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Walk the Talk: Promoting Control of Nursing Practice and a Patient-Centered Culture

2009; American Association of Critical-Care Nurses; Volume: 29; Issue: 3 Linguagem: Inglês

10.4037/ccn2009586

1940-8250

Marlene Kramer, Claudia Schmalenberg, Patricia Maguire, Barbara B. Brewer, Rebecca Burke, Linda Chmielewski, Karen Cox, Janice Kishner, Mary Krugman, Diana Meeks-Sjostrom, Mary Waldo,

Healthcare Quality and Management

How clinical nurses can operationalize the walk aspect of the talk, the values and beliefs inherent in control of nursing practice and a patient-centered culture.To "walk the talk"—putting values into action, leading by example, practicing what you preach—is a best practice related to 2 of the 8 attributes or work processes identified by staff nurses as essential to a healthy work environment. These 2 attributes, control of nursing practice and a culture in which concern for the patient is paramount, are the focus of this article. Another commonality of these 2 essential attributes is that they are the only 2 of the 8 that have as many departmental/hospital-wide implications as they do unit-focused implications. Nurses cannot control practice or engage in activities related to a patient-centered culture at the unit level unless parallel sanction and endorsement for these activities exist at the organizational level. After clarifying and illustrating the walk-the-talk metaphor and the constructs control of nursing practice and shared governance, we present the results of research that pertain to control of nursing practice and a patient-centered culture. We then suggest ways in which clinical nurses can operationalize the walk aspect of the talk, the values and beliefs inherent in control of nursing practice and a patient-centered culture.The cultural metaphor walk the talk is not new, but its use in both popular and professional literature and in everyday colloquial usage is increasing.1,2 In the study that provided the data for this article, the term was freely used by all—staff nurses, managers, physicians, and other professionals—in all hospitals and in all regions of the United States. It was used in conjunction with 3 of the 8 essentials of a healthy work environment: nurse manager support, control of nursing practice, and a patient-centered culture. The following 2 examples illustrate use of this metaphor with respect to a patient-centered culture and control of nursing practice. The first excerpt from a 2001 staff nurse interview3 illustrates the metaphor with respect to culture.The second example illustrates use of the walk-the-talk metaphor in the control of nursing practice. One of the study hospitals that had been invited to participate in the structure-identification studies declined because of a busy schedule of upcoming activities. A week after the invitation was declined, the investigator was informed that the administrative group had been hasty in their decision and that the request was being sent to the shared governance research council for disposition. The council contacted the investigators, sought additional information, endorsed the study, and expedited the institutional review board's review process. The chief nursing executive explained that the council structure was still relatively new and that nurses and administrators were still learning how to make decisions together, how to walk the talk and "practice what we preach."4In the spring and summer of 2006, we conducted a nationwide study4–7 in 8 strategically selected magnet hospitals. The purpose of the study was to ascertain the organizational structures and leadership practices that staff nurses identify as necessary for a healthy work environment, specifically, structures and practices that promote control of nursing practice and a patient-centered culture. To achieve this purpose, we needed to elicit the answers from staff nurses working in patient-centered cultural environments with confirmed control of nursing practice. The Essentials of Magnetism (EOM),8–10 a tool used to measure the extent to which staff nurses confirm that they have healthy work environments, has subscales to measure control of nursing practice and patient-centered culture as well as the other 6 essentials. It has been administered to staff nurses in hundreds of hospitals, mostly magnet hospitals, since its development in 2003. The results of these EOM evaluations were used to select the hospital sample for this study.We selected the 8 magnet hospitals, according to the 8 census-tract regions of the United States, that had the highest or second-highest EOM scores. To obtain the interview sample, we selected the clinical units with the highest EOM scores within each hospital. The "experts" that we interviewed on these units consisted of 244 staff nurses nominated by their peers and managers, 105 nurse managers, and 97 physicians nominated by staff nurses or managers. The number of staff nurses interviewed varied by the size of the unit but usually consisted of 2 or 3 staff nurses, 1 nurse manager, and 1 physician per unit. We interviewed the chief operating officer, the chief nursing officer, and 4 to 6 representatives from professional departments such as respiratory therapy, physical therapy, dietary, and pharmacy in each hospital to obtain the perspectives of these personnel of the nursing department and the degree of interdepartmental collaboration. We also conducted "participant-observation," a qualitative research technique,11,12 in all central and unit council meetings during the 4-day on-site visit.The American Nurses Credentialing Center, which governs magnet designation, refers to control of nursing practice as "shared" or "unit-based" decision making related to an environment in which administrators use a participative management style.13 The Institute of Medicine,14 in the institute's delineation of 5 evidence-based management practices needed for a healthy work environment, define it as "involving workers in decision making pertaining to work design and work flow." Staff nurses in magnet hospitals define control of nursing practice as a work process through which nurses at all levels in the organization have input and make decisions on issues of importance that affect nurses, the context of nursing practice at unit, departmental, and hospital levels, and the quality of patient care provided.15 The input includes access to power and exchange of information, views, and judgments; the decision making is interdependent and shared; and the issues of importance include practices, standards, policies, and selection of equipment.Nurses wrote of control of nursing practice as follows:Staff nurses in both the United States15,16 and Canada,17 now4,18,19 and in the past,20 concur with well-established precepts of a profession in distinguishing between clinical autonomy and control of nursing practice. Clinical autonomy is individual, patient-centered decision making with the patient as the primary and often sole beneficiary. In much of the nursing literature,18,19 clinical autonomy and control of nursing practice are combined, referred to simply as decision making, and are discussed as though they were the same attribute. The American Association of Critical-Care Nurses standards for maintaining and sustaining a healthy work environment21 group the 2 dimensions of autonomy under a single standard, effective decision making, but particularly note the principle of unique and combined spheres of practice that is so critical in selecting the appropriate type of decision making: independent or interdependent. Control of practice, articulated by Flexner22 almost 100 years ago in his characteristics of a profession, is the self-regulation and self-determination of professional issues, practices, and standards by professionals. The following excerpt from an interview with a staff nurse illustrates the application of this definition to nursing. (All excerpts in this article are from interviews with staff nurses unless noted otherwise. NM indicates excerpts from interviews with nurse managers; MD, excerpts from interviews with physicians.)As in any form of self-regulation or self-determination, a structure is needed to facilitate smooth and accountable operation. In nursing, control of nursing practice is operationalized through shared governance or similar structures. Born on the heels of the participative management and decentralization themes of the early 1980s, shared governance is a nursing management innovation that legitimizes nurses' control of nursing practice while extending the influence (input and decision making) of nurses at all levels, to administrative areas previously controlled by management.23 Shared governance is a structural configuration of councils and committees that provide formal mechanisms that ensure nurses' responsibility, right, and power to make decisions and to control nursing practice.Whether termed shared leadership, clinical governance, collaborative governance, shared decision making, or simply the nursing council, the structure alone will not "bake the cake." The structure must be accompanied by best management practices that make shared governance possible through implementation of principles such as partnership, ownership, accountability, and equity.4 Investigators and experts have noted or empirically shown that shared governance structures that are not practical and are not accompanied by best management practices will not enable nurses to control practice. Laschinger and Wong24 state that "most shared governance efforts are seen by staff as chiefly structural, with staff nurses on councils and committees but without the authority to have significant control over professional practice, thus leading to cynicism and unwillingness to assume accountability for client outcomes." Cynicism, unwillingness to be accountable, and lack of decision making were also reported in a nationwide survey25 of staff nurses working in hospitals that supposedly had shared governance systems in place.Although shared governance is not identified as a force of magnetism or listed as a source of evidence,26 it is commonly understood that shared governance or a similar structure is required for designation as a magnet hospital. However, staff nurses in some magnet hospitals did not confirm the existence of workable shared governance structures. In 3 of 34 magnet hospitals participating in 2 different studies,8,10 staff nurses reported that shared governance structures were not viable and workable and did not enable the nurses to control nursing practice. So, the question becomes as follows: What makes shared governance structures viable and what best practices make shared governance structures effective in enabling nurses to control nursing practice? Those are the questions we posed to the 500 experts we interviewed in the study reported here.The experts interviewed identified 2 structures, shared governance and career ladders, and 5 practices that enabled nurses to control nursing practice within the organization.Many shared governance formats, varieties, and names were described. Most of the structures were labeled something other than shared governance. The structures followed different models4,23; the councilor model was by far the one most frequently used. Councils were usually organized according to different functions, such as practice, quality improvement, research, evidence-based practice, education, and informatics. In some hospitals, the councils were organized according to professional role, such as staff nurse, charge nurse, nurse manager, educator, and advanced practice nurse.In smaller organizations, functions were grouped into fewer types of councils, and not all central councils were replicated at the unit level. Compared with smaller organizations, larger hospitals had more councils, sometimes with a double focus such as charge nurse practice council or staff nurse evidence-based practice council, and central councils were more often replicated at the unit level.Career ladder programs, specifically the criteria delineating participation and/or leadership in council activities were frequently cited as enabling and promoting nurses' control of practice. Movement through the steps of the career ladder was usually associated with salary increases or bonuses. Although important and much appreciated, increases in salary and bonuses were not the only or necessarily the chief motivating factors for participation in control of nursing practice, but they were a facilitator. Many nurses stated that they participated in a career ladder program because they had a professional responsibility to do so.The 5 best practices that promoted control of nursing practice were specific behaviors demonstrating the walk aspect of walk the talk—managers' and leaders' actions that made shared governance structures workable, thus facilitating nurses' control of nursing practice. Nurses in one hospital described walk the talk as follows:In the literature, providing access to power is usually referred to as "empowerment." The experts described it as "leaders and managers who made you feel that you had something to contribute and that you had the power to make decisions that affect nursing practice, and that you were not only allowed to use that power, but were expected to do so." Shared governance structures "that worked" were perceived as a source of formal power.Shared governance structures and control of nursing practice are about authority, power, and influence. Staff nurse interviewees did not appear to be afraid of or shy away from the concept of power. They had clearly adopted the newer meaning of this word. Rather than power meaning "to impose your will upon another," power is the capacity to cause change, influence events, initiate action, and control outcomes.4,27 Traditionally, power was conceptualized as a fixed mass, a finite quality; if one person had power, someone else had lost it. Power was described this way by a speaker at the September 2006 magnet hospital conference in Denver. A newer concept and one used in all 8 hospitals, is that power is infinite; power has an exponential quality that can be released, distributed, and shared to the mutual benefit and growth of all involved.28 A staff nurse remarked as follows:On the basis of research by Laschinger and Wong,24 we anticipated that "access to power" would be a possible indication of viable shared governance structures. Thus, we tested all staff nurses (not just those on the units with high EOM scores) in the 8-hospital sample by using the Conditions of Work Effectiveness Questionnaire II, a tool used to measure the extent to which nurses perceive that they are empowered. In this tool, empowerment is defined as access to power. The tool is used to measure 4 specific lines of power—information, opportunity, support, and resources—and access to both formal and informal power. Staff nurses in these 8 magnet hospitals scored quite high in empowerment, higher than any other sample of staff nurses reported in the literature and within a percentage point of nurses in advanced practice positions.29Information, opportunities, and support were the chief sources of power. The chief source of informal power in the majority of the 8 hospitals was the opportunity and expectation that staff nurses would collaborate with physicians and other professionals in events such as regularly scheduled interdisciplinary patient care rounds.30,31 The interdependent decision-making characteristic of these kinds of rounds had the force and power of all participating professional disciplines.4Another source of informal power was an "integrated" shared governance model rather than the usual "silo" model (ie, shared governance structures housed in and operated out of individual departments).32 Integrated models in which the shared governance structure was housed in the hospital, not in any single department, were described by interviewees in 3 of the 8 hospitals. Compared with nurses in the other hospitals, nurses in these 3 hospitals had significantly higher empowerment scores, particularly with respect to the informal power generated through collaborative interactions with colleagues as noted earlier. The integrated model was also reported as being far more efficient than the silo model: "When all disciplines are represented in council, you can discuss the impact and implications and make decisions without having to go back and check with each separate department.""Time and opportunity to participate" and '"individual differences in contributions" were 2 of the major factors cited by interviewees that will "make or break" the viability and workability of a shared governance structure and the effectiveness of the structure in enabling control of nursing practice. The first factor, time and opportunity to participate, is largely a best management practice issue of having enough staff members so that nurses can get off the unit to attend meetings and paid time off to attend when day-long meetings are held. The second factor, recognizing the contribution of different nurses and making it possible for them to contribute in different ways, not only increases the workability of the shared governance structure but also results in a wider scope of participation with the benefits of participation accruing to a larger group of people.Using recognition to reinforce participation refers to recognition of the shared governance structure and of the decision-making outcomes, not the individuals involved. When physicians, administrators, and professionals from other departments recognize the worth and value of nurses controlling the context of the practice of nursing in an organization, these nonnurse professionals will use the structure, thus making it more workable and effective. In addition, the act of "working together" generates more informal power.Pride in and acknowledgment of outcomes, accomplishments, and actions of shared governance councils is both self and professionally reinforcing. Nothing succeeds like success. Acknowledgment is also a way in which the work of "less visible" participants can be recognized and appreciated. One nurse remarked as follows:Evidence-based practice teams and their activities are often attractive to a frontline nurse who shuns large group meetings or group decision making. Output from the efforts of these teams provides the moral, ethical, and scientific guidance and authority for the decision making essential to improving quality of patient care.Setting up a shared governance structure and a clinical ladder program and implementing many of the best practices associated with control of nursing practice are leadership functions and responsibilities. But there is much that staff nurses can do to put their beliefs about professional behavior and responsibilities into action.If you believe in the "Professional Democracy" form of self-regulation and self-determination for your profession, if you believe that nurses have not only the ability but the professional right, responsibility, and accountability to control the context of nursing practice in the organization in which they work, you demonstrate this talk by getting involved. Although high expectations are laudable, a new shared governance structure may not work perfectly from the beginning. Self-determination and self-regulation are processes that must be learned. Democracy isn't easy.Participation means identifying and presenting issues, participating in council meetings, providing input on issues, canvassing peers, communicating results of decisions, and ascertaining the progress and disposition of problems and issues. Only 1 of the 8 hospitals we visited had a formal system for keeping track of issues and their disposition. Any nurse who identified a problem or had a question or a "why can't we?" completed a half-page form and submitted it to the nurse's council representative. In this system, it was mandatory that the nurse receive a written reply as to the disposition or decision related to the query within 2 weeks.For workable shared governance structures to positively affect nurses' control of nursing practice, enthusiastic and spirited participation by nurses at all levels is a must. But we are all different. Some nurses may recognize participation as a professional responsibility, but family obligations inhibit full participation. For others, participation is a matter of differences in interests and abilities: I prefer giving direct patient care to sitting in a meeting.Some nurses will want to serve as unit representatives and/or to lead councils. Others, like this meat and potatoes kind of guy, can participate by offering suggestions and recommendations in their unit council, by doing investigative work such as determining the best equipment for various patient procedures, by formulating standards, or by conducting best practice searches on the Internet and evaluating current practices. What is important is that the contributions of all are recognized, respected, and appreciated; that lines of communication are kept open; and that both the problem or issue and the solution or decision are "owned" by all.It is difficult for staff nurses to demand access to power, but they can avail themselves of the lines of power offered: "If you don't use the power presented; you'll lose it." There is nothing wrong with feeling powerful and being responsible and accountable for decisions that reflect that power. One nurse remarked as follows:"By your actions they will know you." Take pride in your accomplishments; know what they are even if you were not involved in every initiative. Recognize the achievements of peers and the group. Accept responsibility and demonstrate a willingness to be held accountable for decisions made. Nurses in one hospital explained the following:Culture is the combination of symbols, language, beliefs, assumptions, and behaviors that manifest people's or society's artifacts, values, and norms, the 3 components or levels of culture.33 When applied to an organization, hospital, or clinical unit, the culture is referred to as a corporate culture, the focus of this article. Artifacts are the visible creations of the culture, the image of the unit, status symbols, rites, rituals, ceremonies, and "sacred cows" (persons, things, or beliefs that cannot be attacked but are revered and protected). An example of an artifact on one of the units in our study was that all professionals who achieved specialty certification were the subject of a "toast and roast" ritual enthusiastically attended by all physicians and nurses on the unit. Values are the time-honored, deep-seated, pervasive beliefs of what "ought to be." They are the standards by which we make decisions that influence every aspect of our lives. Walking the talk is how we make our vision and values tangible.1 Values are the concerns and goals ascribed to by most people in a work group that shape the group's behavior. Norms are the agreed upon ways of doing things. Norms guide performance and include both the implicit and the explicit shared meanings of behavior and the rewards and sanctions associated with compliance or non-compliance.Cultures can be located anywhere along a continuum from rich, dynamic, and powerful to weak or static, depending on how overt and pervasive the norms and values are. In weak cultures, norms are subtle, difficult to discern, or not ascribed to by all. The dynamism of the culture depends on the strength and pervasiveness of values, the longevity of the work group, the attention given to transmitting the culture to new people, and on how well taught and reinforced the values and norms are by group members. The vitality, strength, dynamism, and adaptability of the culture depend on the degree of communication among members and on the degree of acceptance of the values among subgroup members. Three processes need attention to ensure a dynamic culture: establishing values and norms, transmitting the values and norms to new team members, and changing and updating values and norms when necessary.A culture of excellence was associated with the original 1984 Magnet designation and was described as "something almost palpable; you can feel it when you walk into a hospital."34 Designation as a magnet hospital by the American Nurses Credentialing Center is based on the structures (called the Forces of Magnetism) associated with an excellent work environment that were derived from results of the original study and on the criteria for certification of nursing service administrators.13Although the 14 Forces of Magnetism and the sources of evidence for the forces have no references to culture,26 since our first study in the mid-1980s, staff nurses in magnet hospitals have consistently reported the presence of a patient-centered culture in their work environment. In 1988, a total of 88% of the 1634 staff nurses in 16 magnet hospitals and 75% of the 2336 staff nurses in 8 nonmagnet hospitals reported that they worked in a culture of excellence in which "concern for the patient was paramount."35,36 In 2003, in a study10 of 4320 nurses in 26 magnet and nonmagnet hospitals, 90% of the nurses in magnet hospitals and 67% of those in nonmagnet gave affirmative answers for the same item. In 2006, in a study8 of 10 483 nurses in 18 magnet and 16 non-magnet hospitals, 88% of nurses in the magnet hospitals and 74% of those in nonmagnet hospitals reported that concern for the patient was paramount.These consistent findings in large samples in different magnet hospitals would seem to indicate that the emphasis and valuation of culture from the original magnet hospital criteria as an attribute of excellence have survived and withstood the test of time. And even though identified in the original study, culture was not included as a Force of Magnetism, perhaps because culture is an exceedingly difficult construct to measure. In a recent study37 designed to differentiate intensive care unit cultures associated with end-of-life decision making in 4 adult medical and surgical intensive care units, a 6-member research team conducted participant observations and collected data for 5 hours a day, 5 to 7 days a week, for 7 months on each of the 4 units studied before judging that the team had identified the different intensive care unit cultures.Most quantitative tools used to measure culture measure only the value dimension of culture.38,39 Sometimes the dominance of one value over another is measured by presenting competing aspects. In 1985, we used the work of Peters and Waterman40 on a culture of excellence to measure cultural values in hospitals. Because the competition between cost and quality care was, and continues to be, a nagging reality, we constructed the following item: Cost (money) is important, but quality patient care comes first in this organization. In 1988, a total of 77% of nurses in magnet hospitals and 65% of nurses in nonmagnet hospitals responded affirmatively to this item. In 2003, the percentages were 78% and 57%; in 2006, they were 76% and 63%. Unquestionably, in both magnet and nonmagnet hospitals, the percentage of nurses who report a patient-centered culture decreases when respondents are specifically requested to factor in the competing value of cost. But what is truly remarkable is that for all 3 periods, the decrease in percentages remained the same, between 12.5% and 13%. This finding reflects remarkable stability in these competing values over an 18-year period, again showing that in hospitals with a culture of excellence, the value of a patient-centered culture has survived despite the tremendous competing value of "cost" in recent years.In 2001, after staff nurses in 14 magnet hospitals identified the 8 work processes or attributes (1 of which was a culture in which concern for the patient is paramount) essential for a healthy work environment,41 we constructed the EOM tool to measure all 8 attributes. We included the values of a culture of excellence40 as well as the competing cost–patient care item.10 The patient-centered culture subscale of the EOM tool does not measure all 3 aspects or levels of culture; it measures only values and the 3 value processes.In the study reported here, 446 staff nurses, nurse managers, and physicians from the 101 patient care units on which staff nurses had previously confirmed a patient-centered culture were asked, "What are the 5 dominant cultural values of the unit on which you work." (Readers may find it beneficial to respond to this question before reading the results, thus allowing comparison of the readers' work situation with that of these interviewees working on excellent units in excellent hospitals.) We followed the suggestion of Cammann et al37 for eliciting norms, the behavioral aspect of walk the talk, by requesting interviewees to "describe a nurse who 'fits into' the work group on this unit." Sometimes the prompt "What does he or she do that tells you that they fit in" was used. Answers to these questions were descriptions of behaviors. Because norms are agreed-upon ways of doing things, these behaviors should reflect the norms of the unit related to the core cultural values.The total number of responses was 1989 because some interviewees cited fewer than 5. Using thematic and categorical analysis,11,12 we grouped the 1989 value responses into 9 categories on the basis of the explanations and descriptions provided by the interviewees. A total of 57 responses did not fit the 9 categories and were dropped, leaving a total of 1932 identified core values in 9 categories. Normative behaviors described in response to the nurse-who-fits-in question were grouped by value categories and will be used to provide descriptions of behaviors related to the values. In this article, we have used a large number of verbatim excerpts to illustrate both the walk (norms) and the talk (core values) in order to adequately represent the range from this large number of responses.Hospital values were gathered from in-house documents, on-site coinvestigators, chief nursing officers, and the hospitals' official Web sites. Although obtained at the time of the on-site visit, information was not tabulated until interviews from all units had been trans