism Introduction Culture influences leadership from two perspectives. One is the way in which we meet patient needs; the other is the way in which we work together in a diverse workforce. Effective leaders can shape the culture of their organization to be accepting of persons from all races, ethnicities, religions, ages, lifestyles, and genders. These interactions of acceptance should involve a minimum of misunderstandings. Multicultural phenomena are cogent for each person, place, and time. Connerley and Pedersen (2005) provided 10 examples for leading from a complicated culture-centered perspective. For example, “3. Explain the action of employees from their own cultural perspective; 6. Reflect culturally appropriate feelings in specific and accurate feedback” (p. 29). Therefore culturecentered leadership provides organizational leaders, such as nurse managers and effective team members, the opportunity to influence cultural differences and similarities among their unit staff. Concepts and Principles What is culture? Does it exhibit certain characteristics? What is cultural diversity, and what do we think of when we refer to cultural sensitivity? Are culture and ethnicity the same? Various authors have different views. Cultural background stems from one’s ethnic background, socio-economic status, and family rituals, to name three key factors. Ethnicity, according to The Merriam-Webster Dictionary (Merriam-Webster Inc., 2013), is defined as related to groups of people who are “classified” according to common racial, tribal, national, religious, linguistic, or cultural backgrounds. This description differs from what is commonly used to identify racial groups. This broader definition encourages people to think about how diverse the populations in the United States are. Inherent characteristics of culture are often identified with the following four factors: 1.Culture develops over time and is responsive to its members and their familial and social environments. 2.A culture’s members learn it and share it. 3.Culture is essential for survival and acceptance. 4.Culture changes with difficulty. For the nurse leader or manager, the characteristics of ethnicity and culture are important to keep in mind because the underlying thread in all of them is that staff’s and patients’ culture and ethnicity have been with them their entire lives. All people view their cultural background as normal; the diversity challenge is for others to view it as normal also and to assimilate it into the existing workforce. Cultural diversity is the term currently used to describe a vast range of cultural differences among individuals or groups, whereas cultural sensitivity describes the affective behaviors in individuals—the capacity to feel, convey, or react to ideas, habits, customs, or traditions unique to a group of people. Spector (2009) addressed three themes involved with acculturation. (1) Socialization refers to growing up within a culture and taking on the characteristics of that group. All of us are socialized to some culture. (2) Acculturation refers to adapting to a particular culture. An example of this might be what a particular society calls a particular food or how healthcare organizations are changing to blame-free environments to encourage safety disclosures. The overall process of acculturation into a new society is extremely difficult. “America” has a core culture and numerous subcultures. For example, think how differently people in rural American regions dress from those in urban centers, or how a city looks on Saturday night versus Sunday morning. In other words, subcultures expand on how the core culture might be described. (3) Assimilation refers to the change that occurs when nurses move from another country to the United States, or from one part of the country to another. They face different social and nursing practices, and individuals now define themselves as members of the dominant culture. An example of this might be when nurses no longer say they are from their country of origin. They say they are from where they live and practice. Providing care for a person or people from a culture other than one’s own is a dynamic and complex experience. The experience according to Spence (2004) might involve “prejudice, paradox and possibility” (p. 140). Spence used prejudice as conditions that enabled or constrained interpretation based on one’s values, attitudes, and actions. By talking with people outside their “circle of familiarity,” nurses can enhance their understanding of personally held prejudices. Prejudices “enable us to make sense of the situations in which we find ourselves, yet they also constrain understanding and limit the capacity to come to new or different ways of understanding. It is this contradiction that makes prejudice paradoxical” (Spence, 2004, p. 163). Paradox, although it may seem incongruent with prejudice, describes the dynamic interplay of tensions between individuals or groups. We have the responsibility to acknowledge the “possibility of tension” as a potential for new and different understandings derived from our communication and interpretation. Possibility therefore presumes a condition for openness with a person from another culture (Spence, 2004). Cultural marginality is defined as “situations and feelings of passive betweenness when people exist between two different cultures and do not yet perceive themselves as centrally belonging to either one” (Choi, 2001, p. 193). This “betweenness” is a time when managers might perceive disinterest in cultural considerations. This situation might actually reflect cognitive processing of information that isn’t yet reflected in effective behaviors. Ethnocentrism “refers to the belief that one’s own ways are the best, most superior, or preferred ways to act, believe, or behave” (Leininger, 2002b, p. 50), whereas cultural imposition is defined as “the tendency of an individual or group to impose their values, beliefs, and practices on another culture for varied reasons” (Leininger, 2002b, p. 51). Such practices constitute a major concern in nursing and “a largely unrecognized problem as a result of cultural ignorance, blindness, ethnocentric tendencies, biases, racism or other factors” (Leininger, 2002b, p. 51). Providing quality of life and human care is difficult to accomplish if the nurse does not have knowledge of the recipient’s culture as it relates to care. Leininger believed that “culture reflects shared values, beliefs, ideas, and meanings that are learned and that guide human thoughts, decisions, and actions. Cultures have manifest (readily recognized) and implicit (covert and ideal) rules of behavior and expectations. Human cultures have material items or symbols such as artifacts, objects, dress, and actions that have special meaning in a culture” (Leininger, 2002b, p. 48). Leininger (2002b) stated that her views of cultural care are “a synthesized construct that is the foundational basis to understanding and helping people of different cultures in transcultural nursing practices” (p. 48). (See the Theory Box on p. 157.) Accordingly, “quality of life” must be addressed from an emic (insider) cultural viewpoint and compared with an etic (outsider) professional’s perspective. By comparing these two viewpoints, more meaningful nursing practice interventions will evolve. This comparative analysis will require nurses to include global views in their cultural studies that consider the social and environmental context of different cultures. Theory How do leaders, managers, or followers take all of the expanding information on the diversity of healthcare beliefs and practices and give it some organizing structure to provide culturally competent and culturally sensitive care to patients or clients? Purnell and Paulanka (2008), Campinha-Bacote (1999, 2002), Giger and Davidhizar (2002), and Leininger (2002a) provided an overview of each of their theoretical models to guide healthcare providers for delivering culturally competent and culturally sensitive care in the workplace. Purnell and Paulanka’s (2008) Model for Cultural Competence provides an organizing framework. The model uses a circle with the outer zone representing global society, the second zone representing community, the third zone representing family, and the inner zone representing the person. The interior of the circle is divided into 12 pie-shaped wedges delineating cultural domains and their concepts (e.g., workplace issues, family roles and organization, spirituality, and healthcare practices). The innermost center circle is black, representing unknown phenomena. Cultural consciousness is expressed in behaviors from “unconsciously incompetent—consciously incompetent—consciously competent to unconsciously competent” (p. 10). The usefulness of this model is derived from its concise structure, applicability to any setting, and wide range of experiences that can foster inductive and deductive thinking when assessing cultural domains. Purnell (2009) described the dominant cultural characteristics of selected ethnocultural groups and a guide for assessing their beliefs and practices. The Purnell Model for Cultural Competence serves as an organizing framework for providing cultural care, which is based on 20 major assumptions. Campinha-Bacote’s (1999, 2002) culturally competent model of care identifies five constructs: (1) awareness, (2) knowledge, (3) skill, (4) encounters, and (5) desire. She defined cultural competence as “the process in which the healthcare provider continuously strives to achieve the ability to effectively work within the cultural context of a client (individual, family, or community)” (Campinha-Bacote, 1999, p. 203). Cultural awareness is the self-examination and in-depth exploration of one’s own cultural and professional background. It involves the recognition of one’s bias, prejudices, and assumptions about the individuals who are different (Campinha-Bacote, 2002). “One’s world view can be considered a paradigm or way of viewing the world and phenomena in it” (Campinha-Bacote, 1999, p. 204). Cultural knowledge is the process of seeking and obtaining a sound educational foundation about diverse cultural and ethnic groups. Obtaining cultural information about the patient’s health-related beliefs and values will help explain how he or she interprets his or her illness and how it guides his or her thinking, doing, and being (Campinha-Bacote, 2002). The skill of conducting a cultural assessment is learned while assessing one’s values, beliefs, and practices to provide culturally competent services. The process of cultural encounters encourages direct engagement in cross-cultural interactions with individuals from other cultures. This process allows the person to validate, negate, or modify his or her existing cultural knowledge. It provides culturally specific knowledge bases from which the individual can develop culturally relevant interventions. Cultural desire requires the intrinsic qualities of motivation and genuine caring of the healthcare provider to “want to” engage in becoming culturally competent (Campinha-Bacote, 1999). The Giger and Davidhizar Transcultural Assessment Model identified phenomena to assess provision of care for patients who are of different cultures (2002). Their model includes six cultural phenomena: communication, time, space, social organization, environmental control, and biological variations. Each one is described based on several premises (e.g., culture is a patterned behavioral response that develops over time; is shaped by values, beliefs, norms, and practices; guides our thinking, doing, and being; and implies a dynamic, everchanging, active or passive process). Leininger’s (2002a) central purpose in her theory of transcultural nursing care is “to discover and explain diverse and universal culturally based care factors influencing the health, well-being, illness, or death of individuals or groups” (p. 190). She uses her classic “Sunrise Model” to identify the multifaceted theory and provides five enablers beneficial to “teasing out vague ideas,” two of which are The Observation, Participation, and Reflection Enabler and the Researcher’s Domain of Inquiry. Nurses can use Leininger’s model to provide culturally congruent, safe, and meaningful care to patients or clients of diverse or similar cultures. See the following Theory Box. National and Global Directives The American Nurses Association (ANA) has a long and vital history related to ethics, human rights, and numerous efforts to eliminate discriminatory practices against nurses as well as patients. The ANA Code of Ethics for Nurses with Interpretive Statements, Provision 8, states, “The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs” (2008, p. 23). This provision helps the nurse recognize that health care must be provided to culturally diverse populations in the United States and on all continents of the world. Although a nurse may be inclined to impose his or her own cultural values on others, whether patients or staff, avoiding this imposition affirms the respect and sensitivity for the values and healthcare practices associated with different cultures. This provision is reinforced by the ANA position statement (2010), The Nurse’s Role in Ethics and Human Rights: Protecting and Promoting Individual Worth, Dignity, and Human Rights in Practice Settings. The value of human rights is placed in the forefront for nurses whose specific actions are to promote and protect the human rights of every individual in all practice care environments. Similar statements are made with an international emphasis and a specialty emphasis. The ICN Code of Ethics for Nurses (2012) states: The nurse ensures that the individual receives accurate, sufficient and timely information in a culturally appropriate manner on which to base consent to care and related treatment. The nurse shares with society the responsibility for initiating and supporting action to meet the health and social needs of the public, in particular those of vulnerable populations. The nurse demonstrates professional values such as respectfulness, responsiveness, compassion, trustworthiness and integrity. (p. 3) Nurse educators, as a specialty example, are expected to recognize “multicultural, gender, and experiential influences on teaching and learning”; “identify individual learning styles and unique learning needs of international, adult, multicultural, educationally disadvantaged, physically challenged, at-risk, and second degree learners”; and ensure “that the curriculum reflects institutional philosophy and mission, current nursing and health care trends, and community and societal needs so as to prepare graduates for practice in a complex, dynamic, multicultural health care environment.” (National League for Nursing, 2005, pp. 1, 2, 4) These examples illustrate a global concern for cultural sensitivity. Although the emphasis has been on recipients of care, the same attentiveness is needed in the workforce. Patients are aware of how they are treated; and they also see how staff interact with each other. Special Issues Health disparities between majority and ethnic minority populations are not new issues and continue to be problematic because they exist for multiple and complex reasons. Causes of disparities in health care include poor education, health behaviors of the minority group, inadequate financial resources, and environmental factors. Disparities in health care that relate to quality of care include provider/patient relationships, actual access to care, treatment regimens that necessarily reflect current evidence, provider bias and discrimination, mistrust of the healthcare system, and refusal of treatment (Baldwin, 2003). Health disparities in ethnic and racial groups are observed in cardiovascular disease, which has a 40% higher incidence in U.S. blacks than in U.S. whites; cancer, which has a 30% higher death rate for all cancers in U.S. blacks than in U.S. whites; and diabetes in Hispanics, who are twice as likely to die from this disease than non-Hispanic whites. Native Americans have a life expectancy that is less than the national average, whereas Asians and Pacific Islanders are considered among the healthiest population groups. However, within the Asian and Pacific Islander population, health outcomes are more diverse. Solutions to health and healthcare disparities among ethnic and racial populations must be accomplished through research to improve care. Consider how these disparities in disease and in healthcare services might affect the healthcare providers in the workplace in relationship to their ethnic or racial group. It is necessary to increase healthcare providers’ knowledge of such disparities so that they can more effectively manage and treat diseases related to ethnic and racial minorities, which increasingly might include themselves. The healthcare system in the United States has consistently focused on individuals and their health problems, but it has failed to recognize the cultural differences, beliefs, symbolisms, and interpretations of illness of some people as a group. As health care moves toward provision of care for populations, culture can have an even greater influence on approaches to care. Commonly, patients for whom healthcare practitioners provide care are newcomers to health care in the United States. Similarly, new staff are commonly neither acculturated nor assimilated into the cultural values of the dominant culture. Currently, accessibility to health care in the United States is linked to specific social strata. This challenges nurse leaders, managers, and followers who strive for worth, recognition, and individuality for patients and staff regardless of their ascribed economic and social standing. Beginning nurse leaders, managers, and followers may sense that the knowledge they bring to their job lacks “real-life” experiences that provide the springboard to address staff and patient needs. In reality, although lack of experience may be slightly hampering, it is by no means an obstacle to addressing individualized attention to staff and patients. The key is that if the nurse manager and staff respect people and their needs, economic and social standings become moot points. This challenge will intensify as the implications of the Patient Protection and Affordable Care Act of 2010 unfold. If nothing else happens, the diversity of insured patients will increase. Language Translating a message in one language to another language to ensure equivalence includes maintaining the same meaning of the word or concept. Equivalency is accomplished through interpretation, which extends beyond “word-for-word” translation to explain the meaning of concepts. When providing care to a language diverse patient, the nurse must realize that the process of translation of illness/disease conditions and treatment is complex and requires certain tasks. Two important tasks are “(a) transferring data from the source language to the target language and (b) maintaining or establishing cross-cultural semantic equivalence” (International Council of Nurses, 2008, p. 5). The current practice seems to be one of using interpreters rather than translators when speaking with non–English-speaking patients and clients. Why? Purnell and Paulanka (2008) advocate that trained healthcare providers as interpreters can decode words and provide the right meaning of the message. However, the authors also suggest being aware that interpreters might affect the reporting of symptoms, using their own ideas or omitting information. It is important to allow time for translation and interpretation and to clarify information as needed. Promotion of culturally competent care with a translator has legal implications in the United States. The legal foundation for language access lies in Title VI of the 1964 Civil Rights Act, which states: No person in the United States, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefit of, or be subjected to discrimination under any program or activity receiving federal financial assistance (Chen, Youdelman, Brooks, 2007, p. 362). The federal government has interpreted and treated language as a proxy for national origin, and language assistance should be pursued. These activities supported by the Civil Rights Act include access to health care. Additionally, once a healthcare provider accepts any federal funds (e.g., Medicaid payments), the provider is responsible for providing language access to all the provider’s patients. Meaning of Diversity in the Organization Leading and managing cultural diversity in an organization means managing personal thinking and helping others to think in new ways. According to Noone (2008), nursing leaders need a workforce that can provide culturally competent care. In addition, nursing’s goal is to create a workforce that reflects the population it serves. This diversity can occur across roles, including advanced practice registered nurses, managers, and chief nurse executives. Managing issues that involve culture—whether institutional, ethnic, gender, religious, or any other kind—requires patience, persistence, and much understanding. One way to promote this understanding is through shared stories that have symbolic power. Staff who know what is valuable to patients and to themselves can act accordingly and derive satisfaction from work. Having a clear mission, goals, rewards, and acknowledgment of efforts leads to greater productivity from a culturally diverse staff who aspire to unity and uniqueness. (The following Research Perspective illustrates this point in providing end-of-life care.) When assessing staff diversity, the nurse leader or manager can ask these two questions: •What is the cultural representation of the workforce? •What kind of team-building activities are needed to create a cohesive workforce for effective healthcare delivery? Cultural Relevance in the Workplace Although the literature has addressed multicultural needs of patients, it is sparse in identifying effective methods for nurse managers to use when dealing with multicultural staff. Differences in education and culture can impede patient care, and uncomfortable situations may emerge from such differences. For example, staff members may be reluctant to admit language problems that hamper their written communication. They may also be reluctant to admit their lack of understanding when interpreting directions. Psychosocial skills may be problematic as well, because non-Westernized countries encourage emotional restraint. Staff may have difficulty addressing issues that relate to private family matters. Non-Asian nurses may have difficulty accepting the intensified family involvement of Asian cultures. The lack of assertiveness and the subservient physician-nurse relationships of some cultures are other issues that provide challenges for nurse managers. Unit-oriented workshops arranged by the nurse manager to address effective assertive techniques and family involvement as it relates to cultural differences are two ways of assisting staff with cultural work situations. Respecting cultural diversity in the team fosters cooperation and supports sound decision making. Nurse leaders and managers who ascribe to a positive view of culture and its characteristics effectively acknowledge cultural diversity among patients and staff. This includes providing culturally sensitive care to patients while simultaneously balancing a culturally diverse staff. For example, cultural diversity might mean being sensitive to or being able to embrace the emotions of a large multicultural group comprising staff and patients. Unless we understand the differences, we cannot come together and make decisions that are in the best interest of the patient. Transculturalism sometimes has been considered in a narrow sense as a comparison of health beliefs and practices of people from different countries or geographic regions. However, culture can be construed more broadly to include differences in health beliefs and practices by gender, race, ethnicity, economic status, sexual preference, age, and disability or physical challenge. Thus, when concepts of transcultural care are discussed, we should consider differences in health beliefs and practices not only between and among countries but also between genders and among, for example, races, ethnic groups, and different economic strata. This requires us to consider multiple factors about all individuals. The range of attitudes toward culturally diverse groups can be viewed along a continuum of intensity (Lenburg et al., 1995, p. 4) from hate to contempt to tolerance to respect and ending with celebration/affirmation. Managers need to be aware of this continuum so that they can apply strategies appropriately to the workforce—for example, contempt versus affirmation. These responses are equally reflected in employee groups. Variables that may influence the nurse’s response may include how the illness is perceived by the culture and the cultural competency of the healthcare provider. If the nurse’s culture is different from the patient’s, whose cultural perspective dominates? It might not be possible to adapt care totally to the patient’s perspective. However, knowing that a difference exists allows for a mutual conversation related to the rationale for care. Similarly if a workplace dispute occurs, trying to see “the other view” can create new insights into a situation. To make cultural competence relevant to clinical practice, Engebretson, Mahoney, and Carlson (2008) linked a cultural competency continuum, in which they identified the levels of competence, to values in health care. They cited the levels as cultural destructiveness, cultural incapacity, cultural blindness, cultural pre-competence and proficiency that would be complementary to patient care. The “clinically relevant continuum” included behaviors of maleficence, incompetence, standardization, and outcomes focused (positive health outcomes). A model was developed that integrated the cultural competence continuum with the clinically relevant continuum and the components of evidence-based care; namely, best research practice, clinical expertise, and patient’s values and circumstances. Their goal was to suggest how to make cultural concerns relevant to clinical practitioners at the level of the patientprovider encounter. To understand, value, and use diversity, nurse managers need to approach every staff person as an individual. This same strategy works for all of us. Although staff of different cultural groups may be diverse in appearance, values, beliefs, communication patterns, and mannerisms, they have many things in common. Staff members want to be accepted by others and to succeed in their jobs. With fairness and respect, nurse managers should openly support the competencies and contributions of staff members from all cultural groups with a goal of achieving quality patient care. Nurse managers hold the key to allowing the full potential of each person on the staff. Body movements, eye contacts, gestures, verbal tone, and physical closeness when communicating are all part of a person’s culture. For the nurse manager, understanding these cultural behaviors is critical in accomplishing effective communication within the diverse workforce population. As if language differences aren’t challenging enough, add on the slang, idioms, and fads inherent to U.S. culture. It is no surprise that culturally sensitive communications is difficult to achieve. Nurses need to ensure that ineffective communication among staff, with patients, and with others does not lead to misunderstandings and eventual alienation. Failure to address cultural diversity leads to negative effects on performance and staff interactions. Nurse managers can find many ways to address this issue. For example, in relation to performance, a nurse manager can make sure messages about patient care are received. This might be accomplished by sitting down with a nurse and analyzing a situation to ensure that understanding has occurred. In addition, the nurse manager might use a communication notebook that allows the nurse to slowly “digest” information by writing down communication areas that may be unclear. For effective staff interaction, the nurse manager also can make a special effort to pair mentors and mentees who have different ethnic backgrounds and encourage staff to learn another language, one prominent among the population served. Even a “word a day” approach could alter a team’s ability to interact with patients. Individual and Societal Factors Nurse managers must work with staff to foster respect of different lifestyles. To do this, nurse managers need to accept three key principles: multiculturalism, which refers to maintaining several different cultures; cross-culturalism, which means mediating between/among cultures; and transculturalism, which denotes bridging significant differences in cultural practices. Each of those principles operates in the workplace. Sometimes we want to keep distinct cultures. For instance, we may advocate for equality unless a particular unit has excellent safety scores. Anyone who wanted to make all cultures alike, and thus increase safety incidents, would be seen as foolish. Healthcare organizations have, as an example, provided various ways to celebrate holy days based on the cultural mix of staff and patients. These practices are designed to acknowledge the individuals who comprise the organization. Cultural differences among groups should not be taken in the context that all members of a certain group or subgroup are indistinguishable. For example, regarding gender differences, women are perceived to have a more participative management style; however, this does not mean that all male managers use an authoritative management model. Likewise, female managers may use multiple sources of information to make decisions, and this does not mean that all male managers make decisions on limited data. Thus the norm for gender recognition should be that women and men be hired, promoted, rewarded, and respected for how successfully they do the job, not for who they are, where they come from, whom they know, or the gender they represent. In today’s workplace, femalemale collaboration should provide efficacious models for the future. Gender does not determine response in any given situation. However, men reportedly seem to be better at deciphering what needs to be done, whereas women are better at collaborating and getting others to collaborate in accomplishing a task. Men tend to take neutral, logical, and objective stands on problems, whereas women become involved in how the problems affect people. Women and men bring separate perspectives to resolving problems, which can help them function more effectively as a team on the nursing unit. Men and women must learn to work together and value the contributions of the other and the differences they bring to any situation. Similar kinds of comparisons can be made related to other elements of diversity. Nurses have embraced information related to generational differences and have used religious and ethnic contexts as ways to begin dialogs about values and beliefs. Dealing Effectively With Cultural Diversity The first individuals in most organizational structure who have to address cultural diversity are the leaders and managers. They have to give unwavering support to embracing diversity in the workplace rather than using a standard cookie-cutter approach. Creating a culturally sensitive work environment involves a long-term vision and financial and healthcare-provider commitment. Leaders and managers need to make the strategic decision to design services and programs especially to meet the needs of diverse cultural, ethnic, and racial differences of staff and patients. Policies in healthcare organizations prohibit discrimination based on several aspects. Such policies, however, don’t necessarily succeed at promoting a culturally aware environment. Nurse managers hold the key to making the best use of cultural diversity. Managers have positions of power to begin programs that enrich the diversity among staff. For example, capitalizing on the knowledge that all staff bring to the patient is possible for better quality care outcomes. One method that can be used is to allow staff to verbalize their feelings about particular cultures in relationship to personal beliefs. Another is to have two or three staff members of different ethnic origins present a patient-care conference, giving their views on how they would care for a specific patient’s needs based on their own ethnic values. Mentorship programs should be established so that all staff can expand their knowledge about cultural diversity. Mentors have specific relationships with their mentees. The more closely aligned a mentor is with the mentee (e.g., same gender, agegroup, ethnicity, and primary language), the more effective the relationship. Programs that address the staff’s cultural diversity should not try to make people of different cultures pattern their behavior after the prevailing culture. Nurse managers must carefully select those mentors who ascribe to transcultural, rather than ethnocentric, values and beliefs. A much richer staff exists when nurse managers build on the valuable culture of all staff members and when diversity is rewarded. The pacesetter for the cultural norm of the unit is the nurse manager. For example, to demonstrate commitment to cultural diversity, a nurse manager might make a special effort to ensure that U.S. black, Asian-American, and Hispanic holidays or other cultural representations on the unit are recognized by the staff. Staff members who are active participants in these programs can then be given positive reinforcement by the nurse manager. These activities promote a better understanding and appreciation of individuals’ cultural heritage. Nurse managers are aware of the increasing shortage of nurses, demanding work environment with its surrounding influences, and statistics indicating that almost 50% of all new nurses leave their first professional nursing position by the first year because of job dissatisfaction and level of stress. This period may be even more challenging for individuals whose culture differs from the predominant unit culture. Continuing-education programs should help nurses learn about the care of different ethnic groups. For example, professional organizations related to cultural groups (National Black Nurses Association, National Hispanic Nurses Association, Philippine Nurses Association of America) and institutions might develop or sponsor a workshop or conference on cross-cultural nursing for nursing service staff and faculty in schools of nursing who have had limited preparation in cultural care or cultural beliefs in healing. Muslims are one of the fastest growing populations in the United States and worldwide. For example, Muslim nurses may feel uncomfortable without long sleeves because of their Islamic dress code. Jewish nurses likely would find a pulled pork barbeque an inappropriate celebration. Males may feel awkward participating in a unit baby shower. The point of all of these examples is to think proactively, ask for input, and consider how best to exhibit cultural sensitivity. Choices, decisions, and behaviors reflect learned beliefs, values, ideals, and preferences. The goal of communication is maintenance or restoration of personal integrity and recognition of worth and respect of individuals or groups. mutual understanding and respect. The first scenario involves a compromise between staff members and a patient’s family, and the second involves a nurse manager and a staff member from a different culture. Passages of life that culminate in happy events also can challenge the nurse manager, for example, the quinceañera observed by Hispanic families. This event is the celebration for 15-year-old girls to be introduced into society. A nurse whose daughter is celebrating this event must have time to make plans for this festive celebration. Because of the significance of the celebration and the pride that the parents take in their daughter, inviting “key” staff to the quinceañera is common. Nurse managers who understand and value cultural rituals can help individuals meet their needs and help staff, in general, learn and accept various cultural practices and perspectives. Implications in the Workplace Considering culture from a healthcare staff person and the nursing workforce perspective is a daunting task, one that can lead to a more solidly aligned service-community relationship. Even if the workforce is not as diverse as one might desire, learning about the cultures of the groups within the workforce is important. Making clear that diversity is valued, in fact celebrated, attracts others to engage in the complexity of care. One way is to make clear how staff are valued as people, not as representatives of some group. Showing respect to all patients irrespective of their cultural differences tells the staff that their differences also can be valued. The key is for managers and leaders to attend to the workforce issues with the same zest as they do the patient issues. Cultural differences enrich all of us when we make deliberate efforts to include them in our daily values. Embracing these differences will also enhance the American Association of Colleges of Nursing (AACN) Quality and Safety Education for Nurses (QSEN) Initiative. The overall goal of the QSEN Initiative is to prepare nurses with the knowledge, skills, and attitudes (KSAs) needed to continuously deliver quality and safe patient care (American Association of Colleges of Nursing, 2013). With this initiative we see the need to respect all patients and staff irrespective of their cultural differences to empower Patient/Family Centered Care, which is one of the QSEN initiative competencies. This component recognizes the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs (American Association of Colleges of Nursing, 2013). Conclusion Understanding and valuing cultural differences benefits both patients and colleagues. Culture is a broad term encompassing many diversities. This broadness both enriches our perspective of diversity and provides a complex challenge. All nurses, regardless of their titles or positions, have a role in improving the workplace and patient care by attending to the implications of culture in healthcare. Chapter 10 Power, Politics, and Influence Learning Outcomes • Explore the concepts of professional and legislative politics related to nursing. • Value the concept of power as it relates to leadership and management in nursing. • Use different types of power in the exercise of nursing leadership. • Develop a power image for effective nursing leadership. • Choose appropriate strategies for exercising power to influence the politics of the work setting, professional organizations, legislators, and the development of health policy. Key Terms coalitions empowerment influence negotiating policy politics power Introduction The profession of nursing developed in the United States at a time when women had limited legal rights (e.g., most were prohibited from voting, and many could not own property). Women were viewed as neither powerful nor political; in the late nineteenth century, feminine and powerful were practically contradictory terms. During the twentieth century, as the status and role of women changed, so did the status and role of nurses. Moving into the twenty-first century, the economic and social power of women has evolved, as has the power of nurses. This is significant because nursing historically has been and continues to be a discipline comprised primarily of women. In the twenty-first century, nurses must exercise their power to create a strong voice for nursing in shaping an evolving healthcare environment. In an era of rapid change with a dramatic nursing shortage like none before, healthcare reform offers new opportunities for nurses at the bedside and in the community, for those just entering the profession and those in advance nursing roles. Nurses must use their collective power and flex their political muscles to create a preferred future for an evolving healthcare system, healthcare consumers, and the profession of nursing. History The word power comes from the Latin word potere, meaning “to be able.” Simply defined, power is the ability to influence others in an effort to achieve goals. Power was once considered almost a taboo in nursing. In nursing’s formative years, the exercise of power was considered inappropriate, unladylike, and unprofessional. In nursing’s earliest decades in the United States, many decisions about nursing education and practice were made by persons outside of nursing (Ashley, 1976). Nurses began to exercise their collective power with the rise of early nursing leaders such as Lillian Wald, Isabel Stewart, Annie Goodrich, Lavinia Dock, M. Adelaide Nutting, Mary Eliza Mahoney, and Isabel Hampton Robb and the development of organizations that evolved into the American Nurses Association (ANA) and the National League for Nursing (NLN) (Lewenson, 2012). Many social, technologic, scientific, and economic trends have shaped nursing and nurses and nursing’s ability to exercise power during the twentieth and early twenty-first centuries. The American Medical Association (AMA), in 1988, proposed a new category of healthcare worker (the registered care technologist or RCT) to replace nurses during a nursing shortage. Nurses and nursing organizations responded powerfully. Nursing leaders came together in “summit meetings” to formulate powerful responses to the AMA and implemented a range of actions, including public education and the education of legislators. A new healthcare worker did not materialize from this proposal. Today, in an era of expanding nursing roles (e.g., advanced practice nurses and new roles for graduates of doctor of nursing practice [DNP] programs), nurses must continue to exercise their power to shape the continuing development of the profession of nursing and the future of the healthcare system and manage the efforts of medicine and others to control nursing practice. The media, politicians, organized medicine, some healthcare executives, and some nurses have traditionally viewed nurses and nursing as powerless. That view began to change dramatically in the 1990s as nurses began to appear more often on local and national news and on talk shows as experts on health care, the changes occurring in the healthcare system, and the effect of these changes on the public. Nurses have become increasingly visible in political campaigns on the local, state, and national levels, both as candidates and as political influentials. For example, Congresswoman Lois Capps, MA, BSN, RN, represents a California congressional district, assuming the office held by her husband upon his death. A former school nurse, Congresswoman Capps has since been reelected by her constituents to the House seat. The 113th Congress (2013-2015) included six nurses, including one licensed practical nurse (LPN) (American Nurses Association [ANA], 2013a). Nurses and nursing have gained new respect in the political arena in recent years. Sheila Burke, MPA, RN, FAAN, served as Chief of Staff for Senator Robert Dole while he was Senate Majority Leader in the United States Congress, making her one of the most powerful congressional staff people in Washington. Mary Wakefield, PhD, RN, FAAN, was appointed the administrator of the Health Resources and Services Administration (HRSA) under President Barack Obama. She served in the 1990s as chief of staff to North Dakota senators Kent Conrad and Quentin Burdick. And Marilyn Taveneer, RN, was named the chief administrator of the Centers for Medicare and Medicaid Services in 2013. Into the Twenty-First Century Thirty years ago Roberts (1983) addressed the historical evidence of oppressed group behavior among nurses, based on models developed from the study of politically and economically oppressed populations. Oppressed group behavior is apparent when a population is dominated by another group; this population begins to take on the characteristics of the dominant group; and the oppressed population rejects the characteristics of their own group (Roberts 1983), often bullying and abusing their peers. In the twenty-first century, bullying and incivility have become epidemic in both nursing education and clinical settings (Clark, Landrum, & Nguyen, 2010; Croft & Cash, 2012; McNamara, 2012; Vessey, DeMarco, & DiFazio, 2011). Bullying reflects the abuse of power and a fear of the power of others (see Theory Box, p. 171). Bullying and incivility disrupt the healthcare workplace. The problems of bullying and incivility have been tied to patient safety (McNamara, 2012), requiring that The Joint Commission finally address this workplace issue through a Leadership Standard issued in 2009 and clarified in 2012 (The Joint Commission, 2012). The Joint Commission standard demands that leaders ensure that a code of conduct is implemented to ensure patient safety and a culture of quality. This requires leaders to be proactive in addressing the potential for incivility and bullying in the healthcare workplace. Policy, Power, and Activism Schools of nursing too often fail to socialize students to be activists and to prepare them for leadership demands. Students need to be exposed to the concepts of political action and public and health policy to ready as nurse leaders to deal with issues within nursing and health care. A policy is just a plan for action related to an issue that affects a group’s well-being or ability to function. All nurses need to continue to expand their understanding of the concept of power and to develop their skills in exercising power. Avoiding involvement in the politics of nursing in the workplace, in the profession at large, or in the area of public and health policy limits the power of the individual nurse and the profession as a whole. Some nurses are still uncomfortable with politics and the use of power, treating “politics” as if it was a dirty word. Historically, politics has been viewed with some disdain. Writer Robert Louis Stevenson noted, “Politics is perhaps the only profession for which no preparation is thought necessary.” But contemporary nursing’s need to thrive within a healthcare system demands that nursing education prepare nurses to engage in professional, workplace, and legislative politics. Politics can be defined in many ways. One simple definition of politics that this author uses when teaching health policy and politics in nursing is “a process of human interaction within organizations.” Politics permeates all organizations, including workplaces, legislatures, professions, and even families. Young children often learn that one parent is more likely to readily give permission for special activities or more likely to buy toys and other desired items. They quickly learn to ask permission or ask for a desired item from that parent before asking the other. This is an unwritten political rule in many families. Political activism should be an unwritten rule in nursing (see the Literature Perspective). The American Association of Colleges of Nursing (AACN) identifies health policy as one of the essentials for baccalaureate, graduate, and doctoral education (AACN, 2006, 2008, 2011). Focus on Power Some nurses, including both new graduates and seasoned veterans, have too often viewed power as if it were something immoral, corrupting, and totally contradictory to the caring nature of nursing. However, the definition in this chapter (the ability to influence others in an effort to achieve goals) demonstrates the essential nature of power to nursing. Nurses routinely influence patients to improve their health status. When nurses provide health teaching to patients and their families, the goal is to change patient/family behavior to promote optimal health. That is an exercise of power in nursing practice. Coaching other nurses to improve their performances is an exercise of power. Serving as the chief nursing officer of a hospital or health-related corporation, managing a multimillion dollar budget, demonstrates another exercise of power. Social scientists have studied the use and abuse of power in human organizations. They have analyzed and categorized the sources and applications of power in human experience. Hersey, Blanchard, and Natemeyer (1979) offered a classic formulation on the bases of social power. Leavitt, Mason, and Whelan (2012) offered a revised view of types of power that readily applies to the efforts of nurses in the workplace, in professional organizations, and in politics (see the Theory Box on p. 171). These types of power are not mutually exclusive. They are often used in concert to exert influence on individuals or groups. Having a high-status position in an organization immediately provides stature, but power depends on the ability to accomplish goals from that position. Although some may think that “knowledge is power,” acting on that knowledge is where the real power lies. Sharing knowledge expands one’s power and, in turn, empowers others, including colleagues and patients, by giving them information or skills that they need to take action in a situation. Influence is the process of using power. Influence can range from the punitive power of coercion to the interactive power of collaboration. Coaching a new graduate to complete a complicated nursing procedure successfully demonstrates the ability of the experienced nurse to influence that orientee. The coach uses expert, positional, and informational power to influence the orientee not only at that moment but also perhaps over the span of a career. Nurses can use personal, expert, and perceived power while working on the campaigns of legislators who support nursing and healthcare issues. Empowerment Empowerment is a term that has come into common usage in nursing. That term has been used extensively in the nursing literature related to administration and management; it is also highly relevant to the domain of clinical practice. Empowerment is the process of exercising one’s own power to facilitate the participation of others in decision making and taking action so they are free to exercise power (Leavitt, Mason, & Whelan, 2012). Empowerment is consistent with the contemporary view of leadership, a paradigm that is exemplified by behaviors characteristic of all nurse leaders: facilitator, coach, teacher, and collaborator. Nursing leaders, in employment settings or in professional organizations, exercise power in making professional judgments in their daily work. These leadership skills are also essential to effective followers. Powerful nurse managers enable nurses to exercise power, influencing them to grow professionally. Powerful nurses support their patients and families so they can participate actively in their own care. Hence these leadership skills can be viewed as an essential component of professional nursing practice whether one is a clinician, an educator, a researcher, or an executive/manager. Sharing Power Nurses, including some leaders, sometimes view power as a finite quantity: “If I give you some of my power, I will have less.” Empowerment emphasizes the notion that power grows when shared. Envision the exercise of shared power along a spectrum from low to high levels of sharing. The opposing ends of the spectrum can be characterized by two very different groups of nurses: •Nurses who view power as finite will avoid cooperation with their colleagues and refuse to share their expertise. •Nurses who view power as infinite are strong collaborators who gain satisfaction by helping their colleagues expand their expertise and their power base. Empowered nurses make professional practice possible, creating a culture that satisfies all nurses. Empowered clinicians are essential for effective nursing management, just as empowered managers set the stage for excellence in clinical practice. Encouraging a reticent colleague to be an active participant in committee meetings serves to empower that nurse and to shape practice policy with the institution. Guiding a novice nurse in exercising professional judgment empowers both the senior nurse and the novice clinician. Coaching a patient on how to be more assertive with a physician who is reluctant to answer the patient’s questions is another form of empowerment. Personal Power Strategies Developing a collection of power strategies or tools is a critical aspect of personal empowerment. These strategies are used in situations that demand the exercise of leadership. Such strategies support one’s professional power base and developing political skills within an organization (Boxes 10-1 and 10-2). These strategies also indicate to others that one is a powerful nurse and a leader. These boxes identify personal power strategies beyond those discussed in this section. These “power tools” have been developed and collected by this author during more than 40 years of nursing experience and observation of successful, effective, powerful nurses. Strategies for Developing a Powerful Image Consider the words of Lady Margaret Thatcher, former prime minister of Great Britain: “Being powerful is like being a lady. If you have to tell people you are, you aren’t.” You don’t have to wear a sign around your neck to show that you are powerful! The most basic power strategy is the development of a powerful image. If nurses think they are powerful, others will view them as powerful; if they view themselves as powerless, so will others. A sense of self-confidence is a strong foundation in developing one’s “power image,” and is essential for successful political efforts in the workplace, within the profession, and within the public policy arena. Several key factors contribute to one’s power image: •Self-image: thinking of oneself as powerful and effective •Grooming and dress: ensuring that clothing, hair, and general appearance are neat, clean, and appropriate to the situation •Good manners: treating people with courtesy and respect •Body language: maintaining good posture, using gestures that avoid too much drama, maintaining good eye contact, and being confident in movement •Speech: using a firm, confident voice; good grammar and diction; an appropriate vocabulary; and strong communication skills Concern about a powerful image may seem superficial. However, the impressions we make on people influence the way they view us now and in the future, as well as how they value what we do and say. We get only one chance to make a first impression. Given similar educational and experiential backgrounds, who is more likely to be hired for a nursing position: the candidate who comes dressed in a suit or the candidate who arrives in jeans and sandals (Chaffee, 2012a)? Who will be seen as the more competent professional by a patient: the nurse in wrinkled scrubs or the nurse in neat street clothes and a freshly laundered lab coat? Who will have a greater positive impact on a member of the state legislature: the nurse who visits in a sweatshirt and shorts or the nurse in business attire? A powerful image signals to others that one is professionally competent, influential, powerful, and capable of exercising appropriate judgments. Attitudes and beliefs are other important aspects of a powerful image; they reflect one’s values. Believing that power is a positive force in nursing is essential to one’s powerful image. A firm belief in nursing’s value to society and the centrality of nursing’s contribution to the healthcare delivery system is also important. Powerful nurses do not allow the phrase “I’m just a nurse” in their vocabulary Instead, powerful nurses can enhance the profession by responding to statements of appreciation with the phrase, “I’m a nurse; it’s what we do,” as one of this book’s contributors says. Behavior reflects one’s pride in the profession of nursing. This not only increases a nurse’s own power but also helps empower nursing colleagues. Make a Commitment to Nursing as a Career Nursing is a profession; professions offer careers, not just a series of jobs. Decades ago, nursing marketed itself to recruits as the perfect preparation for marriage and family. Some people still view nurses only as members of an occupation who drop in and out of employment, not as members of a profession with a long-term career commitment. Having a career commitment does not preclude leaving employment temporarily for family, education, or other demands. Having a career commitment means that nurses view themselves first and foremost as members of the discipline of nursing with an obligation to make a contribution to the profession. Status as an employee of a particular hospital, home health agency, long-term care facility, or other venue is secondary to one’s status as a member of the profession of nursing. Value Continuing Nursing Education Valuing education is one of the hallmarks of a profession. The continuing development of one’s nursing skills and knowledge is an empowering experience, preparing nurses to make decisions with the support of an expanding body of evidence. Seminars, workshops, and conferences offer opportunities for continued professional growth and empowerment. Seeking advanced nursing degrees or postbaccalaureate/postgraduate certificates is also a powerful growth experience and reflects commitment to the profession. At one time, some nurses sought to get ahead in nursing by seeking education outside of nursing at the baccalaureate and graduate level. To develop expertise in nursing, one must be educated in the discipline of nursing. This evolution is now seen in employment policies that specify degrees in nursing as opposed to a generic statement about bachelor’s or master’s degree. Communication Skills The most basic tool is effective communication skills (Chaffee, 2012a). These same communication skills ensure nurses’ effective interaction with patients and families. Listening skills are essential leadership skills. Just as the clinician listens to the patient to collect assessment data, the leader uses listening skills to assess and evaluate. Managers and other leaders who are good listeners develop reputations for being fair and consistent. Listening for recurring themes related to minor issues of staff dissatisfaction in informal conversations can enable a manager to take action before a staff crisis occurs. Verbal and nonverbal skills are important personal power strategies; the ability to assess these messages is a critical power strategy. Experts in communication estimate that 90% of the messages we communicate to others are nonverbal. When nonverbal and verbal messages are in conflict, the nonverbal message is always more powerful. The basic lessons on the power of nonverbal communication that most nurses learn in an introductory psychiatric nursing course are relevant in all areas of nursing! Networking Networking is an important power strategy and political skill (Chaffee, 2012; Leavitt, Mason, & Whelan, 2012). A network is the result of identifying, valuing, and maintaining relationships with a system of individuals who are sources of information, advice, and support. Networking supports the empowerment of participants through interaction and the refinement of their interpersonal skills. Many nurses have relatively limited networks within the organizations where they are employed. They tend to have lunch or coffee with the people with whom they work most closely. One strategy to expand a workplace network is to have lunch or coffee with someone from another department, including managers from non-nursing departments, at least two or three times a month. Active participation in nursing organizations is the most effective method of establishing a professional network outside one’s place of employment. Although only a minority of nurses actively participate in professional organizations, such participation can propel a nurse into the politics of nursing, including involvement in shaping health policy. State nurses’ associations offer excellent opportunities to develop a network that includes nurses from various clinical and functional areas (Shinn, 2012). Membership in specialty organizations, including organizations for nurse managers and executives, provides the opportunity to network with nurses with similar expertise and interests. In addition, membership in civic, volunteer, and special interest groups and participation in educational programs (e.g., formal academic programs and conferences) also provide networking opportunities. Use of social media, like LinkedIn and Twitter, also can expand one’s professional network around the globe. The nurse must be cautious to avoid mixing one’s personal life and professional life in social media. The successful networker identifies a core of networking partners who are particularly skilled, insightful, and eager to support the development of colleagues. These colleagues need to be nurtured through such strategies as sharing information with them that relates to their interests; introducing them to persons who have comparable interests or who are connected with others of influence; staying connected through notes, e-mail, phone calls, social media, or text messages; and meeting them at important events. Successful networkers are not a burden to others in making requests for support, and they do not refuse the support that is provided. Mentoring Mentoring has become an important force in nursing (Leavitt, Chaffee, & Vance, 2013). Mentors are competent, experienced professionals who develop a relationship with less experienced nurses for the purpose of providing advice, support, information, and feedback to encourage the development of that person. Mentoring has been an important element in the career development of men in business, academia, and selected professions. Mentoring has become a significant power strategy for women in general and for nurses in particular during the past 30 years. Mentoring provides expanded access to information, power, and career opportunities. Mentors have been a critical asset to novice nurses trying to negotiate workplace and professional politics. Effective mentoring in nursing benefits both the mentor and the mentee. Mentors benefit by expanding their own professional development and that of their colleagues, improving their own self-awareness, experiencing the intrinsic benefits of teaching another, nurturing their own interpersonal skills, and expanding their political savvy. Mentees receive one-on-one nurturing and coaching from the mentor, gain insight or savvy about the political rules of the organization and learn about organizational culture from an insider, can expand their selfconfidence in a supportive relationship, receive career development advice, profit from the mentor’s professional network, and have a unique opportunity for individualized professional development. Mentoring is an empowering experience for both mentors and protégés. The process of seeking out mentors is an exercise in growth for protégés. Mentors often come from one’s professional networks. Mentors sometimes select their protégés; at other times, the reverse is true. Protégés learn new skills from influential mentors and gain self-confidence. Mentors share their influence through the influence of those they mentor and gain satisfaction by experiencing the evolution of those nurses into experienced nurses. Goal-Setting Goal-setting is another power strategy. Every nurse knows about setting goals. Students learn to devise patient care goals or patient outcomes as part of the care-planning process. Nurses may be expected to write annual goals for performance reviews at work. Even a project at home (e.g., painting the bedrooms) may necessitate setting goals (e.g., painting a room each day of one’s vacation). Goals help one know if what was planned was actually accomplished. Likewise, a successful nursing career needs goals to define what one wants to achieve as a nurse. Without such goals, one can wander endlessly through a series of jobs without a real sense of satisfaction. To paraphrase what the Cheshire Cat told Alice during her trip through Wonderland: Any road will take you there if you don’t know where you are going. Well-defined, long-term goals may be hard to formulate early in a career. For example, few new graduates know specifically that they want to be chief nurse executives, deans, managers, or researchers; yet, eventually, some will choose those career paths. However, developing such a vision early in a career is an important personal power strategy. Once this career vision is developed, one must create opportunities to move toward that vision. Such planning is empowering—putting the nurse in charge rather than letting a career unfold by chance. Having this sense of vision is consistent with a commitment to a career in nursing, part of developing a power image. This vision is always subject to revision as new opportunities are encountered and new interests, knowledge, and skills are gained. Education and work experiences are tools for achieving the vision of one’s career. Developing Expertise As noted earlier in this chapter, expertise is one of the bases of power. Developing expertise in nursing is an important power strategy. Nursing expertise must not be limited to clinical knowledge. Leadership and communication skills, for example, are essential to the effective exercise of power. Education and practice provide the means for developing such expertise in any domain of nursing—clinical practice, education, research, and management. Developing expertise expands one’s power among nursing colleagues, other professional colleagues, and patients. A high level of expertise can make one nearly indispensable within an organization. This is a powerful position to have within any organization, whether it is the workplace or a professional association. A high level of expertise can also lead to a high level of visibility within an organization. High Visibility The strategy of high visibility within an organization can begin with volunteering to serve as a member or the chairperson of committees and task forces. High visibility can be nurtured by attending open meetings in the workplace, professional associations, or the community. Even if you are not a member, if meetings deal with local health issues, you must be visible. Review the agendas of these meetings if they are circulated or posted online ahead of time. Use opportunities both before and after meetings to share your expertise and provide valuable information and ideas to members and leaders of such groups. Share your expertise at open meetings when appropriate. Speak up confidently, but have something relevant to say. Be concise and precise; members of the committee will ask for more information if they need it. Create your own business cards using a computer and sheets of business card stock (purchased in any office supply store). Give members of these committees your personal card so that they can contact you later for information. Exercising Power and Influence in the Workplace and other Organizations To use influence effectively in any organization, one must understand how the system works and develop organizational strategies. Developing organizational savvy includes identifying the real decision makers and those persons who have a high level of influence with the decision makers. Recognize the informal leaders within any organization. An influential senior clinical nurse may have more decisionmaking power related to direct patient care than the nurse manager. The senior clinical nurse may have more clinical expertise and a greater knowledge about the history of the unit and its personnel than a nurse manager with excellent management and leadership skills who is new to the unit. For example, the executive assistants of chief nursing officers (CNOs) are usually very powerful people, although they are not always recognized as such. The CNO’s assistant has control over information, making decisions about who gets to meet with the nurse executive and when screening incoming and outgoing mail, letting the CNO know when a document needs immediate attention, or placing a memo under a stack of mail for review at a later time. Collegiality and Collaboration Nursing does not exist in a vacuum, nor do nurses work in isolation from one another, other professionals, or support personnel. Nurses function within a wide range of organizations, such as schools, hospitals, community health organizations, governments, insurance companies, professional associations, and universities. Nurses have been divided too long over the appropriate educational level for entry into practice. Nurses are also noted for their failure to join nursing organizations. Developing a sense of unity requires each nurse to act collaboratively and collegially in the workplace and in other organizations (e.g., professional associations). Collegiality demands that nurses value the accomplishments of nursing colleagues and express a sincere interest in their efforts. Turning to one’s colleagues for advice and support empowers them and expands one’s own power base at the same time. Unity of purpose does not contradict diversity of thought. One does not have to be a friend to everyone who is a colleague. Collegiality demands mutual respect, not friendship. Collaboration and collegiality require that nurses work collectively to ensure that the voice of nursing is heard in the workplace and the legislature. Volunteer to serve on committees and task forces in the workplace, not only within the nursing department but also on organization-wide committees. Become an active member of nursing organizations, especially state nursing organizations and specialty organizations consistent with one’s clinical specialty (e.g., AACN) or functional role (e.g., American Organization of Nurse Executives [AONE]). If eligible, become a member of a chapter of Sigma Theta Tau International, nursing’s honor society. Get involved in the politics of organizations, in the workplace, and in professional associations. If the workplace uses shared governance or other participatory models, get involved in these councils, committees, task forces, and work groups to share your energy, ideas, and expertise. Many organizations have interdisciplinary committees that bring together nurses, physicians, and other healthcare professionals to improve the quality of professional collaboration and the quality of patient care. Become an active, productive member of such groups within the workplace and in the professional associations and community groups dealing with healthcare issues and problems. An Empowering Attitude Demonstrate a positive and professional attitude about being a nurse to nursing colleagues, patients and their families, other colleagues in the workplace, and the public, including legislators. This attitude facilitates the exercise of power among colleagues while educating others about nurses and nursing. A powerful image is an important aspect of demonstrating this positive professional attitude. The current practice of nurses to identify themselves by first name may only decrease their power image in the eyes of physicians, patients, and others. Physicians are always addressed as “Doctor.” When they address others only by their first names, inequality of power and status is evident. The use of first names among colleagues is not inappropriate so long as everyone is playing by the same rules. Managers may want to enhance the empowerment of their staff members by encouraging them to introduce themselves as “Dr.,” “Ms.,” or “Mr.” Arriving at work, appointments, or meetings on time; looking neat and appropriately attired for the work setting or other professional situation; and speaking positively about one’s work are examples of how easy it is to demonstrate a positive, powerful, and professional attitude. Magnet™ institutions, as recognized by the American Nurses Credentialing Center (ANCC), are characterized by work environments that empower nurses (ANCC, 2013). Leadership activities have been identified as a critical element of the work culture in Magnet™ hospitals; and quality of leadership is one of the “forces of magnetism.” Developing Coalitions The exercise of power is often directed at creating change. Although an individual can often be effective at exercising power and creating change, creating certain changes within most organizations requires collective action. Coalition building is an effective political strategy for collective action (Askoy, 2010; Bowers-Lanier, 2012). Coalitions are groups of individuals or organizations that join together temporarily around a common goal. This goal often focuses on an effort to effect change. The networking among organizations that results in coalition building requires members of one group to reach out to members of other groups. This often occurs at the leadership level and may come through formal mechanisms such as letters that identify an issue or problem—a shared interest—around which a coalition could be built. For example, a state nurses association may invite the leaders of organizations interested in child health (e.g., organizations of pediatric nurses, public health nurses and physicians, elementary school teachers, daycare providers) and consumers (e.g., parents) to discuss collaborative support for a legislative initiative to improve access to immunization programs in urban and rural areas. Such coalitions of professionals and consumers are powerful in influencing public policy related to health care. Collaboration among groups and individuals with common interests and goals often results in greater success in effecting change and exercising power in the workplace and within other organizations, including legislative bodies. A group of diverse nursing organizations may come together as a coalition to support a modification of the state nursing practice act. Expanding networks in the workplace, as suggested earlier in this chapter, facilitates creating a coalition by developing a pool of candidates for coalition building before they are needed. Invite people with common goals to lunch or coffee to begin building a coalition around an issue. Discuss this shared interest, and gain the commitment of the individuals. Meet informally with members of the committee or task force that is working on this issue. Attend the open meetings of professional groups that share the same interests as the organization to which you belong. Share ideas on how to create the desired change most effectively while building coalitions. Coalition building is an important skill for involvement in legislative politics. Nursing organizations often use coalition building when dealing with state legislatures and Congress. Changes in nurse practice acts to expand opportunities for advanced nursing practice have been accomplished in many states through coalition building. State medical societies or the state agencies that license physicians often oppose such changes. Efforts by a single nursing organization (e.g., a state nurses’ association or a nurse practitioners’ organization), representing a limited nursing constituency, often lack the clout to overcome opposition by the unified voice of the state’s physicians. However, the unified effort of a coalition of nursing organizations, other healthcare organizations, and consumer groups can be powerful in effecting change through legislation. Negotiating Negotiating, or bargaining, is a critically important skill for organizational and political power (Kritek, 2002). It is a process of making trade-offs. Children are natural negotiators. Often, they will initially ask their parents for more than what they are willing to accept in the way of privileges, toys, or activities. The logic is simple to children: Ask for more than is reasonable and negotiate down to what you really want! Negotiating often works the same way within organizations. People will sometimes ask for more than they want and be willing to accept less. In other situations, both sides will enter negotiations asking for radically different things but each may be willing to settle for a position that differs markedly from the respective original position. In the simplest forms of bargaining, each participant has something that the other party values: goods, services, or information. At the “bargaining table,” each party presents an opening position. The process moves on until they reach a mutually agreeable result or until one or both parties walk away from a failed negotiation. Bargaining may take many forms. Individuals may negotiate with a supervisor for a more desirable work schedule or with a peer to effect a schedule change so that one can attend an out-of-town conference. A nurse manager may sit at the bargaining table with the department director during budget planning to expand education hours for the nursing unit in the next year’s budget. Representatives of a coalition of nursing organizations meeting with a legislator may negotiate with the legislator over sections of a proposed healthcare-related bill in an effort to eliminate or modify those sections not viewed by the nursing coalition as in the best interests of nurses, patients, or the healthcare system. Nurses may bargain with nursing and hospital administration over wages, staffing levels, other working conditions, and the conditions and policies that govern clinical practice. This is called collective bargaining, a specific type of negotiating that is regulated by both state and federal labor laws and that usually involves representation by a state nurses association or a nursing or non-nursing labor union (see Collective Action in Chapter 19). Successful negotiators are well informed about not only their own positions but also those of the opposing side. Negotiators must be able to discuss the pros and cons of both positions. They can assist the other party in recognizing the costs versus the benefits of each position. These skills are also essential to exercising power effectively with the arenas of professional and legislative politics. When lobbying a member of the legislature to support a bill that is desired by nurses, one must understand the position of those opposed to the bill to respond effectively to questions that the legislator may ask. Taking Political Action to Influence Policy In the 1990s, Carolyn McCarthy was an LPN from New York when a tragedy turned her life around. Her husband was killed and her son injured by a gunman on the Long Island Railroad. She sought the support of her congressman on gun control legislation as a result of her personal tragedy. He refused to support such legislation. She took extraordinary action, changing her party affiliation from Republican to Democrat and then running against the incumbent for his seat in Congress. She is still an LPN, and served as Congresswoman Carolyn McCarthy (D-NY) until 2014. Taking action may include such simple acts as working in a legislative campaign or volunteering to work on a church committee to establish a parish health ministry. Extraordinary actions like those taken by Carolyn McCarthy are also essential for nursing’s voice to be heard loudly and clearly in the uncertain future (Chaffee, 2012b). Gaining political skills, like any other skill set, is a developmental process. Some suggested strategies for developing political skills are presented in Box 10-2 on p. 173. Learning one’s strengths and areas for improvement requires self-study. The Political Astuteness Inventory (Goldwater & Zusy, 1990) is a helpful tool in determining how well prepared you are to influence legislative politics and public policy, especially public policy related to health care (Box 10-3). The personal power strategies mentioned earlier in this chapter are also important for building one’s political power. Nurses can no longer be passive observers of the political world. Political involvement is a professional responsibility, not just a privilege; political advocacy is a mandate (Priest, 2012). Nurses’ perspectives of the critical issues for improving the healthcare system can shape the policy agenda of the nation’s political leadership. Healthcare reform offers much opportunity for nurses and the profession if nurses are ready to move forward with reform (see the Research Perspective on p. 180). Conclusion Power is played out every day in every setting. Politics are played and often for the good of health care and patients. The abuse of either is what is disheartening. Recognizing the sources of power and using them effectively is a critical aspect to every nurse’s role. Chapter 23 Conflict: The Cutting Edge of Change Appropriate conflict-handling strategies are essential in professional nursing practice because conflict cannot be eliminated from the workplace. To resolve conflicts, nurse leaders must be able to determine the nature of a particular issue, choose an appropriate approach for each situation, and implement a course of action. This chapter focuses on maximizing the nurse leader’s ability to deal with conflict by providing effective strategies for conflict resolution. Learning Outcomes • Use a model of the conflict process to determine the nature and sources of perceived and actual conflict. • Assess preferred approaches to conflict, and commit to be more effective in resolving future conflict. • Determine which of the five approaches to conflict is the most appropriate in potential and actual situations. • Identify conflict management techniques that will prevent lateral violence and bullying from occurring. Key Terms accommodating avoiding bullying collaborating competing compromising conflict horizontal violence interpersonal conflict intrapersonal conflict lateral violence mediation negotiating organizational conflict Introduction Conflict is a disagreement in values or beliefs within oneself or between people that causes harm or has the potential to cause harm. Folger, Poole, and Stutman (2012) add that conflict results from the interaction of interdependent people who perceive incompatibility and the potential for interference. Conflict is a catalyst for change and has the ability to stimulate either detrimental or beneficial effects. If properly understood and managed, conflict can lead to positive outcomes and practice environments, but if it is left unattended, it can have a negative impact on both the individual and the organization (Scott & Gerardi, 2011a, 2011b; Wright, 2011). In professional practice environments, unresolved conflict among nurses is a significant issue resulting in job dissatisfaction, absenteeism, and turnover. Patient dissatisfaction is lower in hospitals in which nurses are frustrated and burned out, which signals a problem with quality of care (McHugh, Kutney-Lee, Cimiotti, Sloane, & Aiken, 2011; Wright, 2011). Successful organizations are proactive in anticipating the need for conflict resolution and innovative in developing integrated conflict resolution strategies that apply to all members (Brinkert, 2010). Conflict can be desirable at times and can be a strategic tool when addressed appropriately. Some of the first authors on organizational conflict (e.g., Blake & Mouton, 1964; Deutsch, 1973) claimed that a complete resolution of conflict might, in fact, be undesirable because conflict also stimulates growth, creativity, and change. Seminal work on the concept of organizational conflict management suggested conflict was necessary to achieve organizational goals and cohesiveness of employees, facilitate organizational change, and contribute to creative problem solving and mutual understanding. Moderate levels of conflict contribute to the quality of ideas generated and foster cohesiveness among team members, contributing to an organization’s success (Almost, 2006). An organization without conflict is characterized by no change; and in contrast, an optimal level of conflict will generate creativity, a problem-solving atmosphere, a strong team spirit, and motivation of its workers. Conflict on an interdisciplinary team can result in better patient care when collaborative treatment decisions are based on carefully examined and combined expertise (Tschannen, Keenan, Aebersold, Kocan, Lundy, & Averhart, 2011). The complexity of the healthcare environment compounds the impact that caregiver stress and unresolved conflict has on patient safety. Conflict is inherent in clinical environments in which nursing responsibilities are driven by patient needs that are complex and frequently changing and in practice settings in which nurses have multiple professional roles (Brinkert, 2010). Healthcare providers are exposed to high stress levels from increased demands on a limited and aging workforce, a decrease in available resources, a more acutely ill and underinsured patient population, and a profound period of change in the practice environment. Conflict among healthcare providers is inevitable and is compounded by employee diversity, high nurse-to-patient ratios, pressure to make timely decisions, and status differences (Wright, 2011). Nurses employed in better care environments report more positive job experiences and fewer concerns about quality care. Interprofessional collaboration has been characterized by effective communication and is a key factor in reducing error and improving patient outcomes (Tschannen et al., 2011). Moreover, hospitals with good nurse-physician relations are associated with better nurse and patient outcomes, making collaboration and conflict resolution among nurses and physicians crucial in promoting quality of care outcomes (Aiken et al., 2012). An important factor in the successful management of stress and conflict is a better understanding of its context within the practice environment. The diversity of people involved in health care may stimulate conflict, yet the shared goal of meeting patient care needs provides a solid foundation for conflict resolution. Because nursing remains a predominately female profession, this may contribute to the use of avoidance and accommodation as primary conflict handling strategies. An international study, however, found that both physicians and nurses were likely to use avoidance as the main strategy to handle conflict (Kaitelidou et al., 2012). The stereotypical self-sacrificing behavior seen in avoidance and accommodation is strongly supported by the altruistic nature of nursing. Avoidance may be appropriate during times of high stress, but when overused, it threatens the well-being of nurses and retention within the discipline. Types of Conflict The recognition that conflict is a part of everyday life suggests that mastering conflict-management strategies is essential for overall well-being and personal and professional growth. A need exists to determine the type of conflict present in a specific situation, because the more accurately conflict is defined, the more likely it will be resolved. Conflict occurs in three broad categories and can be intrapersonal, interpersonal, or organizational in nature; a combination of types can also be present in any given conflict. Intrapersonal conflict occurs within a person when confronted with the need to think or act in a way that seems at odds with one’s sense of self. Questions often arise that create a conflict over priorities, ethical standards, and values. When a nurse decides what to do about the future (e.g., “Do I want to pursue an advanced degree or start a family now?”), conflicts arise between personal and professional priorities. Some issues present a conflict over comfortably maintaining the status quo (e.g., “I know my newest charge nurse likes the autonomy of working nights. Do I really want to ask him to move to days to become a preceptor?”). Taking risks to confront people when needed (e.g., “Would recommending a change in practice that I learned about at a recent conference jeopardize unit governance?”) can produce intrapersonal conflict and, because it involves other people, may lead to interpersonal conflict. Interpersonal conflict is the most common type of conflict and transpires between and among patients, family members, nurses, physicians, and members of other departments. Conflicts occur that focus on a difference of opinion, priority, or approach with others. A manager may be called upon to assist two nurses in resolving a scheduling conflict or issues surrounding patient assignments. Members of healthcare teams often have disputes over the best way to treat particular cases or disagreements over how much information is necessary for patients and families to have about their illness. Yet, interpersonal conflict can serve as the impetus for needed change and can accelerate innovation in approach. Organizational conflict arises when discord exists about policies and procedures, personnel codes of conduct, or accepted norms of behavior and patterns of communication. Some organizational conflict is related to hierarchical structure and role differentiation among employees. Nurse managers, as well as their staff, often become embattled in institution-wide conflict concerning staffing patterns and how they affect the quality of care. Complex ethical and moral dilemmas often arise when profitable services are increased and unprofitable ones are downsized or even eliminated. A major source of organizational conflict stems from strategies that promote more participation and autonomy of direct care nurses. Increasingly, nurses are charged with balancing direct patient care with active involvement in the institutional initiatives surrounding quality patient care. A growing number of standards set by The Joint Commission (TJC) target improving communication and conflict management (Scott & Gerardi, 2011a, 2011b). Specifically, TJC requires that healthcare organizations have a code of conduct that defines acceptable and inappropriate behaviors and that leaders create and implement a process for managing intimidating and disruptive behaviors that undermine a culture of safety. Standards pertaining to medical staff also include interpersonal skills and professionalism (TJC, 2012). The Magnet Recognition Program® of the American Nurses Credentialing Center (ANCC) identifies interdisciplinary relationships as one of the Forces of Magnetism necessary for Magnet™ designation (2012). Specifically, collaborative working relationships within and among the disciplines are valued, demonstrated through mutual respect, and result in meaningful contributions in the achievement of clinical outcomes. Magnet™ hospitals must have conflict management strategies in place and use them effectively, when indicated. The following are other “forces” that are particularly germane to conflict in the practice environment: •Organizational structure (nurses’ involvement in shared decision making) •Management style (nursing leaders create an environment supporting participation, encourage and value feedback, and demonstrate effective communication with staff) •Personnel policies and programs (efforts to promote nurse work/life balance) •Image of nursing (nurses effectively influencing systemwide processes) •Autonomy (nurses’ inclusion in governance leading to job satisfaction, personal fulfillment, and organization success) Stages of Conflict Conflict proceeds through four stages: frustration, conceptualization, action, and outcomes (Thomas, 1992). The ability to resolve conflicts productively depends on understanding this process (Figure 23-1) and successfully addressing thoughts, feelings, and behaviors that form barriers to resolution. As one navigates through the stages of conflict, moving into a subsequent stage may lead to a return to and change in a previous stage. To illustrate, the evening shift of a cardiac step-down unit has been asked to pilot a new hand-off protocol for the next 6 weeks, which stimulates intense emotions because the unit is already inadequately staffed (frustration). Two nurses on the unit interpret this conflict as a battle for control with the nurse educator, and a third nurse thinks it is all about professional standards (conceptualization). A nurse leader/manager facilitates a discussion with the three nurses (action); she listens to the concerns and presents evidence about the potential effectiveness of the new hand-off protocol. All agree that the real conflict comes from a difference in goals or priorities (new conceptualization), which leads to less negative emotion and ends with a much clearer understanding of all the issues (diminished frustration). The nurses agree to pilot the hand-off protocol after their ideas have been incorporated into the plan (outcome). Frustration When people or groups perceive that their goals may be blocked, frustration results. This frustration may escalate into stronger emotions, such as anger and deep resignation. For example, a nurse may perceive that a postoperative patient is noncompliant or uncooperative, when in reality the patient is afraid or has a different set of priorities at the start from those of the nurse. At the same time, the patient may view the nurse as controlling and uncaring, because the nurse repeatedly asks if the patient has used his incentive spirometer as instructed. When such frustrations occur, it is a cue to stop and clarify the nature and cause of the differences. Conceptualization Conflict arises when different interpretations of a situation occur, including a different emphasis on what is important and what is not, and different thoughts about what should occur next. Everyone involved develops an idea of what the conflict is about, and this view may or may not be accurate. This may be an instant conclusion, or it may develop over time. Everyone involved has an individual interpretation of what the conflict is and why it is occurring. Most often, these interpretations are dissimilar and involve the person’s own perspective, which is based on personal values, beliefs, and culture. Regardless of its accuracy, conceptualization forms the basis for everyone’s reactions to the frustration. The way the individuals perceive and define the conflict has a great deal of influence on the approach to resolution and subsequent outcomes. For example, within the same conflict situation, some individuals may see a conflict between a nurse manager and a direct care nurse as insubordination and become angry at the threat to the leader’s role. Others may view it as trivial complaining, voice criticism (e.g., “We’ve been over this new protocol already; why can’t you just adopt the change?”), and withdraw from the situation. Such differences in conceptualizing the issue block its resolution. Thus it is important for each person to clarify “the conflict as I see it” and “how it makes me respond” before all the people involved can define the conflict, develop a shared conceptualization, and resolve their differences. The following are question to consider: •What is the nature of our differences? •What are the reasons for those differences? •Does our leader endorse ideas or behaviors that add to or diminish the conflict? •Do I need to be mentored by someone, even if that individual is outside my own department or work area, to successfully resolve this conflict? Action A behavioral response to a conflict follows the conceptualization. This may include seeking clarification about how another person views the conflict, collecting additional information that informs the issue, or engaging in dialog about the issue. As actions are taken to resolve the conflict, the way that some or all parties conceptualize the conflict may change. Successful resolution frequently stems from identifying a common goal that unites (e.g., quality patient care, good working relations). It is important to understand that people are always taking some action regarding the conflict, even if that action is avoiding dealing with it, deliberately delaying action, or choosing to do nothing. The longer ineffective actions continue, though, the more likely people will experience frustration, resistance, or even hostility. The more the actions appropriately match the nature of the conflict, the more likely the conflict will be resolved with desirable results. Outcomes Tangible and intangible consequences result from the actions taken and have significant implications for the work setting. Consequences include (1) the conflict being resolved with a revised approach, (2) stagnation of any current movement, or (3) no future movement. Constructive conflict results in successful resolution, leading to the following outcomes: •Growth occurs. •Problems are resolved. •Groups are unified. •Productivity is increased. •Commitment is increased. Unsatisfactory resolution is typically destructive and results in the following: •Negativity, resistance, and increased frustration inhibit movement. •Re…
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