The ProfessionalPractice of NursingAdministration

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The ProfessionalPractice of NursingAdrninistration

LTLLIAN M. STMMS, R.N., Ph.D.Ass o c iate P rofe s so r o/ Nursrngand Heahh GerontologrNursrng Health Services AdministrationSchool o/NunsingThe University of MichiganAnn Arbor, Michigan

SYLVIA A. PRICE, R.N., Ph.D.Research AssociateNursing Heahh Services AdministralionSchool o/NursrngThe Universitv of MichiganAnn Arbor, Michigart

NAOMI E. BRVTN, R.N., Ph.D.Assrstant ProfessorDepartment of Pttblic Health NunsingCollege o/NursingUniversit.v of Illinois at ChicagoChicago, lllinois

A Wiley Medical PublicationJOHN WILEY & SONSNew York . Chichester . Brisbane . Toronto . Singapore

Contributors

Yvonne M. Abdoo, R.N., M.S.N.Assistant Professor of NursingSchool of NursingThe Univcrsity of MichiganAnn Arbor, Michigan

Gladys Ancrum, R.N., Dr. PH.Professor of NursingDepartment of NursingBloomsburg UniversityBloomsburg, Pennsylvania

Judith A. Bernhardt, R.N', M.S.Associate Activation Administratorand Senior Hospital PlannerThe University of Michigan HospitalsAnn Arbor, Michigan

Agnes M. Buback, R.N., M.S.N.Associate Administrator and Director of NursingC.S. Mott Children's HosPitalHolden Perinatal and Women's HospitalsThe University of Michigan HospitalsAnn Arbor, Michigan

Catherine Buchanan, R.N', Ph.D.Management Nursing ConsultantHome Health CareLathrup Village, Michigan

Marjorie M. Jackson, R.N., M.S.Associatc Professor of NursingSchool of NursingThe University of MichiganAnn Arbor, Michigan vll

X PREFACE

challenging and gratifying work, with emphasis on the importance ofindividual growth and development through the administrativc expc-rience.

In summary, the goals of this book are to:

1. Present nursing administration as part of professional nursing prac-tice within the total organization.

2. Provide an approach to the practice of nursing administration thatintegrates the clinical and research climate with nursing education.

3. Provide knowledge about the institutional, political, and social con-trols that influence the practice of nursing administration.

4. Forecast emerging trends that influence the professional practice ofnursing in various settings.

5. Provide a conceptual framework for the practice of nursing admin-istration in current and emerging practice settings.

Special acknowledgment is given to Andrew Simms, word processoroperator, and Francile Clevenger, typist, for their able assistance in pre-paring the manuscript.

Lru-rRN M. SrnrusSvlvn A. PnlceNaoruu E. EnvlN

Contents

Part IA Frarnework for the Practice of NursingAdrninist'ation

I Professional Nursing Practice 3

2 Nursing Theories and Models 12

3 Management Theories 24

4 The Person in the Role of Nursing Administrator 36

Part IIThe Context of Nursing Adrninishation Practice

5 Creating the Environment for Nursing Practice 57

6 The Organization of Nursing Practice 68

7 Organizational Change 85

8 Operationalizing Professional Nursing 94

Part IIICurrent and Emerging Challenges

9 Developing Human Potential lO7

10 Managing Fiscal Resources 120Agnes M. BubcLck cmd Nancy V. Moran

l1 Managing Conflict 140

Gladys Ancrum12 Leadership in Care of the Eldcrly 154

XI

Xii CONTENTS

Part tVFacilitating Ilrofessional Nursing Practice

13 Decision Making in Clinical Settings 173

Florence M. Johnston

14 Facilities Planning 185

ludith A. Bernhqrdt

15 Quality Assurance 204

16 Effective Communication 22I17 Nursing Research in a Professional Practice Climate 236

Part VManaging Human Resources

18 Mobilizing Existing Resources 249

19 Staffing and Scheduling 264

Yuonne M. Abdoo

20 Productivity 281

Part VIMoving Beyond ttre Ordinary

2l Mentorship and Networks 295

Catherine Buchanan

22 Marketing Nursing Services 310

23 Current and Emerging Practice Settings 323

24 The Comedy of Management 339

Marjorie M. Jackson

25 The Nursing Imperative: Integrating Practice, Education,and Research 352

Author Index 367

Sulrject Index 373

Purtl

A Flarneworkfor the Practiceof NrrrsingAdrninistration

PROFESSIONAL NURSING PRACTICE 11

2. Wilenski, H. The professionalization of everyone? American Journal of'So-ciology, September 1964, 70(2), 137-158.

3. Schien, E.H. Professional Educatiorz. New York: McGraw-Hill, 1972.

4. Kelly, L. Dimensions of'Professional Nursing,4th ed. New York: Macmillan,r98r.

5. Donabedian, A. Foreword, in M. Phaneuf, The Nursing Audit and Self-regtt-lation in Nursing Practice,2d ed. New York: Appleton-Century-Crofts, 1976.

6. Henderson,Y . Basic Principles of Nursing Care. London: International C<-runcilof Nurses, 1961.

7. American Nurses' Association. The Nursing Practice Act: Suggested State Leg-islation. Kansas City, Mo.: American Nurses' Association, 1981.

8. Schlotfeldt, R. Nursing in the future.NursingOutlook, May 1981, 29(5),295-301.

9. American Nurses' Association. Nursing: A Social Policy Statemenf. KansasCity, Mo.: American Nurses' Associaticln, 1980.

10. State of Michigan, 79th Legislature. Enrolled House Bill No. 4O70. MichiganPublic Health Code, 1978.

I l. Lysaught, J.P. Action in Affimtation: Toward an Unantbiguous Profession ofNursing. New York: McGraw-Hill, 1981.

12. D<rnaldson, S. and Crowley, D. The discipline of nursing. Nursing Outlook,February 197 8, 26(2), 1 l 3-120.

L0 _A _EB4l4sWqB Elg B r H_E_PBAqIICE_ m _N!Bs I N q rA DN{INISTBAION_ _

which nursing practice can occur. The majority of nurses are employedby health care institutions, and thcir clinical practice must intcrfacewith administrative philosophy and policy. The amount of control thatnurses have over their own practice is related to many factors in thisemployer-employee relationship. Thc following chapters cover inno-vative administrativc approaches and factors that influence nursingpractice on both conccptual and pragmatic levels. A nursing adminis-trator must consider both conceplual and pragmatic levels in order toconstruct a supportive and growth-producing environment for profes-sional nursing practice.

SUMMARY

In order for nursing to be a professional practice discipline, nursingmust formulate a theoretical basis for its practice. Nursing theories andmodels provide a conceptual framcwork for the implementation ofnursing practice. The next chapter examines selected nursing theoriesand models.

STUDY QUESTIONS

1. What docs professionalism involve?

2. List at least five essential criteria of a profession.

3. Explain why profession is a social concept.

4. Why is nursing often referred to as an emcrging prolession?

5. Formulate a definition of nursing.6. What are the distinguishing characteristics that differentiate profes-

sional and vocational nursing?

7. According to the National Commission for the Study of Nursing andNursing Education's interactive model, there is no singlc focus fornursing practice. Explain.

8. Why is the field of nursing considered a professional practice disci-pline rather than an academic onc? Explain.

9. Describe the four components of professional nursing practice.

REFERENCES

1 . Etzioni, A., ed. The Semi-Profbssions and Their Organiz.ation. Ne'.v York: TheFree Press, 1969.

l&o_Eqs qq NAL N u&qING PRAgrrcE

giving service, and educating. Furthermorc, somc mcmbers of the prolessionmust engage in enquirl' that is not immcdiatelv applicable to currenl clinicalpractice. As a branch o[ knowledge, the discipline cmbodics more than the scienceo[ nursing and requires rescarchcrs u'ho emplo]' a variety of approache's fiomnursing's perspective (p. 1 l9).

Nursing researchers, clinicians, and educators use information frommany disciplines and need to understand or conduct research in thesefields outside nursing.

Professional practice discipiines such as nursing, medicine, and den-tistry are defined by the application of knowledge in relation to thehealth of clients. Alrhough clinical practice is a major thrust of nursing,other components of professional practice must be considcred, includingresearch, education, and administralion. The four components, therefore,are (I ) clinical (application of knorvledCe), (2)research (development ofknowledge), (3) education (transmission of knowlcdge), and (4) admin-istration (utilization of knowledge), as sh<-rwn in Figure 1.2. These com-ponents need to bc articulated and coordinated toward the full attain-ment of a professional practice discipline. The education componentinfluences policy formation by administration, which in turn nurturesresearch-bascd clinical practice. Nursing administrators are responsiblefor nursing practice, research, and cducation as they relate to profes-sional nursing within an institution.

Administrative support provides the environmcnt and structure in

Professionaln ursi ngpractice

Administration(utilization ofknowledge)

Research(development ol

knowledge)

Education(transmissron o{

knowledge)

Clinical(application of

knowledge)

FIGURE 1.2 Four components of professional nursing practice.

8_e FRAMEWORK FOR THE PRACTICE OF NURSING ADMINISTRATION

FIGURE l.l Interactive model of an emergent, full profession of nursing. Ep-isodic care is that domain ol nursing practice that is essentially curative andrestorative, generally treating ill patients, and most frequently provided in ahospital setting or other in-patient facility. Distributive care is that domain ofnursing practice that is essentially designed for health maintenance and diseaseprevention, generaliy continuous in nature, seldom acute, and increasingly pro-vided in community or emergent care settings. (From J.P. Lysaught, Action inAffirmation: Toward an Unambiguous Profession of Nursing. New York: McGraw-Hill, 1981, p.44, Figure 3-11.)

a mild iilness) and vertically, within a nursing practice (from staff nurseto master clinician).

This conceptual scheme also argues for variation in the educationalpattcrning of preparatory and advanced studies to ensure the educationof the variety as well as the number of nurses needed to implement afull range of client services. It provides for a commitment and careerperspective that includes mobility and increments in responsibility, au-thority, and recognit ion.

Donaldson and Crowley (12) distinguish betwcen academic andprofessional disciplines. The purposc of academic disciplines is to know(and, for some, to apply that knowledge); therefore, they develop de-scriptive theories. Because the professional disciplincs have an addedcomponent of service to people, their theories are both descriptive andprescriptive in nature. While academic disciplines involve basic and ap-plied research, profcssional disciplines also involve clinical research.Donaldson and Crowley (12) caution that:

The discipline, which is a body of knor.r'ledge, must not be confused with itsassociated practice realm, which embodies the processes of conducting research,

nra"ara"ntfgt*(H lntervention Jel6\

=(lnstruction

I

PATIENT CONDITION

PROFESSIONAL NURSING PRACTICE

PROFESSIONAL PRACTICE DISCIPLINES

The legal responsibility and scope of nursing practice are regulated bythe nursing practice acts of each state. For example, according to thcState of Michigan Public Health Code, House Bill No. 4050 (10), thepractice of nursing is "the systemalic application of substantial spe-cialized knowledge and skill derived from the biological, physical, andbehavioral sciences to the care, treatment, counsel, and health teachingof individuals who are experiencing changes in the normal health pr<-r-

cesses or who require assistance in the maintenance of health and theprevention or management of illness, injury, or disability". This defi-nition is appropriate for a professional practice discipline such as nurs-ing, It conveys that nursing emphasizes human health and well-being,which are the concerns of nurses and determine the essential nature ofnursing.

Lysaught (11) has reported that the National Commission for the Studyof Nursing and Nursing Education prescnts an interactive model ofnursing practice that envisages three dynamic continua that operate inclose relationship to one another and, taken logether, explain thc entiredomain o[ needs for nursing and experlise (see Figure 1.1). One axisclassifies the set of nursing behaviors ranging from the initial assessmentof client condition through intervention, instruction, and assessment ofoutcomes and results. The second axis classifies patient condition: well,unwell, or acutely unwell. The commission emphasizes that the "conceptof maintaining wcllness and limiting illness is as much a part of thefull practice of nursing-or medicine-as is thc treatment of acutc ill-ness." The third axis depicts the environmental setting (e.g., instilution,outpatient setting, clinic, home, or community). This axis contains arcasfor thc cnactment of nursing behaviors classified, for simplicity, in twocategorics: episodic care, which includes curative and restorative carc;and distributive care, which is geared toward health maintenance anddisease prevention and takes place with increasing frequency in com-munity and emergenI carc scltings.

In determining proper role lunctions in accordance with client needsand in rclationship to sclecting the optimum environment for care, Ly-saught's interactive modcl focuses on whether the nurses' role is indc-pendent or interdepcndent. This conceptual framcwork suggests no sin-glc focus for nursing practice; it argucs for nursing as a variety o[ specificcapacities, rather than a group of simple skills, and for a relocation ofthc patient and his or her necds to an elemental position in the decision-making process rclated to intervention and care. This model argues fornursing as a profession-not just nurses as individuals-to be preparedfor health intervention in a kaleidoscope of situations. There is roomfor a variety of concentrations and spccializations, both horizontally,across the range of client care needs (from acute cardiac care through

A FRAMEWORK FOR THE PRACTICE OF NURSING ADMINISTRATION

carry out the therapeutic plan as initiated by the physician. She also, as a mem-ber <lf a medical team, helps other members, as they in turn help her, to planand carry out the total program whether it be lor the improvement of health,or the recovery from illness, or support in death. (p.a2)

The American Nurses'Association Congress for Nursing Practice hasproposed a definition that attempts to differentiate between professionaland vocational nursing:

The practice of nursing means the perfcrrmance for compensation of professionalservices requiring substantial specialized knowledge of the biological, physical,behavioral, psychol<lgical, and sociological sciences and of nursing theory asthe basis of assessment, diagnosis, planning, intervention, and evaluating thepromotion and maintenance of health, the casefinding and management of ill-ness, injury, or infirmity, the restoration of optimum function, or the achievementof a dignified death. Nursing practice influences but is not limited to admin-istration, teaching, counseling, supervision, delegation, and evaluation of practiceand execution <lf the medications and treatments prescribed by any person au-thorized by state law to prescribe. Each registered nurse is directly accountableand responsible to the consumer for the quality of nursing care rendered.

The practice of practical (vocational) nursing means the performance forcompensation of technical services requiring basic knowledge of the biological,physical, behavioral, psychological, and sociological sciences and of nursingprocedures. These services are performed under the supervision of a registerednurse and utilize standardized procedures leading to predictable outcomes inthe observation and care of the ill, injured, and infirm, in the maintenance ofhealth, in action to safeguard life and health, and in the administration of med-ications and treatments prescribed by any person authorized by state law toprescribe. (7 , p. 6)

Schlotfeldt (8) emphasizes that nurses should search for a conceptualfocus and definition of their profession that permit inclusion of phe-nomena related to human beings' seeking optimal health. She belicvesthat a definition is needed that will help to establish nursing as a profes-sion whose practitioners are responsible for the gcneral health of humanbeings. Thus, her definition is, "Nursing is assessing and enhancing thegeneral health status, health assets, and health potentials of humanbeings" (p. 298). This definition is unambiguous; focuses on nursingpractice, education, and research; and conveys nurses'knowledge, prac-tice, and scope of accountability. Because it does not encroach upon theresponsibilities of other helping professionals, it is conceptually appro-priate and politically acceptable. Schlotfeldt emphasizes that nursingr.vill become a recognized, learned profession and that nurses will provideessential services that will enhance the health and well-being of oursociety.

The nursing profession makes significant contributions to the evolutionof a health-orientcd system of care. Nursing practice has been health-oriented for over a half a century because o[ its focus on individuals aspersons and on the family as the necessary unit of service (9).

lBoiqs, rIqNAr- NURSING PRACTICE

an occupation, rather than a profession, such as medicine, theology, andlaw. Writers who present this issue acknowledge that some nurses nowperform expanded roles and functions, while others lack the educationalbasis for such a practice. Therefore, it is often difficult to distinguishamong associate-degree, diploma, and baccalaureate-prepared nurses.

Nurses provide services in a variety of settings, such as industry,schools, and public health agencies. Nurses now assume more respon-sibility and accountability for the consequences of their decisions thanin the past. This extension of nursing practice also involves increasedcollaboration with physicians and other health practitioners in the per-formance of their respective roles in the provision of health services, Incollaborative practice, nursing emphasizes psychosocial aspects of healthcare, coordination ofpatient care services, and advocacy ofpatient rights.

As an emerging profession, nursing is recognizing the need to formulatea theoretical base for its practice and to articulate that base to others.Research is evolving in the clinical areas to test nursing theories andrelated theories upon which the practice of nursing is based. Similarly,research in the practice of nursing administration provides an empiricalknowledge base for the various functions and responsibilities associatedwith nursing administration. Nursing must initiate and promote re-search to support the organizational restructuring of the delivery ofnursing services, to define nurses' roles and responsibilities in interdis-ciplinary endeavors, and to provide a data base for a systematic eval-uation of the impact of nursing.

Prolessional roles and functions of nursing are being reexamined. Theprofessional role of the practitioner of nursing has been expanded, lead-ing to a repatterning of nursing education and emphasis on lifelong ca-reer commitment to nursing. This trend has further emphasized the needfor nurses who are creative and possess competencies to function in acollegial relationship with other health care professionals.

NURSING PRACTICE

Nursing is concerned with human health and well-being. It involves thedelivery of humanistic care to people in order to promote and maintainhealth, prevent illness, cure illness and restore health, and coordinatehealth care services to increase continuity.

Discussing the nature of nursing, Virginia Henderson (6) states:

The unique function of the nurse is to assist the individual, sick or well, in theperformance of those activities contributing to health or his recovery (or topeaceful death) that he vu'ould perform unaided if he had the necessary strength,will, or knowledge. And to do this in such a way as to help him gain independenceas rapidly as possible. This aspect of her w<trk, this part of her function, sheinitiates and conlrols; of this she is master. In addition she helps the patient

4a IB4ruElyaBE IoB rHE PRACTICE OF NURSING ADMINISTRATION

This knowledge will enable nursing administrators to develop a con-ceptual framework for their nursing administrative practice.

DEFINITION OF A PROFESSIONAND PROFESSIONALISM

Nursing is an emerging profession and a prolbssional practice discipline.One must have comprehensive understanding of both terms in order topromote the highest level of nursing administrative practice. Manywriters have discussed the history, development, definition, and appli-cation of the concept of a profcssion (1 ,2,3,4). Although these writersexhibit considerable diversity, there is consensus on thc basic premisethat professionalism involves autonomy, mastery of a body of knowledge,and a community of colleagues. The following are essential criteria ofa profession:

1. Provides practical services that are vital to human and social wellare2. Possesses a specialized body of knowledge and skills3. Educates its practitioners in institutions of higher education4. Attracts people who emphasize service over personal gain or self-

interest and recognize their occupation as a long-term commitment5. Formulates and controls its own policies and activities and has prac-

titioncrs who function relatively autonomously in the performanceo[ functions and activities

6. Has a code of ethics that is usually enforced by colleagues or throughlicensure examinations

7. Has a professional association that promotes and ensures quality ofpractice

It should be noted that profession is a social concept. The authorityfor nursing is based on a social contract that is derived fr<lm a complexsocial base. Donabedian (5) states:

There is a "social contract" between society and the professions. Under its terms,society grants the professions authority over functions vital to itself and permitsthem considerable autonomy in the conduct of their own affairs. In rcturn, theprofessions are expected to act responsibly, always mindtul olthe public trust.Self-regulation to assure quality in pcrformance is at the heart of this relation-ship. It is the authentic hallmark of a mature proflession. (p. xiii)

Although there is some agreement as to what constilutcs a profcssionalnurse, much variation in opinion remains. One area of diversity involvesthe length and type o[ educational preparation nccessary to qualify forthe status of professional nurse. Another issue is whelher nursing is rcally

ProfessionallNursing Practice

The purpose of this chapter is lo present a conceptual frameworkfor professional nursing practice. On completion of this chapter,the reader will be able to:

l. List the essential elements of a profession.2. Formulate a definition of nursing.3. Differentiate between professional and vocational nursing.4. Critically analyze the National Commission for the Study of

Nursing and Nursing Education's interactive model for nurs-ing practice.

5. Discuss the distinctive features of academic and professionaldisciplines.

5. Describe the four components of profcssional nursing practicc.

Nursing services constitute a core function of the health care deliverysystem, and nursing administrators conduct and control clinical nursingpractice. As health care delivery systems change and as professionalroles are redefined, effective nursing leadership is cssential. Nurses inadministrative positions participatc in policy and decision making, as-sume responsibility for managing nursing service and related activities,and work cooperatively with professionals from other health disciplinesto ensure that quality client-ccntered care is administered. The acqui-sition and allocation of human and physical resources required to meetthe goals of clinical care are facilitated by the nursing administrator.For example, nursing administralors generally influence the largestproportion of the budgets of hospitals and other health care institutionsand make major decisions affccting the quality of patient care.

Since the hcalth care industry is a human services endeavor, nursingadministrators must havc a thcoretical grounding in the behavioral sci-ences. It is also essential that they acquire knowledge and understandingof administrative theory and be aware of changing concepts in thc field.

2.

3.

4.

20 R ppRtvlEwoRK FoR THF, pRACTTcE oF NURSING ADMINISTRATION

gether or maintenance of a proper balance. Levine states that the purposeof conservation is to maintain the unity and integrity of the patient. Thefour conservation principles are:

Conservation of energy refers to balancing energy output and energyinput to avoid excessive fatigue, i.e., adequate rest, nutrition, andexercise, accurate assessment o[ the patient's ability to perform nec-essary activities without producing excessive fatigue.Conservation of structural integrity refers to maintaining or restoringthe structure of the body, i.e., body defense systems which protectpeople from loss of body fluids, rapid adaptations ro changes in ex-ternal temperature.Conservation of personal integrity refers to maintenance or resto-ration of the individual's sense of identity and self-worth, i.e., respectfrom the nurses, willingness to permit people to make decisions forthemselves whenever possible.Conservation of social integrity refers to the acknowledgment of theindividual within the context of social life. No individual can rec-ognize his/her wholeness unless it is measured against relationshipswith others. (pp. 14-18)

Like Orem's conceptual framework, Levine's nursing theory focuseson the individual (patient). The nurse is concerned with the patient'sfamily and significant others only as they influence the patient's progress.

Levine's theory depicts nursing as an independent practice profession.Levine does not consider the collaborative relationship of nursing withinthe total health care setting. However, nurses in acute care settings coulduse this model. For example, the theory emphasizes the patient's de-pendency (e.g., illness states, limited participation in the planning ofcare). In such settings, the nurse has the major responsibility for as-sessing the patient's ability to participate in his or her own care, whichis in direct contrast to Orem's conceptual model of nursing.

Roy's Adaptation Model

Sister Callista Roy's (12) adaptation model of nursing practice is basedon her philosophy of a human as a biopsychosocial being who, to beunderstood, must be considered as a unit, or whole (p. 11). Human beingsare in constant interaction with their environment. Because they areliving systems, they require matter, cnergy, and information from theenvironment and cope with environmental change through biopsycho-social adaptive mechanisms.

Roy has identified four distinct modes of adapting by which a personresponds to change: (1) physiological, (2)self-concept, (3i role function,

NURSING THEORIES AND MODELS 19

pensatory system, the nurse and the patient perform care measures orother actions involving manipulative tasks or ambulation. A patient inthe supportive-educative system can or should learn to perform the re-quired self-care measure but cannot do so without assistance.

The family, community, and environment are important componentsconsidcred in self-care actions, but the primary focus is on the patient.The goal of nursing action is to involve the patient in his or her ownself-care whenever possible.

Levine's Theory

Myra Levine's theory (11) of nursing is based on the concept of totalpatient care, from which she derives four conservation theories that serve

as the basis of her nursing model. Levine's theory reflects her definitionof nursing, in which she makes the assumptions that nursing is:

l. A human inl.eraction.2. A discipline rooted in the dependency of people and their relationships

with other people.3. Based on intervention that supports or promotes the person's ad-

justment. (pp. 1*3)

The components of Levine's theory are as follows:

l. The patient is in the predicament of illness.

2. The nurse must recognize the patient's holistic response, which in-dicates the nature of the adaptation to illness.

3. The nurse who participates actively in every patient's environmentmust recognize the organismic response of the patient, make an in-tervention in the patient's environment, and evaluate the interventionas therapeutic or supportive. (p. 13)

Levine's theory makes the basic assumptions that the nurse-patientinteraction is determinedby (1)the conditions in which the patient en-ters the health care setting, (2) the functions of the nurse in the situation,and (3)the responsibilities of the nurse in the situation.

The theory implies that the nurse is able to make judgments that willpromote or support the patient's adaptation to the situation based onknowledge. The nurse also is expected to possess the skills necessary toimplement these interventions.

Levine views a person holistically as requiring structural, personal,and social integrity as well as energy to be in a state of health. If anyone of these elements is disrupted or changed, the person is in a stateof altered health. Nursing interventions are based on the conservationof thesc four elements. Levine dcfines conservation as the keeping to-

Accompl ishes pattent'stherapeutic self-care

Compensates for patient'sinability to engage

in self-care

Supports and protectspatient

18 _4 JB4I4E!yqB4 rof,fHE!&AqIcE qF NURSTNG ApMrNrsTRATroN

Wholly compensatory system

Partly compensatory system

Supportive-education system

FIGURE 2.1 Basic nursing systems. (From D.E. Orem, Nursing: Concepts ofPractice,2d ed. New York: McGraw-Hill, 1980, p.98.)

care requisites, three varieties of basic nursing systems are recognized:(.1) wholly compensatory, (2) partly compensatory, and (3) supportive-educative (see Figure 2.1). The nursing system is formed by the nurse'sselection and use of methods of assisting patients and prescribes par-ticular roles for the nurse and the patient.

The r.vholly compensatory nursing system exists when the patient isunable to engage in those self-care actions requiring self-directed and-controlled ambulation to refrain from such activity. In the partly com-

Nurseaction

Performs some self-caremeasures for patient

Compensates for self-carelimitations of patient

Assists patient as required

Performs some self-caremeasures

Regulates self-care agency

Accepts care and assistancefrom nurse

Accompl ishes self -care

Regulates the exercise anddevelopment ofself-care agency

NVSqNG_IUEOBIEIAD M9!EL-S_ I 7

Universal self-care requisites arc universally required by all humanbeings and include (1) maintenance of a sufficient intake of air, water,and food; (2) care related to excrements; (3) balance between activityand rest; (4) balance of solitude and social interaction; (5) preventionof hazards to human life, human functioning, and well-being; and (6,)

promotion of normalcy. Orem stresses that self-care related to the needfor normalcy may be directed toward the promotion of integrated humanfunctioning or the protection and care of the body.

Developmental self-care requisites are the following:

1. Bringing about and maintenance of living conditions that supportlife processes and promote the processes of development, which refersto human progress toward higher levels of the organization of humanstrrrctures and maturation during:a. The intrauterine stages of life and process of birth.b. The neonatal stage of life when (1)born at term or prematurely

and (2)born with normal birth weight.c. Infancy.d. The developmental stages of childhood, including adolescence and

entry into adulthood.e. The developmental stages of adulthood.f. Pregnancy either in childhood or adulthood.

2. Provision of care either to prevent the occurrence of deleterious effectsof conditions that can affect human development or to mitigate orovercome these effects from conditions such as:

a. Educational depreciation.b. Loss of relatives, friends, associates.c. Poor health or disability.d. Terminal illness and impending death (p.a7).

Health-deviation self-care requisites exist for persons who are ill; areinjured; have specific forms of pathology, including defects and disa-bilities; and are under medical diagnosis and treatment. Obviouschanges in (1/ human structure (e.g., edematous extremities, tumors),(2) physical functioning (e.g., dyspnea, joint immobility), and (3) habitsof daily living (e.g., sudden mood changes, loss of interest in life) focusa person's attention on himself or herself. When a change in health statusresults in total or almost total dependence on others for the needs tosustain life or well-being, the person moves from the position of self-care agent to that of patient or receiver of care. The role of nursingfocuses on assisting the individual, family, or significant others to meetuniversal self-care demands or develop new methods of providing self-care.

On the principle that nurses, patients, or both can act to meet patients'

NURSING THEORIES AND N{ODELS 13

(1) envision a theory as a systematic abstraction of reality intended toserve a particular purpose. A systematic abstraction is a defined organ-

izational pattern derived from reality but not reality itself. Approaches

to theory development are themselves organized and patterned, or sys-

tematic. The syslematizalion of abstractions requires rigorous thoughtand action. The words and symbols that comprise a theory are labels

associated with an object, property, or event in the real world. For ex-

ample, the word computer represents an abstraction that denotes a realobject. A theory consists of words, such as the label computer, that rep-

resent abstractions, such as the mental image of a computer, that denote

reality, such as the object computer. Words and other symbols enable

theories to be communicated and understood.Hage (2) states that concepts that refer to classes or categories of phe-

nomena may be called nonvuriable. Such concepts are observed in ty-pologies in which classes are clearly defined, based on the presence orabsence of the property of interest, for example, a nurse or a patient.General variables are concepts used to order phenomena according to

some property or concepts that refer to dimensions of phenomena, for.*u-pl", degree of anxiety or level of mobility. Hage stresses that con-

cepts that 1ru.y ol ".

a continuum should be used more frequently thannonvariables in conceptualization and theory construction. Generalvariables are not restricted to time and place and lend themselves to

more subtle description and ciassilication than do nonvariable concepts.

In general, theories are constructed either deductively or inductively.In deductive theory construction, the concepts under study proceed fromgeneral to specific. Thus, deductive theory construction begins withgeneral axioms and propositions. Deductive theories are developedthrough a logical process that relates concepts in general statements so

that increasingly specific statements can be deducted from them'The process of inductive theory construction proceeds from the spe-

cifics of empirical situations to generalizations about the data. This ap-

proach is best illustrated in the grounded theory of Glaser and Strauss(:). T't-r" process involves sequential formulation, testing, and redevel-opment of propositions until a theory is generated that is integrated,consistent with the data, and in a clear form, operationalized for latertesting in quantitative research.

Simms (a), in referring to the theory of Glaser and Strauss, cites fourstages in the constant comparative method they used in formulating thegrounded theory:

/1/ Comparing incidents applicable to each category, (2) integrating,categoriesand their prolerties, (3) delineating the theory, and (4) writing the theory. Theelements oi th'eory that are generated by comparative analysis are the conceptualcategories, their conceptuil propertics, and generalized relations among thecategories and their propt'rlies.

TJevaluate propositior'rs and refine categories and their properties, relevant

I{ursing Theoriesand Models

The purpose of this chapter is to introduce the concept of theoryand its relationship to nursing administrative practice. On com-pletion of this chapter, the reader will be able to:

1. Define theory.2. Distinguish between deductive and inductive theory con-

struction.3. Describe the four stages of the constant comparative theory

used in formulating grounded theory as depicted by Glaserand Strauss.

4. Briefly discuss Dickoff and James' relationship of inductivetheory to practice.List the critcria a theory must meet in order to have directapplication to practice.Define model.Distinguish among Orem's, Levine's, and Roy's conceptualmodels of nursing practice.Critically analyze Orem's, Levine's, and Roy's models andtheir application to nursing practice.

Nursing theories and models provide the conceptual framework fornursing practice. In a practice discipline such as nursing, conceptualframeworks are useful in directing the thinking of scholars, in the de-velopment of theories, and in guiding the observation of practitionersas the processes of assessment and intervention are carried out.

6.7.

8.

THEORIES

A theory consists of a set of interconnected propositions designed todescribe, explain, and predict an event or phenomenon. Chin and Jacobs

12

NURSING THEORIES AND MODELS 23

5. Wald, F. and Leonard, R. Towards development of nursing practice theory.Nursing Research, April 1964, 13(4), 309-313.

6. Dickoff, J., James, P., and Wiedenbach, E. Theory in a practice discipline:part I. Nursing Research, September/October 1968, 17(5),415-434.

7. Dickoff, J., James, P., and Wiedenbach, E. Theory in a practice discipline:part IL Nursing Research, November/December 1968, l7(6), 545-554.

8. Newman, M. Theory Deuelopment in Nursing. Philadelphia: Davis, 1979.9. Hardy, M. Theories: components, development, evaluation. Nursing Research,

March/April 197 4, 23(2), 100-107.10. Orem, D. Nursing: Concepts of Practice,2d ed. New York: McGraw-Hill, 1980.11. Levine, M. Introduction to Clinical Nursing,2d ed. Philadelphia: Davis, 1973.12. Roy, C. Introduction to Nursing: An Adaptation Model. Englewood Cliffs, N.J.:

Prentice-HalI, 1976.13. Riehl, J. and Roy, C. Conceptual Models for Nursing Practice,2d ed. New

York: Appleton-Century-Crofts, I 980.14. Stevens, B. NursingTheory,: Analysis, Application, Evaluation. Boston: Little,

Brown, 1979.

22 A FRAMEWORK FoR THE PRACTICE oF NURSING ADMINISTRATION

of the individual which occurs by conservation in four areas when adap-tive needs are manifestcd. Roy espouses that nursing is an interpersonilprocess that is initiated by the individual's maladaptation to change inthe environment. The goal of nursing is to assess the adaptation lcveland intervene to promote positive adaptation and integrity.

Like nursing theories and models, management science theories andmodels are commonly used in nursing administration. The nursing ad-ministrator should select the model that is most congruent with his orher own administrative practice. Chapter 3 addresses the major conceptsof administration and management theories applicable to nursing ad-ministrative practice.

STUDY QUESTIONS

1. Formulate a definition of theory.2. What are the major diflerences between an inductive and a deductive

theory?3. List the conditions under which you would use the constant com-

parative theory approach in formulating grounded theory as depictedby Glaser and Strauss. Describe how you would formulate a groundedtheory for a specific hypothetical situation.

4. Explain the rationale for the statement by Dickoff and James thatthe highest level of theory building is situation-producing theory. Whymust nursing theory be at this level?

5. Formulate a definition of model.

6. Given three models for nursing-Orem's, Levine's, and Roy's-selectthe one that would be most applicable to your nursing administrationpractice and explain the rationale for your choice. What are the im-plications for nursing administration in the application of the modelto nursing practice?

REFERE-NCES

1. Chin, P. and Jacob s, M. Theory and N ursing: A Systematic Approach. St. Louis:Mosby, 1983.

2. Hage, F. Techniques and Problems in Theory Construction irz Sociology. NewYork: Wiley, 1972.

3. Glaser, B. and Strauss, A.The Discovery of GroundedTheory. Chicago: Aldine,1967.

4. Simms, L. The grounded theory approach in nursing research. Nursing Re-search, November/December l98l , 20(6), 356-359'

8

9

10

11

12

13

l4

NURSING THEORIES AND MODELS

and, (4) interdependence. Adaptive modes are activated when need ex-

cesses or deficits are created within the individual (p. 14)'

Each adaptive mode is related to underlying needs. For example, the

physiological adaptive mode is related to the need for physiological in-

i"g.ity (e-.g., exercisc and rest, nutrition and elimination, fluid and elec-

trolytes). Adaptation occurs when thc person maintains his or her in-t"gilty through positive response to need deficits or exccsses. The

p"iron', self-c&cept is determined by his or her interactions rvith others.

As external stimuli affect a person, the person adapts according to his

or her self-concept. Role function is the performance of duties relatedto given positions within socicty' The wa1' a person performs thesc dutics

is constantly responsive to outside stimulation. In relation to others, thcpcrson adapts aCcording to a system of interdependcnce, which includes

ih" *uyr an individual seeks help, attention, and affection. Change

r.vithin and outside the person causes changc in the system (13)'

The nurse must be able to consider each client as an individual, as-

sessing his or her needs and acting accordingly. Roy's model encourages

the nurse to utilize and become more proficient in the total assessment

of the patient through observation, interviews, and the performance ofvarioui nursing care activities. An understanding of Roy's four adaptivemodes for responding to change allows the nurse to bring a broad per-

spective to thc planning of nursing care based on individual client needs.

SUMMARY

Barbara Stevens (14) points out that nursing theory takes on significanceonly to the extent that it cxplains and directs nursing practicc. She stales

that nursing practice is largely controlled bv nursing administration.However, thc nursing administrator and his or hcr staff must select a

conceptual modcl or framcwork of nursing that is congruent with thephilosophy, structure, and goals of the nursing department.

A prercquisite lo the implementalion of the model is the revision order'"l,rpm"n1 of guidelines and standards of nursing practice. A formalcducation program to familiarize staff with the model is also cssential.The philosophies and goals of the nursing departmcnt will need to be

r-eexamined to reflect the concepts and tcrminology of the model. A pa-

tient-classification system based on the model will need to be dcveloped.

Nursing is attempting to formulate a thcoretical basis for its practice.Many nursing scholars have advanccd postulates, theorics, and frame-u,orks as a mcans to achieve this goal. Orem focuses on the individual'sself-care needs. Nursing actions are directcd tor'vard enhancing self-careability and therapcutic sclf-care ability ol individuals. While Levineemphasizes the conservation principles ol encrgy, structural integrity,and personal and social integritl'. Thc goal of nursing is the wholeness

2l

14 R pReunwoRr poR THE pn4!rr!q qI_llqBSrNG ApMrNrsrRATroN

qualitative data are drawn from field and documentary sources. Principles un-derlying theoretical or purp<.rsive sampling guide the selection of comparisongroups. . . . The active search for relevant data continues until all critical var-iables and their interrelationships have been saturated and no new relationshipsemerge that suggest more information be collected.

After the conceptual categories and properties are established and interre-lationships cvaluated, thc researcher uses the information to lormulate a thcory.Each element is used to crcate an explanation for the problem or phcnomenaunder study as well as questions for lurther research. The generation of theorvmust bc vierved as a process. Concepts and propositions emerge gradually, andthe ultimate generation of theory is dependent upon the data collected through-out the study (pp. 356-357).

Theory formulation in the discipline of nursing provides a guide forpractice in the discipline of nursing. Some nursing theoreticians use thedeductive process with selected concepts from fields such as sociology,psychology, and physiology. They start with general concepts and usethese as parameters for analyzing specific nursing situations. Othertheoreticians use the inductive approach to theory building in nursing.Wald and Leonard (5) speculate that theorists begin with practicalnursing experience and develop concepts from their inductive analysisof this experience rather than borrowing concepts that they feel will fit.

Dickoff and James (6) describe the relationship of inductive theory topractice. They emphasize that a theory is neither a useless fairytale nora picture of the real. As such, the various kinds of theories can be groupedinto four levels: (1,) factor-isolating theories; (2) factor-relating, or sit-uation-depicting, theories; (3/ situation-relating, or predictive, theories(promoting or inhibiting theories); and (4)situation-producing, or pre-scriptive, theories. In this classification, each higher level presupposesthe existence of theories at the lower level. Dickoff and James (6) statethat "a situation is depicted in terms of factors already isolated; pre-dictive or promoting theories conceive relationships between depictablesituations; and situation-producing theories prescribe in terms of avail-able predictive and promoting theories, and use depicting theories inthe characterization of goal-content" (p. 420).

The factor-isolating ther.rry, or naming, must be considered first becauseall scientific theory begins with the naming of factors. The essentialfunction of naming is to facilitate reference to and communication aboutthe factor associated with the name. This theoretical activity is callcdclassifying or the introduction of technical terminology. To neglect fac-tor-isolating theory is particularly detrimental when a theory is self-consciously being developed for the first time, as in nursing.

After factors are identified, they should be observed in relationships.This level of theory is situation depicting in that it relates the factorsthat have been identilied. Theories that depict or provide conceptionsof intcrrelations among factors, as opposed to among situations, are cor-relations: the joint presence or absence or range of variation between

NURSING THEORIES AND MODELS 15

two factors. Correlations do not imply causation or reference to timesequence; the two factors simply coexist.

In theories classified in the third level, are situation relating. Factorsare related in such a way that predictions can be made, since predictivetheory can state relationships only between such situations as are de-pictable, which is dependent upon what factors have been identified.Causal relationships must show the qualities of priority and directionamong the variables. For example, if A causes B, one must show that Aprecedes B; that when A occurs, so does B; that when A increases, Bincreases; and that when A decreases, B decreases. Therefore, situationsmay be connected causally.

The highest level of theory is situation-producing theory. This levelexceeds predictive theory by stating not only that A causes B but alsohow to bring about A or how to facilitate A's production of B.

Dickoff and James (7) contend that to have impact on practice, nursingtheory must be at the highest level: situation-producing theory. Nursesconfronted with hundreds of situations must have a prescription for ac-

tion. This prescription is made as a result of situation-producing theory.Newman (8) emphasizes that in order for a theory to have direct ap-

plication, it must meet the following criteria:

1. The focus is on the life process of man.

2. The purpose is understanding the patterns of the life processes whichrelate to health.

3. A total elaboration of the theory contains an action component whichfacilitates hcalth.

These criteria are consistent with the current conceptual models ofnursing, which include prescriplivc-level thcory.

MODELS

The relationship belween variables may be depicted by a model. Hardy(9) statcs that an investigator may formalize a theory, identify its pos-tulates, identify or derive its propositions, and then decide that theproblem of relationships is best represented by a model. A model is asimplified representation of a theory, certain complex events, stmctures,or systems. A model is a conceptual representation of a reality situation.

Conceptual models provide a framework that directs the work ofscholars in the formulation of theories. Diffcrences among the variousconceptual models of nursing are apparcnt in terms of emphasis, un-derlying assumptions, definition of health and illness, and designationof the goal of nursing.

16 A FRAMEwoRK FoR THE PRACTICE oF NURSING ADMINISTRATIoN

The following conceptual models and thcories of nursing illustratethese differences. The objective of this discussion is to familiarize thenursing adminislrator with selected nursing models and theories cur-rently being used in nursing practice. It is important that nursing ad-ministrators be knowledgeable about differences in emphasis so thatthey may adapt these models to interface with their philosophy of nurs-ing practice within the context of their organizational (practice) setting.

CONCEPTUAL MODELS AND THEORIESOF NURSING PRACTICE

Orem's Conceptual Framework

Dorothea Orem (10) describes nursing as a response of human groupsto one recurring type of incapacity for action to which human beingsare subject, that is, thc incapacity to care for oncself or onc's dependentswhcn action is limited because of health or health care needs. Fromnursing's perspective, human beings are viewed as needing continuousself-maintenance and self-regulation through a type of action termedself-care.

Self-care is care that is performed by oneself for oneself rvhen one hasreached a state of maturity that enables one to take consistent, effective,and purposeful action (pp. 32-33). Sclf-care involves lhe practice of ac-tivities that people initiate and perform on their own behalf in main-taining life, health, and well-being.

Orem stresses that self-care has purpose. It is action that has patternand sequence whcn it is effectively performed, contributes to humanstructural integrity, human functioning, and human dcvelopment. Thepurposes attained through the kinds of actions callcd self-care are re-ferred to as self-care requisites. Orem describes three types of self-carerequisites:

1. Universal self-care requisites are common to all human beings duringall stages of the life cycle, adjusted to age, developmental state, andenvironmental and other factors. They are associated with lif'e pro-cesses and with the maintenance of the integrity of human structureand functioning.

2. Dcvelopmental self-care requisites are associated with human de-velopmental processes and with conditions and events occurringduring various stages of the life cycle (e.g., prematurity, pregnancy)and events that can adversely affect development.

3. Hcalth-deviation self-carc rcquisites are associatcd v,'ith genctic andc<.rnstilutional delccts and human struclural and funclit-rnal dcviationand with thcir cflccts ancl mcdical diagnosis and treatmcnt (pp. 37-4l).

Management Theories

The purpose of this chapter is to trace the development of the man-agement schools of thought and their application to nursingadministration. On completion of rhis chapter, the reader will beable to:

1. Identify the major premises of the classical, behavioral, andmanagement science schools of administration, or manage-ment.

2. Discuss the contribution of the following people to thcir re-spective schools of management: Taylor, Fayol, the Gilbreths,Mayo, and Barnard.

3. Describe the major differences among the classical, behavioral,and management science schools.

4. Discuss the emergence of the systems approach in the studyof organizations.

5. Differentiate between open and closed systems.6. Critically analyze the contingency management approach.7. Differentiate among theories X, Y , and Z.8. Critically analyze the qualiry circle approach in relation to

participative management.9. Describe and discuss the incorporation into nursing admin-

istration of the concepts of thc management schools, the sys-tcms approach, contingency application, and theory Z.

Nursing administrators must be knowledgeable about administrativetheory from the field of management. The following discussion of themajor schools of administration, or management, theory will familiarizenursing administrators with pertinent concepts and principles in thatfield. This knowledge will enhance the incorporation of specific conceptsinto nursing administrative practice.

Early in this century, the study and lormulation of theorics of modernmanagement began. Over the years, three major schools of administra-tion, or management, theory have developed: the classical school, thebehavioral school, and the management science school. Concepts from

24

MANAGEMENT THIORIE! 25

all these schools have been incorporated into the field of nursing admin-istration.

SCHOOLS OF ADMINISTRATIVE THEORY

Classical School

The classical theory of management emphasizes the functions of a man-ager. The classical writers focus on prescriptive management theory:on how managers should perform their functions. According to thisschool, the function of management is to discover the "one best way"to perform manual tasks. This approach is based on the classical eco-nomic theory that human beings are basically motivated by a desire foreconomic betterment. The classical theorists identify three componentsof the management process: planning, organizing, and controlling. Theclassical school of managernent consists of scientific management, orthe management of 'uvork, and classical organization theory, or the man-agement of organization.

One of the major contributors to the field of scientific managementis Frederick W. Taylor (1), who in 1911 published The Principles of-Sci-entific Managemertr. This work, along with studies conducted before andafter i1s publication, established Taylor as the father of scientific man-agement. In it, he defines guidelines for improving production efficiency.Taylor theorizes that the cause of industrial conflict is the ineflicientuse of scarce resources. Taylor's work concentrates on the worker andthe worker's tasks. It advocates the scientific selection and training ofrvorkers, the coopcration of management and labor to accomplish workobjectives, and a more equal division of responsibility between managersand workers.

Taylor's efforts inspired others to continue his work. Frank and LillianGilbreth conducted time and motion studies. Lillian Gilbreth was anindustrial psychologist who received her doctor's dcgree in that field in1915. She raised a dozen children and was depicted in the book andmovie Cheaper by the Dozen. The Gilbreths directed their efforts towardrvork arrangements, eliminating unnecessary hand and body motions,and designing the proper tools for optimizing work performance. FrankGilbreth emphasized that in applying principles of scientific manage-ment, one must consider the workers and understand their personalitiesand needs. The Gilbrelhs concluded that it is not the monotony of workthat results in worker dissatisfaction but, rather, management's lack ofinterest in workers.

contemporary with the work of Tayior is that of Henri Fayol, of France,

u'ho was .oncerned with principles of organization and the [unctions

28 A FRAMEWORK FOR THE PRACTICE OF NURSING ADMINISTRATION

management theory that prcceded them. Through the work of the be-

havioral scientists, some aspects of the early thcories have bcen modified,whilc others have withstood the test of scientific validation. Whereas

the classical writers overemphasize the technical and structural com-ponents of management, the human relationists overstate the psycho-

social aspects.

Management Science School

The prop<_rnents of the management science school attempt to apply sci-

entific knowledge to the solution of large-scale management problemsin all types of organizations. Management science can be considered an

extension o[ scientific management. The primary emphasis of this school

is on the establishment of normative models of organizational behaviorfor maximizing efficiency. This approach is also referred to as manage-

ment science, Operations research, or decision science and is related toindustrial engineering and mathematical economics.

Although attempts have been madc to distinguish between operationsresearch and management science, it is very difficult to do. Severalwriters emphasize that the lerm nlanagenlent science is broader thanthe tcrm operations research in that it encompasses such fields as math-ematical economics and the behavioral sciences and is also closely re-

lated to the physical sciences and enginecring. Operations research is

operationally oricnted, whilc management science is directed towardthe establishment of a broad theory. There is also a close relationshipbetwcen management science and industrial engineering. Both disci-plines are concerned with the same problems and often use similartcchniques.

Kast and Rosenzweig (5) emphasize thaL, although managemcnl sci-

ence and opcrations research rcpresent a loose conglomeration of in-

terests and approaches, there are key concepts that permeate the field:

1. Emphasis on scientific method

2. Systcmatic approach to problem solving

3. Mathematical model building4. Quantification and utilization of mathematical and statistical pro-

cedures

5. Concern with economic and technical rathcr than psychosocial as-

pects

6. Utilization of computers as tools

7. Emphasis on the systems approach

8. Seeking rational decisi<tns under varying degrecs of uncertainty

9. Orientation toward normativc rathcr than descriptive models (p. 87)

MANAGEMENT THEORIES 29

General Systems Theory

The development of general systems theory has provided a basis for the

understanding and integration of scientific knowledge from a variety ofspecialized fields. Kast and Rosenzweig (5) define a system as "an or-ganized, unitary whole composed of two or more interdependent parts,components, or subsystems and delineated by identifiable boundariesfrom its environment suprasystem" (p. 98). The key concepts of gcneral

systems theory are as follows:

1. A system is more than the sum of its parts; it must be viewed as a

whole.2. Systems can be considered open or closed. A system is considered

open if it exchanges information, energy, or material with itsenvironment; a closed system does not interact with its environ-ment.

3. A system has boundaries that separate it from its environment'

4. Closecl systems are subject to entropy (a tendency to mn down), whichincrcases until thc entirc systcm fails. Open systems that receive in-puts from their environment do not cxperience entropy if these inputs

arc as great as the energv the s.vslems usc plus their outputs. In open

systems, entropy can be arrested or transformed into negative entropy(a process of more complele organization and ability to translormresources) by importing more from the cnvironment than the systems

use and export.5. If an open system is to survive, it must receive enough inputs from

its environment to offset its output plus the energy and materialsused in the operation of the system. When a system achieves such a

balance, it is in a steady state, or a state ol dynamic equilibrium.Thc system remains in dynamic equilibrium through thc inflow ofmaterials, energy, and information.

6. If a system is to achieve a steady state, it must have feedback; in-formation concerning the process of the system is fcd back as inputinto the system.

7. Systems have subsystems and are also part of a suprasystem; theyare hierarchical.

8. Closed systems tend toward entropy and disorganization, whereasopen systems tend toward increased elaboration, differentiation, anda higher level ol organization.

9. Open systems can achieve desircd results (such as the steady state)in various ways by means of a process called equilfinalitlt Somc resultsmay be achieved with different initial conditi<,rns and in differentways.

A FRAMEWORK FOR THE PRACTICE OF NURSING ADMINISTRATION

Organizations should be considered in terms of a general open systemmodel. The internal functioning of an organization must be congruentwith the demands of organizational tasks, technology, external envi-ronment, and the needs of its members if the organization is to be ef-fective.

The view of an organization as an open system suggests a differentand more difficult role for the administrative executive than his or herrole in a closed system. The open system interacts with its environmentand moves toward a steady state while maintaining capacity for workand energy transformation. New management must deal with externaluncertainties and ambiguities and must be flexible in order to adapt tonew and changing requirements. For example, the hospital organizationreceives input from its external environment in the form of personnel,financial and material resources, and information; it transforms outputof health care services and rewards into an organization that is sufficicntto maintain employee participation.

An early systems theorist was Chester Barnard, who in 1938 wroteThe Functions of the Executive, based on his years of experience as pres-ident of the New Jersey Bell Telephone Company. He focuses on thepsychosocial aspects of organization and management. Barnard (6) con-

iid"rr the organization a social system in his definition of a formal or-ganization as a "system of consciously coordinated activities or forces

of t*o or more persons" (p. 73). He defines the functions of the executivein a formal organization as the followinS (1) the maintenance of or-ganizational communication through a scheme of organization coupled

with loyal, responsible, and capable people; (2) the securing of essential

services from individuals in the organization; and (3) the formulationand definition of purpose.

Katz and Kahn (7) conceptualize the role of the executive or manager

as one of a number of organizational subsystems. Such subsystems op-

erate together to meet organizational needs and accomplish necessary

tasks. Katz and Kahn identify maintenance structures that function tomaintain stability and predictability in the organization. The purpose

of such structures is to preserve a steady state of equilibrium. Such

structures may resuit in a tendency toward organizational rigidity, the

preservation of the status quo in absolute terms. Or they may necessitate

mediation between task demands and human needs to keep the struc-tures in operation. Such mechanisms for maintaining stability seek to

formalize, or institutionalize, all aspects of organizational behavior.The boundary structures of procurement of materials and personnel

and product disposal involve transactional exchanges with the envi-ronrlent. These mechanisms concern acquiring control of sources of

supply and creating an organizational image'idaptlu" structure concerns the survival of the organization. Both the

maintenance and adaptive stmctures move in the direction of preser-ving

MANAGEMENT THEORIES 31

constancy and predictability in the conditions of organizational life. Katzand Kahn (7) emphasize that the adaptive function can focus either onattaining control over external forces and maintaining predictability inthe operations of the organization or on achieving internal modificationsof organizational structures to meet the needs of a changing world.

The managerial system cuts across all the operating structures of pro-duction, maintenance, environmental support, and adaptation. Themanagerial system is the controlling, or decision making, aspect of theorganization. Karz and Kahn (7) further state that "the complexity oforganizational structures implies that the functions of management arealso complex. Three basic management functions can be distinguished:ll) the coordination of substructures, (2) the resolution of conflicts be-tween hierarchical levels, and (3) the coordination of external require-ments with organizational resources and needs" (p. 91).

Contingency Management Movement

Investigators who examine the functioning of organizations in relationto the needs of their members and the external forces impinging uponthem emphasize the contingency approach to management. Comparedto the systems approach, contingency views of organizations emphasizemore specific characteristics and patterns of interrelationships amongsubsystems. The contingency, or situational, approach accepts the dy-namics and interrelationships inherent in organizations and in the be-havior of their members. Some theorists make no distinctions betweenopen systems and contingency theory. Others emphasize that the purposeof the contingency approach is to develop specific functional relation-ships between independent environmental and dependent managementvariables.

Robbins (8) points out that the contingency movement began by iden-tifying common characteristics that might exist in a variety of situationsand that could make it possible to qualify a theory to the specifics of asituation. If one cannot say, "If X, then Y," possibly one can say, "If X,then Y, but only under the conditions specified in Z."

Three components of the contingency approach are the environment,management concepts and techniques, and the interrelationships be-tween them. For example, management concepts and techniques maybc classified as process variables, including planning, organizing, di-recting, communicating, and controlling; quanlitative variables, in-cluding decision making, linear programming, and operations researchmodels; behavioral variables, including learning, behavior modification,motivation, and group dynamics; and systems variables, including gen-eral systems theory, systems design, and management information sys-tems. The contingency approach is designed to relate the environmentto these various management concepts and techniques.

MANAGEMENTTHEORIES 35

6. Barnard, C.I. The Functions of the Executive. Cambridge, Mass.: HarvardUniversity Press, 1938.

7. Katz, D. and Kahn, R. The Social Psychology of Organizations. New York:Wiley, 1978.

8. Robbins, S.The Administrative Process,2d ed. Englewood Cliffs, N'J.: Pren-tice-Hall, 1980.

9. McGregor, D. The H uman Side of Enterprlse. New York: McGraw-Hill, 1960.

1 0. Ouchi, W .G . Theory Z. Reading, Mass. : Addison-Wesley , 1982 .

A FRAMEWORK FOR THE PRACTICE OF NURSING ADMINISTRATION

teracting with its environment. The contingency approach to admin-istration emphasizes that there should be a congruence betr.veen the or-ganization and its environment and among its various subsystems.

McGregor's theories X and Y have helped clarify direction for the fieldof organizational behavior toward a more humanitarian approach. Thephilosophy of a theory Z management approach is that the organizationcan significantly benefit from a management style based on trust andon workers'involvement in discussions that affect them and their prod-uct.

It is important to note that recognizing the contributions of the variousschools of management is more important than identifying the type ofschool, its functions, and principles. Many modern management tech-niques are direct outgrowths of these schools'various approaches.

STUDY QUESTIONS

1. What is the major premise of each of the three schools of adminis-tration, or management?

2. Which of Fayol's management principles have influenced nursingadministration? Explain.

3. What are the major differences between an open and a closed system?4. How is the systems approach applicable to management practiccs

in nursing administration?5. What is meant by a contingencv view of organization?6. What assumptions do theory X managers and theory Y managers

make about people?

7. Select a problem in nursing administrative practice that could bereduced or eliminated by utilizing the theory Z management ap-proach, involving the quality circle process.

REFERENCES

1 . Taylor, F .W . The Principles of Scientific Management New York: Harper andBrothers,1911.

2. Fayol, H. General and Induslrial Managemenl. London: Sir Isaac Pitman &Sons, 1949.

3. Filley, A., House, R., and Kerr, S. Managerial Process and OrganizationalBehavior. Glenview, Ill.: Scott, Foresman, 1976.

4. Donnelly, J., Gibson, J., and Ivancevich, J. Fundamentals of Management.Dallas: Business Publications, Inc., 1975.

5. Kast, F. and Rosenzweig, J. Organization and Management: A Systems andContingency Approach,3d ed. New York: McGraw-Hill, 1979.

MAN AEMINI lFrEqREq 33

ues within the organization. Consensual decision making pr<-rvides thedirect benefits of information and value sharing and at the same timcopenly signals the commitment of organizations to those values.

One expression of worker participation in a theory Z managementapproach is the quality circle, or Q circle. The Q circle was developedin Japan as a useful method of achieving high quality, improved pro-ductivity, and increased cmployee morale. Quality circles are disciplinedoperations. It is imperative that the staff be knowledgeable regardingthe concept of theory Z. Quality circle training programs must be a partof the total implementation plan.

A typical Q circle consists of two to ten employees who are assignedto that circle. Each circle's employces form a natural working group inwhich everyone's work is related. Workers meet together regularly toidentify a problem and collect data on the type and nature of that prob-lem. At the conclusion of the study period, members analyze the data,develop and try solutions, and evaluate results. If thcse stcps can beundertaken cntirely by members of the circle, they implemcnt thc stepsto correct it. If the problem is more gencral, then members may call forthe formation of a Q circle team to seek out organization-wide solutions.It is important to note that ultimately a solution is identificd and im-plemented.

Once solutions are implementcd and, often, a designated period oftime has passed, the circle musl evaluate thc outcome. The results arecompare d with the goals to dctermine the extent to which the identifiedproblem was solved. If thc goal has not been achieved, the circle analyzcswhy. The circle then returns to the solution development phase and for-mulates another solution and a plan for implementation. A formal reportof the circle's activities is presentcd to the appropriate group within theorganization. Quality circles have been very effective not only in solvingproblems but also in increasing worker productivity and enhancing jobsatisfaction.

SUMMARY

The classical school of management focuses on the structure of formalorganizations, the process of management, and thc functions of a man-ager. The behavioral school emphasizes human relations and th.r sci-cntific approach to the study of human behavior in organizations. Theactivities of the management science school are characterized by an em-phasis on the mathematical modeling of systems.

Systcm concepts provide the c<-rnceptual framework for understandingorganizations. General systems theory includes concepts related to thcunderstanding and integration of knowledge lrom a variety of disciplines.Svstetn thcorists generally view an organization as an open systcm in-

32 A FRAMEWORK FOR THE PRACTICE OF NURSING ADMINISTRATION

Theory X and Theory Y

Douglas McGregor (9) has written that the vertical division of labor pro-posed by the classical management theorists is based on a set of negativeassumptions many managers have about their employees. He has sug-gested that organizations can achieve their goals more effectively if theyaddress the human needs of organizational members and utilize theirpotential. What McGregor calls theory X is based on traditional auto-cratic assumptions about people, while theory Y is founded on behav-iorally based assumptions about people. Mosl management actions flowdirectly from the particular theory of human behavior managers hold.

Theory X refers to an autocratic approach to managing. It assumesthat most people dislike work and will try to avoid it if possible. Ac-cording to this theory, people have little ambition and avoid rcspon-sibility. They are self-centered, indifferent to organizational needs, andresistant to change.

Theory Y implies a humanistic and supportive approach to the man-agement of people. It assumes that people are not inherently lazy andindolent but that they may become so as a result of experience. Accordingto theory Y, people exercise self-direction and self-control in the serviceof obiectives. They have potential. They have imagination, ingenuity,and creativity that can be applied to work.

McGregor argued that the conventional management approach ig-nored the facts about people because these managers adhere to theoryX and follow an outmoded set of assumptions about their employees.McGregor contends that most people are close to the theory Y set ofassumptions. These managers need to change to a whole new theory ofworking with people: theory Y.

Theory Z

Advocates of theory Z suggest that involved workers are the key to in-creased productivity. With the current interest in Japanese theory Zmanagement, the question arises whether such participatory manage-ment techniques can be adapted to American organizations.

William Ouchi (10) contends that the Japanese quality edge is theresult of a management style based on trust, subtlety, and worker in-volvement. Trust and subtlety (i.e., relationships between peoplc, de-

termining who works best with whom) improve productivity througheffective coordination. The assumption is that if workers' ideas are heard,

the result is a satisfied, motivated, and productive work force. Consensus,

participative decision making, lifetime employment, and a commitmentto organizational goals are facets of this approach.

In a theory Z organization, the participative process is one of themechanisms that provides for the dissemination of information and val-

The Person in the Roleof lNursing Adrninistrator

The purpose of this chapter is to emphasize the person in the roleof nursing administrator by focusing on the importance of thc ad-

ministrator's personal attributes and leadership skills. On com-pletion of this chapter, the reader will be able to:

l. Conceptualize the nursing administrator in professionalpractice as a leader and administrator.

2. Discuss the Maslow and McClusky concepts of self-actuali-zalion and transcendence as they relate to the nursing ad-

ministrator.3. Relate the concept of leadership to excellence in administra-

tion.4. Articulate the key personal attributes of the successful nursing

administrator.5. Describe personal support systems as important coping

mechanisms.6. Support the importance of time management for the effective

administrator.

It is a myth that only those who cannot practice, teach and those who

cannot teach, aclministrate. True administrators are leaders who love

the challenge and hard work of creating a climate in which professional

nursing practice can occur. They are catalysts not only for their own

activitLi but for those of others. Contrary to the beliefs of many nurscs,

the excellent nursing administrator must possess the highcst level of

ability and the greatest personal skills. Such leaders are not bound by

thinking about *hut.unt ot be done. Rather, they see the same puzzles

others see, but they envision different ways of putting them togcther.There is a leaderihip crisis in nursing, a critical shortage at all levels

of nursing administrators with the political, psychological , and social

-u.rug"-"nt skills needed to cope rvith today's changing world (1).

36

38 A FRAMEwoRK FoR rHE PRACTICE oF NUBqIryg A44INI9rB4IIQN

have technical knowledge as well as executive ability. Financial knowl-edge and training in every detail of work were essential skills. Some ofthese early directors may well have been queen bees, but it is unlikelythat they separated themselves from the rest of nursing, since they livedin the hospital they directed and kncw the nursing staff extremely well.

THE NURSING ADMINISTRATOR AS A LEADER

Nursing administrators cannot create a climate for professional practiceunless they are leaders as well as managers. Administration can be car-ried out by nonnurses, but true leadership in a professional practicesetting must be manifested by a nurse with leadership skills. The workof nursing administrators differs from that of other hospital adminis-trators in that nursing involves professionals, or what Drucker (6) calls"knowledge workers." The productivity of knowledge workers requiresthat people be assigned where there is potential for results and not whereknowledge and skill cannot produce results. The utilization of nursingresources according to level of education, experience and, strengths isof critical importance today for all nurses in administrative posts.

There are no known ways of training great leaders, and the preparationof leaders in nursing has become the challenge of this decade for schools

of nursing. Most deans and program directors will claim to be preparingIeaders, but the fact remains that true leaders simply are not emergingfrom nursing graduate programs.

According to Zaleznik(7), managers and leaders differ fundamentallyin their world views, perceptions, and personal characteristics:

1. Attitudes toward goals: managers tend to adapt impersonal attitudestoward goals; leaders adapt a personal and active attitude towardgoals.

2. Conception of work: managers act to limit choices as they seek theaccomplishment of specific tasks through predetermined combina-tions of people and ideas; leaders work to develop fresh approachesto long-standing problems and to open issues for new options.

3. Relation with others: managers prefer to work with people, avoidsolitary activity, and relate to people according to the role they play;leaders are more empathetic and are concerned with what events

and dccisions mcan to participants.

4. Sense of self: managers are once-born personalities and belong to theinstitutional environment; leaders tend to be twice-born personalitiesand separate from their environment; they may work in organizationsbut never belong to them.

THE PERSON IN THE ROLE OF NURSING ADMINISTRATOR 37

Nurses are unprepared or unwilling to assume leadership roles. Women

are not socialized to assume leadership roles, nor do existing nursingprograms really address the need to prepare nursing leaders who are

cffective administrators. Chaska (2) speaks of the nursing profession as

being in a "mist" of conflicting views about professionalism and profes-

sional practicc.The hospital is the primary area of employment for nurses, with sixty-

five percent of all nurscs employed in a hospital setting (3, p.21). Hos-

pitals are big business, and most nursing administrators are not prepared

io function within a complex corporate structure. It may be possible

that much of the burnoul experienced by nurses at all levels is due tcl

the inability of nurses in leadership roles to function in complcx cor-porate structures.

Regardless of the setting for practice-whether hospital, communityhealth agency, or long-term care setting-nursing administrators need

to know how to compete effcctively in a businesslike world. Spitzer (3)

suggests thal nursing administrators necd to:

1. Reverse the tendency toward isolationism and communicate withothers outside of nursing as well as within nursing.

2. Expand tcamwork skills.3. Understand management concepts and organizational goals.

-1. Promote an organizational stn-lcture and environmcnt that encourage

involvement of sfaff nurses at all levels rathcr than the practice ofcreating and maintaining "Queen Bees'" (p.2a)

The prevalence of the queen bee syndrome interferes with the advance-rnent of professional nursing in any instilutional setting.

The quecn bec syndromc has been identified by Halsey (4) as certainantifeminist behaviors of women who successfully secure positions inmanagement and other traditionally male-dominatcd carecr worlds.Queen bees in nursing administration positions are not an advantagero nursing. These individuals have a desire to work independenfly ofurher nurses, iclentify with people oulsidc nursing, align tenaciously withrhe institution, and have little interest in making changes that wouldbenefit nursing. They seek to preserve their own images, demand per-sonal loyalty, and have a strong need to run the entire show at the cx-:ense of other competent women. Thcy are high achievers and excellcntrn their arca of interest, but thcy are not leaders.

Early directors of nursing, called superintcndents, did run the wholeshou, in hospitals but not nccessarily at the expense of other nurses.

Erickson (5) dcscribes the nursing superintendent as the forerunner ofirodern hospital and nursing administrators. These early dircctors wcreresponsiblc for nursing service and education. They werc expectcd to

rHE PERSON IN rHE ROLE oF NURSING ADI\{IN!9rB4IQ& 39

Managers develop through socialization, and leaders develop throughp".ronul mastery. For a leader, self-esteem does not depend solely on

positive attachments and real rewards. Leaders cannot be bought bythe institution. They have visions and dreams that managers may never

see. As nursing seeks to become recognized as a profession, it is increas-

ingly important to have visionaries in leadership roles in order to findnew answers to old unresolved questions.

Who, then, are leaders? Lundberg (8) says that leaders are people who:

l. Know where they are going.

2. Know how to get there.

3. Have courage and persistence.

4. Can be believed.5. Can be trusted not to sell their cause for personal advantage'

6. Make missions important, exciting, and possible'

7. Make subordinates feel that their role in the mission is important.

8. Make others feel capable of performing their role.

Managers, says Drucker (6), are paid to enable people to do the workfor which they are paid. Nursing administrators do not earn their pay

il they do not create a professional practice climate in which nurses can

do their work. Leaders make a difference in the lives of those who workfor them and with them.

MASLOW, MCCLUSKY, AND THE NURSINGADMINISTRATOR

The able nursing administrator is not only self-motivated but is alsoable to create an environment in which others are motivated. To mo-tivate others requires a strong self-concept and a high place on the ladderof Maslow's hierarchy of needs (9). In other words, the able nursing ad-

ministrator is one who has reached the stage of self-actualization.Maslow's theory of motivation can be applied to almost every aspect

of human life, but it has special significance for those who lead andguide others. Maslow's theory provides a basis for the higher needs ofpsychological growth. People are initially motivated by basic physio-logical needs. As those needs are satisfied, the individual moves towardthe level of higher needs and becomes motivated by them. This is theheart of Maslow's theory. klost previous studies assumed that needscould be isolated and stuc,ied separately. Maslow considered the indi-vidual an integrated whole. The identification of needs for grorvth, de-

velopment, and utilization of potential are an important part of self-

4 iB4l4EMB4 FoR rHE PRACTTCE oF NURSTNG ADI4Ar]€JRATTON

FIGURE 4.1 Maslow's hierarchy of needs.

actualization. Maslow has described this need as the "desire to becomemore and more what one is, to become everything that one is capableof becominC" (9).

Figure 4.1 depicts Maslow's hierarchy of needs. Maslow's hierarchyhas been applied to patient needs. It also has significant application forthe nurse as a person. Nursing administrators as nurse persons andleaders of other nurse persons have a special need to reach the level ofself-actualization. Nurse persons are described by Simms and Lindberg(10) as fully functioning individuals who are comfortable with using theself as well as technical skills in professional practice. This impliei theneed for growth and development of the nurse as a person.

Self-actualization is the desire for self-fulfillmcnt, to make actual allone's potentialities. Maslow related potential to the concept of growth,and by growth he meant the constant development of talents, capacities,creativity, wisdom, and character. To play a role satisfactorily, a personmust have a self-concept that fits the role.

More recently, Howard Mcclusky (11) 'f the university of Michigan,

delineated educational necds for oldcr persons ranging from survivalthrough maintenance, to growth and beyond. The Mcclusky conceptualframework is readily adaptable to the growth and development of nurs-ing administrators and provides a companion schema to Maslow's hi-erarchy. within the framework of ranges of necds, Mcclusky proposed

GroMh needs(Being values, metaneeds)

Self-esteemEsteem of others

Love and belongingness

Physiological(Air, water, food, shelter, sleep, sex)

THE PERSON IN THE ROLE OF NURSING ADMINISTRATOR 49

the seeds of a desired change and then rigorously making sure the seeds

grow and multiply.

Creativity

A distinctly human quality, creativity is not any one thing, but containsthe common elements of all creative thought: divergent thinking, flex-ibility, fluency, and originality. Creativity is the highest order of con-ceptualization and problem solving. By definition, to create is to evolvesomething from one's own thought. True innovation must come fromrvithin. Innovating means not succumbing to the fallacy that there isnot enough time to be creative. It comes from a can-do, rather than acan'l-do, philosophy.

Creativity sets the excellent administrator, the tme leader, apart fromthe minimum-level performer. Anyone can be taught the four maximsof management: planning, organizing, implementing, and evaluating.One can learn to memorize the rules of delegation and time managementand still not have anything to delegate or any reason to save time.

The successful nursing administrator is a creative problem solver. Tobe creative, nursing administrators must free themselves from their ownpremature judgment. They must allow themselves time for theorizingand hypothesizing. Many creative people recognize that they give in-termittent attention to problems of interest; that is, they are aware ofincubation periods when much subconscious activity may be occurring.It is important, therefore, to develop an increased awareness of theproblems to which one would like to direct attention. Functioning cre-atively, one can combine intuition and scientific principles to achievesuperlative problem solving. Such functioning is the highest level ofprofessional skill. Creativity is truly the art of seeing what everyone elseis seeing but thinking what no one else has thoughr.

The essential problem for teachers of the professions is the difficultyof providing a transition from academic experience to work experience.Many educators struggle over how to teach administrators the qualitiesof a leader. Epstein (25) discusses the "missing factor" in the teaching:leadership skills and the need for leadership are packaged together forstudents without the opportunity to make creative inferences. The com-petency-based movement in education threatens to shroud further thedevelopment of creative leaders. There is a difference between compe-tence and the full functioning of excellence in the practice of adminis-tration.

The excellent nursing administrator is a leader who is creative. Crea-tivity can be recognized only if it is observable by others. The outcomesof creativity are recognized in the results of one's labors either as ac-complished, recognizable feats or as changed behavior of fellow workers.

The creative leader is in fact an effective teacher, one who influences

48 a pnanteWg-B4 tqBl4! JBaAIIcE oF NURSING ADMINIWIo-N

modalities ranging lrom integraged charlrnB to lrue co\aborative care

planning and implementation. Nursing administrators must listen toutt th" aiguments against joint practice and still persevere toward es-

tablishinf a feasiblelnstitutional or unit model. They must be prepared

to face ttre wrath of nurses and physicians alike who are unwilling to

collaborate in a pr<.lfessional, meaninful way'Nursing administrators must be willing to meet one to one, in small

groups oii.r lurg" groups-whatcvcr it takes to nurture discussion and

ia"triify opposition. All,owing one's ideas to bc thoroughly challenged

u.rd q.r"rtioned enables one to verify thosc ideas and to remain in one's

goal without becoming known as a stubborn tyrant. Stubbornness is

iot to be confused with courage, for stubbornness implies a closed mind,

one that is not willing to test out new ideas'It takes courage to work in the midst of negative criticism. It takes

courage to meeiwith opponents and try to achieve a meeting 'f the

minds. It also takes courage to face the opposition and maintain presence

of mind and dignity without becoming pompous or resorting to shallow

thinking. It tafes .or.ug" to swim daily with the sharks as well as the

friendly-dolphins. It takes courage to maintain composure and not show

orr.,, *o.rnds, though some may be deep. Above all, it takes courage to

remain clry eyed even when angered to frustration and tears (24).

Conviction

A conviction is a strong persuasion and belief, an opinion held withcomplete assurance d"rpii" opposing arguments, a belief stronger than

an impression and less slrong than positive knowledgc. Onc cannot have

.o.rr.g" without convictions, and one cannot have convictions withoutstronf inner discipline and high ideals. one who has conviclion about

.rursiig icleals is willing to attempt to convert others to the same way

of thin"king ancl to "rtublith

goals that are meaningful to nursing and

the institution.With conviction comes the ability to communicate one's opinion. Not

only does one have an opinion, but one is also able to communicatc that

opinion orally and in writing. A lot is written about communication in

the nursing lite.ut.rr", but little is written about having something to

communiclate. The nursing administrator must communicate from a

base of knowledge an<l experience that reflects understanding of thc is-

sues under discussion.The nursing administrator with conviction is a nagger, one who kecps

needling away at others in orcler to move toward goals of worth: when

others b"elieve-an idea has been dropped, they soon realize they are being

bombar4ed from another quartei. Administrators with courage and

conviction bring about change and desired internalization of ideas in

others without ftrce. Rather, they bring about such results by planting

46 A FRAMEWORK FOR THE PRACTICE OF NURSING ADMINISTRATION

3. Position power: the degree to which the leader has influence overpower variables

The basic premise of Fiedler's theory is that the performance of a groupis contingent upon the style of the leader and how favorable the situationis for the leader. Robert House (18), of the University of Toronto, hasproposed a contingency path-goal model of leadership that integratesthe expectancy model of motivation with the structure and considerationresearch developed by Kahn and Katz (15). The model describes theleader as being responsible for "increasing the number and kinds ofpersonal payoffs to the subordinates for work-goal attainment and mak-ing paths to these payoffs easier to travel" (19). The path-goal modelproposes that the scope of the job and the characteristics of the sub-ordinates moderate the relationship between a leader's behavior andsubordinates' performance and satisfaction.

In applying path-goal theory to nursing, the leader uses skills in struc-turing and consideration to increase worker motivation (20). The leaderinitiates structure by defining his or her own role and the roles of sub-ordinates toward goal achievemcnt. Voluntcers need a high level of di-rection, staff nurses less, and clinical nurse specialists very Iittle. Theleadership skill lies in knowing how to balance structure and consid-eration with the particular situation.

All nursing administrators should be leaders; if they are not, theyshould develop the capability or bc replaced. The morale and motivationof staff nurses are highly dependent on the leadership skills of the nursingadministrator and on the work climate.

PERSONAL ATTRIBUTES OF SUCCESSFULNURSING ADMINISTRATORS

Donna Diers (2 1) aptly discusses the personal attributes of successfulnursing administrators as the softer aspects of leadership-those char-acteristics that do not fall conveniently into boxes in a diagram. Theyare intangible traits that are not easily researched, for example:

. Vision

. Political skills' Creativity' Charisma' Knowledge of other peoples' motivations and pressures' Ability to read the dynamics of a situation

It is not enough to be able to plan, organize, set goals, and achieve goals.One must be able to dream-to envision the future. Says Diers, "A vision

44 _A IB4MEtyo R4 teB ryr p lBA,cUc E- Al xlBAry Al D_Iq N I s TB4rtq\

Rcsearch efforts to isolate traits have resulted in inconsistent conclu-sions. Thc major central idea that has emerged is that intelligcnce, ex-troversion, sclf-assurance, and empathy tend to be relatcd to achievingand maintaining a leadership position. Moloney (13) suggcsts that lead-ership stylc traits can be identified, however. Although requisitc traitsare inconsistent, the following leadership styles can be observed inpractice:

1. Autocratic leader: dcmonslrates aggressive dominance; commandsand expects others to follow.

2. Participative leader: includes followers in decision making; assumesfollowers can be motivated to self-direction, self-actualization, andcreative performance.

3. Laissez-faire leader: permits group mcmbers to have freedom tofunction and set goals indepcndently of the leader.

4. Instrumental leader: exhibits rational rathcr than supportive behav-ior; plans, directs, organizcs, controls, and coordinates the activitieso[ followers.

5. "Great man" leader: behavior based on the belief that people canlearn leadership from studying the examples of the lives of great men.(pp.21-35)

The two most popular behavioral studies to date have been conductedby Kcrr and others (14) ar Ohio State University and Kahn and Katz(15) at the University of Michigan. These studies identified two dimen-sions of leadcrship behavior: (,1) initiating structure and (2) consider-ation. Initiating structure rcfers to the extent to rvhich a leader defincsand structures his or her role and those of subordinatcs. Considerationrclers to thc interpersonal relationships variable. Blake, Mouton, andTapper (16) addressed two concerns: (7) production of rcsults and (2)

concern for personnel as persons. None of the three approaches addresscdthe social situations in rvhich leaders must act.

For example, the social situation varies according to the characteristicsol the group, the nature of group tasks, and lhc particular circumstanccsrelcvant to a given leadership position. Hcrshcy and Blanchard cited inMoloney (13) have studied the rclationship of thc psychological, or per-son, dimension to the sociological, or rolc, dimension in specific situ-ations. Thcir work has added to the lcadership literature in terms ofsclf-understanding, group tasks, the concept of group bchavior, indi-vidual behavior within a group, and the importance <-rf interpersonalrelationships within a given situation.

The work of Blake, Mouton, and Tapper (16) is particularlv useful fornursing administrators as they attempt to understand and develop theirown lcadership style and ability t<-r'uvork with groups in a given situation.

THE PERSON IN THE ROLE !4IURSING ADMINISTRU 43

enhance the nursing administrator's power base and ability to influenceothers. McClusky's category 5, the nced for transcendence, matches Mas-low's level of self-actualization. Although McClusky envisioned tran-scendence as uniquely relevant to the later years, it is also pertinent tothe nursing administrator who must move beyond self in motivatingothers. One rarely reaches this level carly in life. By definition, achievingthe highest level of one's existence is a feature of the later years.

Figure 4.3 depicts an adaptation of the McClusky hierarchy of edu-cation in terms of the developing administrator. A great educator, How-ard McClusky believed that education is not an option but, rather, anindispensable means of existence. For the fully functioning professionalperson, lifelong learning is mandatory.

Many nurses rebel at the possibility of becoming an administrator.They are bound up in the care functions and feel that unless they per-sonally deliver hands-on care, they have somehow abandoned theprofession. They fail to see that influencing others to deliver qualitycare can have greater impact on the quality of care than any individualeffort could.

What, then, is the able administrator like? What characterizes theRuth Freemans, the Lillian Walds, the Florence Nightingales? To beginrvith, they all conveyed a sense of togetherness-wholeness, confidence,u'isdom. They were teachers, rational thinkers, dreamers, and inde-pendents. They did not seek to emulate others' leadership styles. Theyhad their own. In true Maslovian fashion, they moved up the ladder tostrong self-concept and self-actualization. They were the sum total oftheir individual lives, educations, genes, and experiences. Nursing ad-ministrators should be leaders; if they are not leaders, they should notadministrate.

LEADERSHIP STYLES AND EXCELLENCEIN ADMINISTRATION

The leadership literature is voluminous, and yet no theorist has beenable to fully describe the "perfect 10," the effective leader- administratorri'ho is a self-actualized person who can lead common people to do un-common things in a productive fashion. Robbins (12) discusses threebasic approaches to explaining effective leaders:

t. Trait studies are designed to find universal personality traits thatleaders have to a greater degree than nonleaders.Behavioral research is undertaken to explain leadership in terms ofbehavior.

1

3. Contingency models are constructed to explain situational variablesas well as leadership traits and behavior.

42 a pRRnpwoRr poR_T4E pB4eTIqEeIIrrBSING,Aqtvt1NIqIB4rfqN__

ranging from coping needs to transcendence. The first level, coping needs,refers to the need for basic education for survival and self-sufficiency.The second category, expressive needs, is based on the premise that peoplehave a need to engage in activities for the sake of the activity itself. Thehuman personality is capable of a wide range of expression beyond ha-bitual routines. Talents and interests flower if properly cultivated.

Category 3, contributive needs, refers to the assumption that all peoplehave a need to give to others and society, a desire to bc of service. 1n-

fluence needs comprise category 4. Pcople need to exert influence on thecircumstances of living and the world about them. Applied to nursing,the right kind of education and utilization of experience can greatly

HIGH SELF.ESTEEMRegard for needs of othersAble to follow others as well as to leadNot threatened by competitionRisk taker

OWN LEADERSHIP STYLEBuilds on own uniquenessEstablished lifelong learning patternMotivates othersTop management

SELF-ESTEEMRecognizes self as administratorAdditional education and specific interestsAnchors and personal supports

LOVE AND BELONGINGNESSComfortable in clinical worldMiddle managementHead nurse and nursing director roles

SAFETYBeginning work experienceFew if any risksComfort with clinical knowledge

AND SECURITY

Basic educationBeginning adaptation 10

PHYSIOLOGICAL

professional career

FIGURE 4.3 The developing administrator

THE PERSON IN THE ROLE OF NURSING ADMINISTRATOR 41

a theory of margin. According to this theory, people are constantly en-

gaged in a struggle to maintain a margin of energy and power.Margin is a function of the relationship of load to power. Load refers

to the self and the social demands a person must meet in order to main-tain a minimal level of autonomy. Power is made up of the resources,

abilities, possessions, positions, allies, and so on, that a person can com-mand to cope with load. Margin can bc increased by reducing load orincreasing power. Margin can be decreased by increasing load or re-ducing power.

The crucial element in this scheme is the surplus, or margin of powerin excess of load. This margin confers autonomy on individuals, gives

them an opportunity to exercise a range of options, and enables themto achieve growth and development. A major force in the achievementof this outcome is education that will assist in creating margins of powerfor the maintenance of well-being and continuing growth toward self-

fulfillment.Figure 4.2 demonstrates the scope of needs in McClusky's hierarchy,

TRANSCENDENCE NEEDSSelf actualizationComprehensive, individualized learning

INFLUENCE NEEDSCivic and political organizationEducation for leadership, community action and problem solving

Physical educationLiberal educationHobbies and personal

Physical well-beingSocial adiustmentPsychological health

FIGURE 4.2 CategoriesGrabowski and Mason,Ciearinghouse, 1.97 4.)

Societal contributionIn-service leadershipCommunitv awareness

CONTRIBUTIVE NEEDS

EXPRESSIVE NEE,DS

interests

COPING NEEDS

of educational needs. (Adaptededs., Education for the Aging.

from H. McClusky, inSyracuse, N.Y.: ERIC

High 9

8

l

2

Low 1

THE PERSON IN THE ROLE OF NURSING ADMINISTRATQR 45

1,9I am the staff members'

friend and will do anYthingso that they will like me.

tttttlllloo

I consult with staff membersto work on mutual goals. TheY

understand their role andresponsibilities, and thereis mutual Problem solving.

5,5I am a middle-of-the-roader

nurse and avoid controversy or

taking sides. The hosPital'srules and regulations Provideguidelines for mY suPervision

1,1The hospital Provides me

with a job, which is allI ask. I have little

concern for staff services.

9,1I expect staff membersto do what I think theY

ought to do.

t23456789Concern for hosPrtal services Hieh

FIGURE 4.4 The nurse administrator grid. (From R.R. Blake, J.S. Mouton, and\1. Tapper, Gricl Approaches for Managerial Leadership in Nursing. st. Louis:,\Iosby, O 1981, p. 2.)

Figure 4.4 clepicts 81 positions categorizing the relationship between

the nurse manager and the nursing staff. Position 9.9 is considered ex-

cellence and connotes an administrator who is moving to the ultimatein mature, meaninglul relationships.

Later leadership work produced the contingency models, with (1) theautocratic-democratic continuum, (2) the Fiedler, a1'd (3)the path-goalmodels becoming the best known (12). The autocratic-democratic modeldepicts two extreme positions on either end of a continuum, with manypositions between. The contingency approach suggests that neither thedemocratic nor the autocratic extreme is effective in all situations.

Thc Fiedler (17) model suggests three contingency dimensions:

1. Leader-member relations: how well liked, respected, and trusted theleader is

2. Task structurc: the procedural nature of job assignments

6

N

o

oocoO

THE PERSON IN THE ROLE OF NURSING ADMINISTRATOR 47

serves as an energy source, a star to guide us, a hook on which to hangdreams of glory. Goals, on the other hand, are achievable end points,termini to measure progress. A good vision will outlive any leader; itgives one a legacy" (p.7).

Often people in leadership roles get so involved with their work thatthey never step back to see if they are on target. They do not take thetime to assess their personal and professional goals or their strengthsand weaknesses. Moon (22) suggests that professional nursing admin-istrators must pursue excellence in themselves in order to improve thequality of life in their institutions. This means developing and main-taining their knowledge base, keeping up to date, sharing knowledgervith colleagues, and taking time to "smell the flowers."

Successful administrators in nursing must have goals and dreams andideas and a love of their work. Benjamin Mays (23), at the 1980 WhiteHouse Conference on Aging, expressed his views on professional admin-istration in the following statement:

It must be borne in mind that the tragedy in life doesn't lie in not reaching yourgoal. The tragedy lies in having no goal to reach. It isn't a calamity to die withdreams unfulfilled, but it is a calamity not to dream. It is not a disaster to beunable to capture y<,rur ideal, but it is a disaster to have no ideal to capture. Itis not a disgrace not to reach the stars, but it is a disgrace to have no stars toreach for. Not failure, but Iow aim, is sin. (p. 7)

Of the possible personal attributes that nursing administrators need,courage, conviction, and creativity are the most important. One's sur-lival as a nursing administrator depends on these three attributes.

Courage

A nursing administrator with courage has the mental or moral strengthto venture, persevere, and withstand danger, fear, or difficulty. Courageimplies a firmness of mind and will in the face of difficulty and a de-termination to achieve one's ends. Courage is synonomous with mettle,spirit, resolution, and tenacity.

One may not ordinarily think of the nursing administrator as cou-rageous, but he or she assuredly needs to be. It takes courage to makechanges that need to be made even though those changes are unpopularand little appreciated. It is very risky to move into uncharted water.For example, establishing a unification model between nursing serviceand nursing education in an environment of alienation and distrust canbe very stressful. The nursing administrator attempting to establish sucha model must be prepared to withstand personal and professional crit-icism, Many barriers must be broken down and many friendships es-rablished before the two groups can collaborate within a total nursingcommunity.

Courage may also be required to establish meaningful joint practice

51

rl releasing the energy accompaning excessive tension' A sense of humor

is both a ierror-ral aliribute incl a personal supporr system. Humor is

;p;;;rfj weapon rhat can help esiablish trust and fellowship at work,

.rt home, and in group interaiions' Jackson (29) proposes the use of

humor as a deliberate nursing technique. "Laughing with someone en-

lrtlcls him/her within a network of human love, understanding, and sup-

rort [p. \))l'The phenomenon of burnout deserves special attention and is more

:ully addressed in Chapter 20. Burnout is not unique to administrators,'rut they are prime victims of what is known to the military as battleati-sue. Maslach (30) aptly descrjbes burnout as a "syndrome of emo--,rona\ exhauslion and cynicism that frequent\y occurs among people',i ho do "people" work-who spend considerable time in close encoun-iers." Nursing administrators need to recognize that burnout can happenio them and their staff and that steps need to be taken to mitigate itslccurrence. Personal support systems become extremely important inproviding channels through which individuals can tune off from their,,vork role and its demands. Female nursing administrators especiallyneed to see their families as support systems rather than handicaps. Too.rften, children of working women are perceived as interferences with:roductivity rather than as assets.

TIME AND CHANCE

The self-actualized, fully functioning nursing administrator has mastered:ime management, for time management is really self-management.\lcCarthy (31) emphasizes that one cannot really manage time. To bea good self-manager, one must have a positive professional self-image.nd enough initiative to change oneself. McCarthy states that there are--r'e degrees of initiative, ranging from waiting to be told what to do toecting on one's own.

In order to determine personal and career goals, one must conduct a

-ormal time analysis. Douglass and Douglass (26) suggest that most peo-:le have about two hours a day to do various personal things. Theyjuggest that administrators should determine how they currently spend:heir time in eight broad areas and then decide how they would like tosoend their time. Douglass and Douglass propose that the things people,, alue most can be divided into these eight categories: career, family,social life, financial stability, health, personal development, spiritual:evelopment, and leisure. To achieve a satisfying, fulfilling life, one most;ontrol one's life and decide how one will spend one's time in these.rreas.

The focus of this chapter has been the person. Within that conceptualiramework, time can be seen as a personal resource that enhances one's

52 A FRAMEWORK FOR THE PRACTICE OF NURSING ADMINISTRATION

power to cope with the demand, or load, of one's job. As discussed earlyin this chapter, the surplus of power-the margin-enables individualsto be autonomous. Time is perhaps the single resource over which theindividual can maintain a large degree of control. Powerless adminis-trators are "can't" people, "never have enough time" people' Lack oftime is an excuse for all manner of uncompleted tasks.

The fully functioning nurse administrator maintains a margin of power

and energy through time management and timing. Time and chance are

linked, and time is perceived as opportunity. In administration, one has

seconds, minutes, days, seasons, and years to accomplish one's goals.

Many conferences are held and many books have been written abouttime management. None provides a formula that works unless the in-dividual sees time as an energ\t and power resource'

SUMMARY

Personal attributes and leadership skills are cr-ucial to the role of nursing

administrator. Personal attributes, personal support systems, andlearned administrative behaviors combine with management skills toproduce a competent leader-administrator. Knowing one's strengths and

weaknesses, building on one's educational and work experiences, and

the uniqueness of one's life experiences and leadership capabilities are

essential components of a satisfying, rewarding experience in admin-istration. The work of Maslow and McClusky in developmental psy-

chology is a useful conceptual framework for the development of the

self-actualized, transcended leader-administrator capable of creating a

climate of motivation and productivity for others.

STUDY QUESTIONS

1. Identify two nurse executives and describe their lcadership and ad-

ministrativc styles.

2. Explore Maslow's concept of self-actualization and Mcclusky's con-

cept of transcendence in terms of your own development. Where do

you perceive yourself on the laddcr?

3. Relate the concepts of courage, conviction, and crcativity to a situ-ation in nursing administration. To what extent does 1,our personal

administrative style influence the operationalization of these con-

cepts?

4. Compare leadcrship and administration r.vithin a nursing framework.Relate the concept of leadership to excellence in administration.

6.

THE PERSON IN THE ROLE OF NURSING ADMINISTRATOR 53

5. Describe the structure, consideration, and situational variables inleadership research.Discuss the concept of personal support systems as it applies to you.

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