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Growing Nurse Leaders: Their Perspectives on Nursing Leadership and Todays Practice Environment

Susan M. Dyess, PhD, RN, AHN-BC, NE-BC

Rose O. Sherman, EdD, RN, NEA-BC, FAAN
Beth A. Pratt, MSN, RN
Lenny Chiang-Hanisko, PhD, RN
With the growing complexity of healthcare practice environments and pending nurse leader retirements,
the development of future nurse leaders is increasingly important. This article reports on focus
groupresearch conducted with Generation Y nurses prior to their initiating coursework in a Masters Degree
program designed to support development of future nurse leaders. Forty-four emerging nurse leaders across
three program cohorts participated in this qualitative study conducted to capture perspectives about nursing
leaders and leadership. Conventional content analysis was used to analyze and code the data into categories.
We discuss the three major categories identified, including:idealistic expectations of leaders, leading in a
challenging practice environment, and cautious but optimistic outlook about their own leadership and
future, and study limitations. The conclusion offersimplications for future nurse leader development. The
findings provide important insight into the viewpoints of nurses today about leaders and leadership.
Citation: Dyess, S., Sherman, R., Pratt, B., Chiang-Hanisko, L., (January 14, 2016) "Growing Nurse Leaders:
Their Perspectives on Nursing Leadership and Todays Practice Environment" OJIN: The Online Journal of
Issues in Nursing Vol. 21 No. 1.
DOI: 10.3912/OJIN.Vol21No01PPT04
Keywords: Nursing leadership, emerging nurse leaders, practice environments, succession planning, healthy
work environments, multi-generational workforce, Generation Y, academic-practice partnership, leadership
The development of future leaders is a vital obligation for current nurse leaders. Yet despite recognition of the
need to do succession planning, the absence of an adequate leadership pipeline has been cited as a key challenge
in nursing today (Thompson, 2008; Sherman & Pross, 2010; Sverdlik, 2012). We now find ourselves at the
convergence of a perfect storm in healthcare. Three million baby boomers born 1946-1964 (Zemke, Raines, &
Filipczak, 2000) will turn 65 each year for the next twenty years (American Hospital Association [AHA], 2014).
Their growing needs for services will place huge demands on an already challenged health delivery system. At
the same time, many current nurse leaders are in this same generational cohort and will soon retire (Hader,
Saver & Stelzer, 2006). Their potential replacements will be an equally large cohort of Generation Y nurses
born between 1980 and 2000 who are expected to comprise 50% of the nursing workforce by 2020 (AHA,
2014). With the changes accompanying health reform, these young nurse leaders have a unique opportunity to
play key roles in partnering with other healthcare professionals to lead in the improvement and design of the
health system and practice environments (Institute of Medicine [IOM], 2010). To meet these challenges, we
need to be certain that we have a large enough cadre of emerging leaders in nursing who are both interested in
leadership and well prepared to assume the roles (American Organization of Nurse Executives [AONE],
2014; Scott & Yoder-Wise, 2013).
In January 2012, an academic-practice partnership composed of 24 community leaders was formed in South
Florida. The project goal was to recruit young nurses early in their careers into a Masters degree program in
Nursing Administration and Financial Leadership before they accept formal leadership roles. This is a paradigm
shift from the historical pattern where nurse leaders have often fallen into their positions without leadership
education (Sherman, Bishop, Eggenberger & Karden, 2007). With the growing complexity in leadership roles,
community nurse leaders recognized the value of having emerging nurse leaders who would assume these roles
with leadership education and the right skill set. Dr. Tim Porter-OGrady, an internationally known nurse
futurist, served as a consultant on the project.
This article reports on focus group research conducted as part of a larger study with each of three program
cohorts prior to beginning their academic education. The findings indicate that future nurse leaders may be
reluctant, even fearful, of entering formal leadership roles. Yet, they are also hopeful that their efforts can
contribute to improving work environments, unite teams, and implement changes needed to advance healthcare.
Their perspectives about leadership before they assume the role provide valuable insight into current nursenurse leader relationships and also have implications for the planning of future leadership development
programs and succession planning efforts.

Emerging Nurse Leader Development

Effective succession planning through the identification and development of emerging nurse leaders is now
recognized as an essential business strategy for organizations (Kim, 2012). Nursing workforce predictions
indicate that there could be a shortage of up to 67,000 nurse managers by 2020 (Shirey, 2006). Not only is there
a strong business case for orderly transitions in organizations, but younger staff now look for these professional
opportunities when seeking employment. Meister and Willyerd (2010) in their research with thousands of
members of Generation Y found that an employers willingness to develop the skills and talents of their staff
ranked first in 10 criteria used by this generation to select a new position.
Shirey (2009) describes the first ten years of nursing practice as the promise phase. She observes that it is
during this phase that young nurses are both socialized into the profession but also gain the knowledge and
skills to help position them for the future. Generation Y (born between 1980 and 2000) are in this phase of their
careers and are ideal candidates for emerging leader programs. Successful experiences in developmental
programs can translate into a nursing leadership career (Bulmer, 2013; Titzer, Shirey & Hauck, 2014). While
most of their beliefs and values are not vastly dissimilar from other cohorts at a similar point in their
development, Generation Y has two compelling differences in behavior from the generations who preceded
them that need to be taken into consideration when doing leadership development. The first is their
incorporation of technology as a sixth sense and a means of interacting with the world. The second is their
expectation of organizational accommodation that is an outgrowth of how they were parented and treated
throughout their education (McCready, 2011).
It is this expectation of accommodation that has proven to be challenging for many nurse leaders. Leadership
strategies and developmental activities that have worked well with other generations are not always as effective
with our newest generation of nurses Generation Y (Hutchinson, Brown & Longworth, 2012). Turnover in the
first year of employment among this generation is a persistent problem in many organizations. Generation Y
nurses are less accepting and more critical about workplace practices than the generations who have preceded
them. The RN Work Project funded by the Robert Wood Johnson foundation is a longitudinal study that tracks a
national sample of new nurses focusing on their career changes and work attitudes. Currently, 31% of new
graduates leave their first job within the first two years and almost three quarters (73%) do not receive guidance
to appraise gaps in practice or how to respond as a member of the professional team with practice environment
improvement initiatives (RN Work Project, 2014).
In spite of this higher job turnover, Generation Y is optimistic about nursing and may leave employers but not
the profession. In a recent nationwide study conducted by AMN Healthcare (2013), this age group was the most
likely to recommend nursing as a career. They also report more interest in pursuing higher education in nursing.
When satisfied with their jobs, they have been noted to have greater organizational commitment than either
Generation X or the Baby Boomers (Keepnews, Brewer, Kovner & Shinn, 2010) but are also more likely to
monitor and consider employment opportunities in other settings (Tourangeau, Thomson, Cummings & Cranley,
2013). Recruiting and retaining Generation Y nurses in leadership may prove challenging without significant
changes in the current structure of roles. Fear of failure is a significant concern in this generation (American
Psychological Association [APA], 2012), so leadership development programs that promote hope and
encouragement about the progress that they are making is important feedback. Generation Y nurses are just
beginning to move into leadership roles. There are few studies about their perceptions of current leaders and
their potential contributions in these roles. In order to accomplish more effective succession planning, a better
understanding is needed about motivational and environmental factors that could prove challenging in their
willingness to become leaders and accept leadership responsibilities.
Research Methodology
The qualitative findings presented in this article were part of a larger action research design promoted by
Stringer (2007) that guided a three year funded project. Approvals for all aspects of the study were obtained
from the University Institutional Review Board at Florida Atlantic University. Each year (2012, 2013, and
2014), a focus group was conducted with cohort members prior to the beginning of their coursework in a
Masters Degree program for Nursing Administration and Financial leadership. Each group was asked the same
seven questions related to their perceptions about nursing leadership, the practice environment, healthcare
challenges, and the future of healthcare (Table 1).
The focus groups were audio-taped and transcribed verbatim. Transcripts were independently coded by three
nurse researchers with qualitative research experience using a conventional content analysis approach explained
by Hsieh and Shannon (2005). This form of analysis was selected because the aim of this part of the study was

to describe the phenomenon of perceptions of leadership from future nurse leaders without using predetermined
categories. After an initial review of the texts, the codes were agreed upon by the three researchers. Then,
consensus was reached on the categories that ultimately emerged. To ensure trustworthiness of the data and
efforts of qualitative rigor, peer debriefing, thick description, ongoing reflective commentary, member checking
and an audit trail were utilized (Lincoln & Guba, 1985).
Idealistic Expectations of Leaders. Responses to the focus group questions indicated that emerging nurse
leaders have extremely high, possibly unrealistic, expectations of their leaders. Qualities they expect in a leader
include flexibility, clinical expertise, and administrative capability. These emerging leaders also expect their
leaders to be available and present on the unit to assist with patient care when needed. Their comments
indicated a limited understanding of the range of responsibilities and time commitment associated with the role
of nurse leader. As part of the idealism, they expect leaders to know their staff members thoroughly and
participate with the staff in standard shift efforts such as answering the phone or passing medications when
needed. Exemplars of this expected idealism are noted with the following quotes from participants who
described the qualities of a nurse leader, I think as a nurse leader you should always be one step ahead of
others and be knowledgeable in a broad expanse of things, and, you can never ask your staff to do anything
that youre not willing to do yourself. Others described an important quality for the leader is to be one of the
regular staff such as, and if they dont see you as part of the team you cant be the leader of the team without
being part of the team. Other aspects of the ideal leader are shared,
As a leader, you have responsibility for letting the community know the level of service the organization
provides, the quality of the services that we provide and that also promoting healthcare as a whole, the health of
the community but also for future employees that this may be a wonderful place to come work for so youre
kind of the PR person for the facility at the same time.
In fact, the participants, not yet in leadership, were critical if they perceived their current nurse leaders to be
unable to meet their clinical expectations of what a leader should be. One participant recalled a time when
her charge-nurse refused to assist her to initiate an intravenous line. No I cant, I am too busy was the reply
from the leader. The emerging nurse leader then rhetorically asked, doing what; sitting in front of a computer
doing barely anything? Others involved in the focus groups described their perception of not being supported
my direct supervisor isnt as involved as we actually think she should be between pre op and PACU
(post anesthesia care unit). We have one supervisor and in certain situations were kind of left to fend for
ourselves and make our own decisions. In addition to constant support, the focus group participants voiced
their expectation of nurse leaders to know each staff member personally and to be available when needed
seemingly at a moments notice. The emerging professional leaders did acknowledge that this expectation of
continuous accessibility to ones manager is often challenging because many manage more than one unit. One
participant communicated her observations of this challenge; you have the nurse manager that is a leader of the
NICU and the PICU and the Pediatric department and as a result, of that, hardly know staff theyre never
around and it is difficult to get to know them.
The emerging leaders in the focus groups desired their nurse leaders to advocate for them as they serve in the
capacity of an organizational bridge between administration and the front line staff. They recognize that their
managers might feel sandwiched between the desires of higher level administration and the needs of front-line
staff but still expect high level advocacy:
I think leadership is walking the fine line between what your organizational needs are versus what the personal
needs of maybe your employees and your peers are also. There is such a pull between what is mandated maybe
financially by the administrative entities versus what your employees feel are their needs, wants and whats
realistic between the two.
Overall, this category of idealistic expectations for nurse leaders was consistent across the three cohort groups
and prominent in their voiced responses and in their non-verbal agreement to what was articulated. Heads
nodded affirmatively when their peers expressed their perception of qualities needed in a nurse leader. Yet when
they discussed their expectations of nurse leaders, participants simultaneously communicated the challenging
realities of their practice setting and their impact on leaders.
Leading in a Challenging Practice Environment. The current practice environment is perceived to be
challenging on many levels by the emerging leaders. This theme surfaced repeatedly in the focus groups. The
participants communicated their perception that the current focus on achieving high scores on various
satisfaction surveys and performance measures has captured everyones attention in the hospital and seemed to
take precedence over all other initiatives. They did not seem to recognize the demands on leadership in a
complicated practice environment where reimbursement is driven by meeting performance goals. Emerging

leader comments indicated the frustration that they feel with these environmental challenges. One student noted,
they seem to emphasize the importance of core measures and checklists, but simple things like the vital
machine or the dynamap wasnt working. We only have like five for the floor and theres two of them are
broken. Its kind of like something you would think would be easily manageable and easy to fix but still doesnt
get done. The comments highlight the expectation of leading conspicuously in a challenging practice
environment. For example, one focus group participant compared the practice environment to emergency warcare by vividly describing the perceived challenges of hospitals as practice settings:
We are in the front line fighting the war, but we are not getting all the ammunition that we need, because this
group over here needs to go take that mountain. Then all of a sudden we have to turn around and go to this
mountain to fight. Now we are fighting so much and pulling in every direction that we lost the main focus about
what we need to do. Right now the hospitals are sick and they are only being managed to keep them alive, not
heal. They are getting a heart transplant, but they have no kidneys and they have no brain.
Frequent policy and procedure modifications were noted by participants as adding to the volatile nature of a
practice setting because changes were not always well communicated to staff by their leadership. One
participant observed that the boats are not always rowing in the same direction, because people are doing
different things. Another noted the constant change and an apparent lack of commitment to staff
satisfaction amplifies the challenges of leadership.
Poor teamwork was also cited as another perceived challenge in the current practice environment. Teamwork is
important to emerging leaders in Generation Y. Several nurses indicated it was their perception that night shift
had better teamwork than day shift: nights always seem to work together, because they are always team
players, and days they just do their own thing. Some viewed the consistency of team members working
together as essential, when you work with different people from different weekends it changes things, like we
dont like it, it makes it harder. Still others viewed newer nurses as better team players than established nurses.
Nonetheless, the participants believe they will contribute solutions to the challenges with their leadership.
Cautious but Optimistic Outlook about their own Leadership and Future. Despite challenges noted, they are
willing to take leadership roles because they see the potential to change their environments through better
teamwork, a healthier work environment, and a strong connection to front line staff. This optimism is
tempered by realism as one stated with wise anticipation of a future role in leadership, I always say its easy to
tell somebody what to do, if youre not the one doing it.
Still, each focus group participant sought admission to a Masters program with a concentration on nursing
leadership. A number of their admission essays reflected their hopes of leadership to include, the ability to
change some of the things that Ive seen that I dont like by having the tools to manage and balance what is
to come.
They expressed enthusiasm about their own abilities to lead in a different way. One emerging leader observed
that as leaders they could be different from what they view in practice today:
The thing is you can be different when you hear the complaints.if you hear, oh Ive never seen the
manager, theyre always in the office not doing anything, you can be that one walking outside and asking
hows everything, how you doing today, hows your patients? You can be that different one.
Their confidence in the ability of nurses to provide the leadership to change healthcare was expressed by a
participant who noted, Id like to see that the nurses are spear-heading these things and are running
organizations so we wont have such a big gap between what nurses are doing with patients and
Yet as the focus groups conversations advanced, they also talked about their fear of failure as nurse leaders.
They had observed leaders in their environments lose their roles. One nurse jokingly stated Your head will be
the first one thats going to be cut off. Others were concerned about the difficulty of combining the sensitivity
of a nurse with the coldness of business. There was anxiety about leading in an environment where there is an
inability to share new ideas and say no, in addition to pressure to do whats not right for nursing. Another
participant expressed her concern as she hopes to assume the role of leadership:
Theres a utopia that you kind of think about before you really are in it. I am going to make it this way and
everything better but its harder than you think. You have to really be committed to do leadership right. To know
that your life is probably going to change, the hours youre going to spend at work will change, and the
commitment that you are going to make to your employees will change. Not just your employees and staff but

to your employees as people. Being compassionate, having that open door not just for issues that occur on the
floor but their own personal things that they are going to bring to you and that youre going to have to figure
out... its so stressful but if you are really in it and youre really committed and your invested then leadership is
worth it.
In the midst of their expression of idealism and challenges, the participants recognize that they are the future of
nursing leadership. While they may be cautious about their future, they are ready to embrace all that comes with
Were kind of the future of healthcare you know, were it so anything that we can take from this education or
any further experiences will eventually kind of guide us towards what healthcare will be so it kind of depends
on us.
A key concern for nurse leaders today is who will replace them when they retire. Nurse leaders may
inadvertently sabotage succession planning efforts when they are not conscious about their leadership, or send
negative verbal and non-verbal messages about leadership roles. Staff nurses have limited opportunity to
observe their own managers and often have no idea about the scope of the role (Prestia, Dyess & Sherman,
2014). This limited view of leadership is unfortunate because with exposure to the leader role, nurses develop a
deeper respect for the challenges faced by their current leaders. Our experience with this project indicates that
once emerging leaders begin work with their nurse manager preceptors as part of practicum course work, they
develop very different perceptions about the leadership role than were expressed in these focus groups. In their
reflective journals kept during practicum experiences, they often observed that they gain a new appreciation of
the range of leadership activities nurse leaders were engaged in throughout their daily routine.
Without intentional guidance, formal coaching, and role modeling, many young nurses may decide against
becoming a leader based on what they observe in the practice environment. They may evaluate these roles as
not being consistent with their personal values and beliefs. The future of nursing leadership could be in jeopardy
if their decision is to just say no.
This study captured the perceptions of emerging nurse leaders from one geographic area at the beginning of
their education program and prior to their acquisition of a formal leadership role during an era of significant
healthcare transition. The results of this research are not intended to be generalizable across time or with a more
geographically diverse group of young nurses. This is a study limitation, but these focus group findings are an
important reminder about the gaps in communication and role understanding that often exist between nurse
leaders and their staff.
Conclusion: Implications for Nurse Leaders
With the expected large-scale retirements of many Baby Boomer nurses, the future of nursing leadership will be
in the hands of Generation Y nurses early in the next decade. Viewpoints expressed by the participants in this
research indicated that current nurse leader-staff relationships may not be as positive as is needed to establish a
healthy and nurturing work environment. Unrelenting change in healthcare, focus on costs and increased span
of control in many leadership roles have contributed to their perceptions.
Although not yet widely reported in the nursing literature, there is recent research to support the viewpoints of
these emerging leaders that the current healthcare environment has taken a toll on leader-staff relations. Over
the past seven years, the American Association of Critical Care Nurses (AACN) has funded research to study
the work environments of critical care nurses as well as nurses in other high acuity areas such as the emergency
department. A research team led by Dr. Beth Ulrich surveyed nurses nationally about each of the six key healthy
work environment factors, asking specifically about perceptions of how well their frontline leaders and Chief
Nursing Officers were doing on each of these dimensions. Studies were conducted in 2006, 2008, and 2013. The
2013 study included a very robust sample of 8000 nurses nationwide. The findings indicated a deterioration of
scores at a statistically significant level on every dimension for both frontline managers and CNOs (Ulrich,
Lavandero & Early 2014).
The study conducted by AACN and the research presented in this article should be a call to action for current
nurse leaders. In addition to building more cohesive relationships with staff, there is clearly a need for leaders to
do a more effective job of communicating with staff about the leadership role and responsibilities. The good

news in this research is that Generation Y nurses are interested in nursing leadership and are confident about
their ability to make positive changes in their environments. To alleviate their concerns about failure in the role,
they will require structured leadership development programs and strong mentorship.
Growing future nurse leaders is a long term quest that requires both planning and action. Our emerging leaders
will ultimately replace our current leaders and continue the very important work being done to improve nursing
practice environments, and most importantly, patient outcomes. Yet succession planning is challenging today in
a healthcare environment that is fast paced and constantly changing. Current nurse leaders are often so
consumed with their day to day work, and they are unaware of the impressions that young emerging leaders
may have about their roles and impact. Kouzes and Posner (2012), two well-known leadership experts in the
field of business, have noted that the most significant contribution todays leaders can make for the future is to
develop their successors so they will adapt, prosper, and grow. Porter-OGrady and Malloch (2015) advise that
the shifts happening in the healthcare environment today demand that leaders challenge their thinking and
practices to recognize that the crux of leadership is in the power of relationships. Leaders, they observed, will
increasingly devote their energies to helping others to adapt to the new rules for thriving in the world of work
(p. 22). The findings from this research indicate gaps in communication and understanding between nurse
leaders and their staff that need to be bridged to recruit and retain Generation Y nurses into leadership roles.
Acknowledgement: The project described in this article is funded, in part, with a HRSA Advanced Nursing
Education Grant D09HP22615-01-00. None of the authors has financial claims or conflicts of interest
associated with this manuscript.
Susan M. Dyess, PhD, RN, AHN-BC, NE-BC
Email: sdyess@fau.edu
Susan M. Dyess is an Associate Professor at Florida Atlantic University in Boca Raton, FL. She has been the
project director for two key nursing leadership initiatives that supported novice nurse transition, and emerging
nurse leader development. She is author or co-author on 15 publications in peer-reviewed journals.
Rose O. Sherman, EdD, RN, NEA-BC, FAAN
Email: rsherman@fau.edu
Rose O. Sherman is a Professor and Director of the Nursing Leadership Institute at Florida Atlantic University
in Boca Raton, FL. She has written more than 60 peer-reviewed articles on nursing leadership topics and has
received 2.5 million dollars in grant funding for leadership development research and program initiatives. Rose
is an alumnus of the Robert Wood Johnson Executive Nurse Fellow Program and currently serves on the ANA
Leadership Institute Advisory Board.
Beth A. Pratt, MSN, RN
Email: bpratt4@fau.edu
Beth A. Pratt is a PhD student and research assistant at Florida Atlantic University in Boca Raton, FL. She is
Vice President for the Nursing Student Council, Co-founder for the College of Nursing Student Organization,
and Student Liaison for the Graduate Nurses Student Academy.
Lenny Chiang-Hanisko PhD, RN
Email: lchiangh@fau.edu
Lenny Chiang-Hanisko is an Associate Professor at Florida Atlantic University in Boca Raton, FL. She is a
qualitative researcher and has published numerous articles using phenomenology, grounded theory,
ethnonursing, descriptive thematic analysis and content analysis methods. She is a Transcultural Nursing
Scholar and currently member of the University Research Committee at Florida Atlantic University. She serves
as a visiting scholar for several universities in Taiwan and China.

Global nursing leadership


Pamela Thompson MS, RN, CENP, FAAN,

Kristiina Hyrkas PhD, LicNSc, MNSc, RN

First published: 13 January 2014

DOI: 10.1111/jonm.12215

The theme of this issue is Global Nursing Leadership. The terms global or globalisation are not new, but
have been used increasingly since the mid-1980s, for example, in the newspapers and media. How often do we
stop and think: what do these really mean? What is globalisation? Today it is easy to Google everything and
find from the internet that Globalisation is the process of international integration arising from the
interchange of world views, products, ideas, and other aspects of culture Advances in transportation and
telecommunications infrastructure, including the rise of the telegraph and its posterity the internet, are major
factors in globalisation, generating further interdependence of economic and cultural activities In 2000, the
International Monetary Fund (IMF) identified four basic aspects of globalisation: trade and transactions, capital
and investment movements, migration and movement of people and the dissemination of knowledge
Globalisation has been an unfolding trend for over three decades, as our communities and cultures become both
closer via the internet and also more diverse, as people migrate, move and travel for different reasons. Nurses
and nurse leaders are in the fore front of their communities and increasingly face the need to understand and
take initiatives in responding to this rapidly changing world. Today health services, including nursing, are
undergoing fast changes. Health reforms are occurring in many parts of the world and this trend is accelerating.
The wake-up call is that health care reforms are also many times part of a much wider process of social and
political restructuring. How ready and prepared are we, as nurse leaders, for being part of this change,
restructuring and reform processes? Those of us who are or will be in key leadership and management positions
need to be well prepared to work effectively in interdisciplinary teams, plan and manage effective and costefficient services, involve communities and key stakeholders in health care planning and delivery, formulate
policies and prepare and empower nurses, nurse managers, leaders, educators, and staff for the future.
Our biggest challenge in the 21st century is the transformation of nursing. Global nursing leadership requires
active participation and leadership in practice, education, research, and policy/political arenas. To participate in
this transformation process and innovative development of new health care systems, nurse leaders must be
super active within the national, but also multinational and multidisciplinary decision processes that discern
health care at home and abroad. For this to happen we need to provide our nurse leaders with new tools and
knowledge. In other words, we need to ensure that our global nurse leaders have a good understanding of the
health care system, social and political context, purposes of health reform, a vision of how health and nursing
services may be developed in their countries, the ability to plan strategically for and manage change, and the
strength and confidence to be proactive in a challenging and often stressful change environment.
Global nursing leadership has been increasingly highlighted in the literature, for example, from workforce
(Douglas 2011, Rollins Gantz et al. 2012), educational and capacity building (Nichols et al. 2011, Blaney 2012,
Clark Callister 2012, Zittel et al. 2012) and quality/excellence perspectives (Ferguson 2013). An important
remark here is that global nursing leadership is based on and needs to draw from the expertise of
international scholars, researchers who can expand our perspectives with new knowledge to review and enhance
our understanding on leadership and skills within a collaborative and stimulating learning culture and
networking across borders.
When we compiled this issue, our starting point was an assumption that global nursing leadership can be
enhanced by sharing the selected articles and research from authors all over the world. We are convinced that
every reader and leader can find remarkable similarities with their own experiences and in the topics studied
and discussed despite cultural differences. We strongly believe that global nursing leadership, evidence-based
practices and high quality health care services are promoted by connecting nurses worldwide to share ideas,
innovations and new knowledge through the articles of this issue. This issue illuminates the theme from the
following perspectives: empowerment, competency development, effective leadership including workforce and
patient care safety issues and excellence of global leadership.

The first three articles focus on empowerment. MacPhee et al.'s (Part 1, pp. 415) from Canada demonstrate
how leaders use of empowering behaviors can be increased through training and a workplace empowerment
process. The reported findings are showing that leader empowering behaviors can be associated with more
engaged staff and healthier work environments. The second article (Part 2, pp. 1628) from these investigators
focuses on reporting results how a leadership development program impacted staffs perceptions of
organizational support and commitment. The leader-empowering behaviors were found to be catalysts for staff
empowerment; with structural empowerment mediating the effects of leader empowering behaviors on
organizational commitment. The results of these studies illuminate a new perspective on empowerment from the
leaders and also staffs perspectives. Bish et al. (pp. 2937) provide insights into the perceptions of structural
empowerment of nurse leaders in Australia. The results of this study show that rural nurse leaders perceive
themselves to be moderately empowered. Additional research is still needed to increase our knowledge on
empowerment of rural nurse leaders and what global strategies would best support their leadership practices.
The next three articles examine competency development. Miskelly and Duncan (pp. 3848) report on an
evaluation of an in-house nursing and midwifery leadership program aimed at improving leadership capacity in
clinical environments in New Zealand. This article provides evidence that in-house leadership programs can
equip front-line nurses and midwives with opportunities to enhance their professional identity and expand their
skills in a variety of ways. Stoddart et al. (pp. 4959) discuss the changing leadership roles in Scotland and how
the role of the senior charge nurse in providing clinical leadership has been evolving. This article reports about
senior charge nurses experiences in relation to the implementation of a national clinical leadership policy.
Evaluation of this policy from the senior charge nurses perspective suggests that the policy is emerging as a
major step forward in the development of clinical leadership, clinical team performance and improvement of
care delivery. Shapira-Lishcinsky (pp. 6069) explores Israeli nurses ethical decision-making in order to
identify the benefits of team simulations for authentic leadership. The findings demonstrate that simulations are
beneficial and should be incorporated more into nursing practice, for example, to help resolve power conflicts
and to develop authentic leadership.
The following five articles focus on effective leadership, workforce and patient care safety issues.
Lawrence and Richardson (pp. 7079) describe the leadership experiences of modern matrons in the UK.
Modern matrons were re-introduced to the National Health Service in 2002; however, minimal research has
been available exploring how modern matrons experience effective leadership. This article describes how
matrons place great emphasis on adapting their leadership style and how they demonstrate their leadership
credibility though walking the walk. The results show that modern senior leadership roles are complex
requiring leaders with ability to adapt their leadership style to meet various challenges. Premji and Etowa (pp.
8088) address a need for research on workforce utilization patterns of ethnic and linguistic minorities in
Canadian health care settings. This study developed a diversity profile of the nursing workforce in Canada. The
results suggest that there is a need to increase diversity in nursing by facilitating the entry of certain groups in
frontline management jobs and of all minority groups in higher level positions. The authors recommend efforts
to increase diversity in nursing accompanied by commitment and resources to effectively manage diversity
within organizations. Palmer (pp. 8996), a researcher from the US, reports a study that adds to our knowledge
about the nursing workforce and satisfaction in South America. This study is of professional nursing work
environments in Ecuador. The paper reports, among other things, that the top factor of decreased satisfaction
was low pay and this was also the factor for nurse turnover. Identified strategies to decrease turnover and
increase satisfaction include: increasing pay, providing opportunities for nursing advancement, promoting the
value of nursing, creating clinical protocols and enhancing autonomy. Keys (pp. 97105) focuses on a
workforce issue in the USA in her article Looking ahead to our next generation of nurse leaders. Generation X
nurse managers work with structures that were created by Matures and are now managed by Baby Boomers.
This study is timely, because there is a paucity of research specific to the generation of nurses next in line to
assume leadership roles. The study highlights the importance of preparation for the Nurse Manager role,
openness to innovative scheduling alternatives and tailored support and feedback.
Vaismoradi et al. (pp. 106116) report that there is a lack of knowledge in the international literature how nurse
leaders facilitate provision of safe care and achieve the goal of a safe health care system. This article focuses on
describing how nurse leaders can facilitate safe care. The results indicate that to facilitate safe care, nurse
leaders should improve nurses' working conditions, develop the nurses practical competencies, assign duties to
nurses according to their skills and capabilities, administer appropriate supervision, improve health care
providers professional relationships and encourage their collaboration, empower nurses and reward their safe
practice. The authors emphasize that a health care system needs to combine its efforts and strategies with
nursing leadership in facilitating safe care and improving patient safety.

The last two articles illuminate excellence within the context of global leadership. Honkavuo and Lindstrm
(pp. 117126) focus on exploring difficult situations as a part of clinical nursing in Finland. Nurses are
repeatedly exposed to situations that may cause them suffering and reduce their ability to serve patients. This
article increases nurse leaders awareness of difficult situations and how they can approach and alleviate
suffering. The authors emphasize that nurse leaders support, understanding, sympathetic attitude, ethical value
basis, personality and ability to discuss are important aspects for nurses, help alleviate suffering and create a
foundation for the nurses professional development. The Anonson et al. (pp. 127136) article reports the
characteristics of exemplary nurse leaders in times of change from the perspective of frontline nurses in Canada.
Large-scale changes in the health care system and associated challenges have highlighted the need for strong
leadership at the front line. The study identifies six qualities of exemplary nurse leaders that allowed them to
effectively assist and support frontline nurses: a passion for nursing; a sense of optimism; the ability to form
personal connections with their staff; excellent role modeling and mentorship; and the ability to manage crisis
while guided by a set of moral principles.
In conclusion, nursing leaders must innovate and explore to discover the paths to achieving excellence for those
they lead and serve. We are a community of leaders who can significantly impact health care in our individual
settings. However, it is imperative that we share our knowledge and experience with colleagues around the
globe. Together we can learn how best to leverage our knowledge regarding the changes required in our health
care systems. It is nursing leadership that can be a pivotal force in creating a healthier tomorrow for the patients,
clients and citizens for whom we provide care. It is our hope that the articles in this issue will stimulate,
provoke, and mobilize your desire to be an active and informed leader of our global community. Finally, the
editors would like to thank all the authors for sharing their perspectives and findings that will help us transform
nursing through global nursing leadership.

Strategies for Enhancing Autonomy and Control Over Nursing Practice

Marla J. Weston, PhD, RN

Clinical nurse autonomy and control over nursing practice (CONP) have been associated with increased nurse satisfaction and improved
patient outcomes - both elements of a healthy work environment. This article outlines strategies for enhancing autonomy as well
as strategies for enhancing CONP and describes the importance of articulating expectations for autonomous practice, enhancing
competence in clinical expertise, establishing participative decision making, and developing nurses' skills in making decisions. In addition, the
critical role of nurse leaders and the need to work upstream to influence the social, political, and economic factors affecting nursing
practice are discussed.
Citation: Weston, M.J., (Jan. 31, 2010) "Strategies for Enhancing Autonomy and Control Over Nursing Practice" OJIN: The Online Journal of
Issues in Nursing Vol. 15, No. 1, Manuscript 2.
DOI: 10.3912/OJIN.Vol15No01Man02
Key words: autonomy, control over nursing practice, decision making, empowerment, healthy work environment, leadership, nurse
satisfaction, nursing practice participative decision making, professional practice, professionalism

A healthy work environment is one that is invigorating, robust, flourishing, and able to flexibly adapt to a constantly changing set of


Much like health in a person represents more than the absence of disease, a healthy work environment encompasses

more than absence of malfunction. Like a healthy person who is active and contributing to the world, a healthy work environment garners
employee engagement and energy toward collectively producing desired results. A healthy work environment not only establishes a desirable
workplace, but also provides the infrastructure to positively impact the effectiveness of the work itself. A healthy work environment is one that
is invigorating, robust, flourishing, and able to flexibly adapt to a constantly changing set of circumstances.
The value and contribution of nurse autonomy and control over nursing practice (CONP) in creating a healthy work environmentboth in
terms of nurse satisfaction and the quality and safety of patient outcomeshave been consistently demonstrated (Aiken, Clark, Sloane, Lake
& Cheney, 2008; Lake & Friese, 2006). Moreover, recent research has reported that a positive work environment, including higher levels of
autonomy and CONP, is not associated with increased nursing costs (Mark, Lindley, & Jones, 2009).
Autonomy refers to the ability to act according to ones knowledge and judgment, providing nursing care within the full scope of practice as
defined by existing professional, regulatory, and organizational rules (Weston, 2008). Nurses in Magnet facilities have described their culture
as supporting autonomous practice, expecting and encouraging them to utilize their nursing expertise to deliver the best in patient care
(Kramer & Schmalenberg, 2003a). They perceived that the organization supported their nursing actions and clinical judgment.
CONP refers to the nurses ability to shape departmental and organizational policies and practices related to nursing care (Weston, 2008).
Nurses with high levels of CONP have the responsibility and opportunity to provide input and make decisions related to their practice,
including policies and personnel issues affecting the context of the care they deliver (Kramer & Schmalenberg, 2003b).
From the very first research on Magnet hospitals, the concepts of both autonomy and CONP were associated with a healthy work environment
and professional practice (McClure, Poulin, Sovie, & Wandelt, 1983). Subsequently, autonomy and CONP have been suggested as intervening
variables to explain the relationship between magnet hospitals and positive patient outcomes (Aiken, Smith, & Lake, 1994).
Both autonomy and CONP have been associated with job satisfaction and nurse retention (Kramer & Schmalenberg, 2004). In addition, they
have been associated with increased respect, status, and recognition for nurses (Hinshaw, 2002). CONP has been positively correlated with
nurse autonomy and job satisfaction; and negatively associated with personal and situational job stress (Forbes, Bott, & Taunton, 1997). Not
surprisingly then, work environments where nurses report high levels of autonomy and CONP have been associated with lower staff turnover
rates and less nurse burnout (McClure, Poulin, Sovie, & Wandelt, 2002; Vahey, Aiken, Sloane, Clarke, & Vargas, 2004). McGilton and Pringle
(1999) reported that nurses perceived control over organizational issues appears to more strongly predict job satisfaction than nurses
perceived control only in the clinical domain. In other words, while both autonomy and CONP impact job satisfaction, CONP appeared to have
the stronger influence. Findings that autonomy and CONP impact employee satisfaction are consistent with the literature in other industries
(Cotton, Vollrath, Froggatt, Lengnick-Hall, & Jennings, 1998; Sagie, 1994). Within management literature, the degree of worker participation
in decision making has been found to relate positively to satisfaction with work (Black & Gregersen, 1997).
Nursing work environments with higher levels of autonomy and CONP have also been associated with increased performance and improved
patient outcomes. Autonomy and CONP have been identified as important work environment attributes for enhancing patient safety (Institute
of Medicine, 2004). In addition, even when controlling for nurse staffing and education, hospitals with better care environments, i.e. those
having more nurse autonomy and CONP, were found to be associated with significantly lower mortality rates (Aiken et al. 2008). Laschinger
and Havens (1996) found that CONP strongly predicted nurses perceptions of effectiveness of patient care. In addition, higher reported levels
of CONP were positively associated with nurse executives perceptions of the quality of patient care delivered (Havens, 2001). Similarly, in the
management literature, employee autonomy and control have been associated with improved outcomes. A positive, but weak, relationship
has been demonstrated between participation in decision making and performance (Black & Gregersen, 1997; Sagie, 1994).

In light of the importance of autonomy and CONP, understanding these concepts and their applicability in practice can support the
development and sustainability of a healthy work environment. This article will provide strategies that nurses can use to strengthen nurse
autonomy and CONP in the healthcare setting. In addition the critical role of nurse leaders and the need to work upstream to influence the
social, political, and economic factors affecting nursing practice will be discussed. The Table offers a concise summary of these strategies.

Strategies for Enhancing Autonomy

While a nurses scope of practice is legally defined based on educational qualifications and specific experiences, professional and
organizational expectations determine the degree to which autonomous practice occurs. As described in the following section, strategies for
enhancing autonomy are based on setting clear expectations for autonomous decision making and providing support for increasing the
knowledge and expertise of nurses.
Clarify Expectations about Clinical Autonomy
Professionally and organizationally sanctioning and supporting the application of nursing knowledge and expertise in the care of patients has
been associated with enhancing autonomous nursing practice (Kramer & Schmalenberg, 2003a). Nurses can enhance autonomy by clearly
communicating and organizing their work to ensure that they have the freedom to act on nursing decisions using sound clinical judgment.
Describing expected behaviors involves communicating that nurses are expected and encouraged to make decisions about clinical patient care
that are based on the science and art of nursing. This involves setting an expectation of independent nursing action and supporting decision
making within the scope of nursing practice. In addition, because nursing practice involves both independent and interdependent actions,
clearly identifying acceptable responses to situations that are at the edge of nurses commonly accepted scope of practice is helpful in this
process (Stewart, Stansfield, & Tapp, 2004). Examples of such identifications include outlining expectations related to verbal physician orders
and establishing protocols for over-the-counter medications. Behavioral expectations can be formally outlined in orientation programs,
demonstrated by preceptors, and highlighted through ongoing discussions about clinical practice.

...patient care rounds can be organized in a way that ensures that nurses contribute to decision making about the treatment plan of patients.


addition to clearly defining expectations for autonomous clinical practice, incorporating nursing knowledge and expertise into clinical practice
embeds autonomous practice into patient care. For example, patient care rounds can be organized in a way that ensures that nurses
contribute to decision making about the treatment plan of patients. The nurse is positioned to discern subtle trends and changes in a patients
condition, to know the unique personality and strengths of the patient, and to have established a caring relationship with the patient
(Manojlovich, 2007). Including nurses in clinical rounds maximizes the valuable contribution of their unique perspective and information in the
care of patients. With nursing input, more diverse solutions can be explored, patient care planning is more robust, interdisciplinary
communication is improved, and care coordination can provide for more effective implementation of plans.
Recognizing autonomous practice can reinforce verbally communicated expectations. For example, acknowledging exemplary performance by
having nurses share clinical examples that highlight autonomous practice provides a venue for displaying sanctioned autonomous practice.
Nursing grand rounds, poster sessions on clinical case studies, and/or situations shared during staff meetings can all be used to illustrate
examples of autonomous nursing practice. In addition, emphasizing expected behaviors through recognitions and rewards outlines for nurses
the realm of autonomous actions. Clinical ladder programs formally reward and recognize clinical practice, further delineating expected
autonomous actions.

Novice nurses quickly observe the nature of clinical judgment and autonomous nurse actions demonstrated by more senior colleagues...


modeling expected behaviors also reinforces autonomous clinical practice. Novice nurses quickly observe the nature of clinical judgment and
autonomous nurse actions demonstrated by more senior colleagues and use these observations to identify accepted levels of independent and
interdependent decision making. Clinical nurse leaders and clinical nurse specialists in the practice setting can engage in behaviors reflective
of autonomy and serve as an ongoing resource for role modeling, coaching, and mentoring excellence in clinical practice.
A component of coaching for autonomous behavior includes addressing when behaviors are not within the range of expected actions. For
example, if nurses are not making the expected autonomous decisions, coaches can compare actual with expected actions to show how to
make the expected nursing contributions and behaviors more explicit. Addressing inappropriate actions using constructive feedback can guide
autonomous nursing practice. If nurses take clinical actions that are not appropriate or not successful, constructive feedback can redirect their
practice patterns.
Studies have suggested that creating a climate that is supportive of nursing practice will augment the level of autonomous practice. For
example, nurses working in Magnet hospitals perceived that managers were more supportive of their independent clinical decision making
than did nurses working in non-Magnet hospitals (Upenieks, 2003). Because of perceptions of support, nurses in Magnet hospitals may be
more willing to assume the risk for making autonomous patient care decisions. Building trust in the clinical setting by supporting nursing
actions that may be risky, yet are safe, encourages innovative practice and enhances autonomy.
Enhance Competence in Practice
The establishment of the sound clinical judgment needed for autonomous practice requires a foundation of nursing expertise. Although
difficult to define, nursing expertise is a combination of knowledge and skill along with extensive experience (Jasper 1994). Thus,
implementing strategies to increase the competence of nurses by creating a learning environment can foster autonomy. Stewart, Stansfield,
and Tapp (2004) reported that autonomy can be fostered by enhancing competence and confidence through strategies such as teaching
rounds, formal continuing education, and a climate of inquiry in everyday practice. Also during staff meetings, clinicians can share
complicated patient scenarios that have challenged their autonomous decision making to both exemplify excellence in practice and receive
feedback on how to further enhance patient care. Promoting evaluation of autonomous practice in this way allows for unique variation in
culture and norms between units.

...implementing strategies to increase the competence of nurses by creating a learning environment can foster autonomy.

Encouraging the

continuous examination of practice allows nurses to reflect on the degree of autonomy present in their decision making. In addition,
establishing an evidence-based practice approach may develop and enhance autonomy. By identifying and evaluating relevant research while
simultaneously assessing and incorporating information about patient preferences into their plans, nurses have the opportunity to make
autonomous patient care decisions. Further, development of skills related to communication, interdisciplinary teamwork, and negotiation can
assist nurses to master the skills necessary to advocate for their patients.
Creating an environment that supports both formal and informal continuing educational opportunities and learning provides for autonomous
clinical practice. Baccalaureate-prepared nurses have reported a higher preference for both clinical autonomy and CONP (Blegen et al., 1993).
In addition, masters-prepared nurses have reported significantly higher professional autonomy in clinical nursing situations compared to
nurses prepared with a diploma or associate degree (Schutzenhofer & Musser, 1994). Further, Ericsson, Whyte, and Ward (2007) found that
nurses with specialty nurse certification and specific clinical training demonstrated higher levels of expertise. Tuition reimbursement and
support for returning to school can enhance the development of skills and competence needed to support autonomous practice.
The importance of the culture of learning cannot be stressed enough. For example, while nurse managers at non-Magnet hospitals focused on
adequate staffing as a critical element, managers at Magnet hospitals emphasized educational opportunities and an autonomous climate as
being a vital factor for nurse satisfaction (Upenieks, 2003). In the Mrayyan study (2004) supportive management, education, and experience
were identified as the three most important factors in enhancing autonomy over patient care and unit operations.
In summary, autonomy can be increased by strategies that incorporate the unique knowledge and expertise of nurses into clinical patient
care. Clarifying the expectation that valuable nursing knowledge should be applied in the practice setting provides the framework for
enhancing clinical autonomy. Professional enrichment and education build the clinical knowledge and competence that is a necessary
foundation for nurse autonomy.

Strategies for Enhancing Control over Nursing Practice

Most nurses practice as employees, and as a result must structure their work within imposed rules that have a profound effect on their
practice (Hess, 2004). To truly control their practice, nurses must have both the right and the power to make decisions affecting the rules
surrounding their practice. Nurses must create and use decision-making structures at the workgroup, organizational, and professional levels
of practice.
Establish Participative Decision Making

Historically the concepts of empowerment and participatory management have been laden with a paternalistic tone of people in positions of


allowingstaff to provide input and participate in some operations.

The structure of an organization or profession

operationalizes goals and values in support of achieving desired outcomes (Wolf, Triolo, & Ponte, 2008). An organized structure for nurse
participation in decisions, along with an explicit communication processes contribute to enhancing CONP. Kramer and Schmalenberg (2003b)
have shared that nurses in organizations with high levels of CONP describe an operative structure that is in place, one that is recognized as
authoritative by others. The representatives in the structure are known and some input is sought and expected from all nurses. In addition,
staff nurses have responsibility and accountability for the issues and solutions discussed within the structure. The classic example of such a
structure is a shared governance council with nurses actively managing decisions related to their practice.
The importance of nurses having responsibility and accountability for professional and practice issues cannot be stressed enough. The
structure for CONP is one in which the responsibility for nursing care of patients is placed with staff nurses (Hinshaw, 2002). Historically the
concepts of empowerment and participatory management have been laden with a paternalistic tone of people in positions of
authority allowing staff to provide input and participate in some operations. Fundamentally, this is where many shared governance programs
go awry. In these situations, although an organizational structure is established and nurses are permitted to provide input into key decisions,
the ultimate authority for the decision making continues to reside with managers and administrators. In contrast, autonomy and CONP need
to be founded on a process of engagement where nurses, as knowledge workers, are expected to make and own decisions (Porter-OGrady,

...nurses should be included along with physicians and administrators on key organizational committees that establish patient care policies and


Because nurses typically work as employees within a larger structure and within the healthcare system itself, nurses must

have a formal structure for participating in organizational and system decisions. For example, within employment settings, nurses should be
included along with physicians and administrators on key organizational committees that establish patient care policies and procedures. The
expectation should be set that nurses will share a full and equal voice in, and responsibility for making patient care decisions (McKay, 1983).
Not only does this foster strong, productive nurse-physician and nurse-administrator relationships, it also contributes to necessary
interdisciplinary richness (Hinshaw, 2002; Ponte, 2004).
Whatever organizational structure is used, nurses should be able to make program and resource decisions without going through layers of
bureaucracy that stifle innovation and implementation. In addition, to be involved, nurses must be active on hospital and professional
committees. Organizing an involvement-friendly environment where it is easy for nurses to participate in meetings will increase CONP
(Forum for Shared Governance, n.d.). Nurses can maximize the opportunity for colleagues to attend meetings or complete committee work by
adequately staffing for patient care. Fundamentally, nurses need to foster the understanding that their work involves both the direct clinical

care of patients as well as the management of the context in which that care is delivered. As a result, both clinical patient care and
organizational and committee work are within the realm of nursing practice. Nurses cannot effectively practice without the right resources
(including an appropriate amount and mix of caregivers, supplies, and supporting systems) or without the necessary evidence-based policies
and practices. To control practice, nurses must have some influence over necessary resources and policies for their practice (Hess, 2004). To
do so, nurses must ensure that they and their colleagues are well-represented and able to be influential whenever and wherever key decisions
are being made that will impact the nature, scope, and context of their practice.
Enhance Competence in Decision Making

...nurses need to foster the understanding that their work involves both the direct clinical care of patients as well as the management of the

context in which that care is delivered.

Although it is important that clinical nurses serve on committees, they are generally underprepared

to do so; hence they are challenged in representing their needs. Studies find that clinical nurses participate to a greater extent in decisions
related to clinical patient care decisions than to unit or organizational decisions (Anthony, 1999; Blegen et al., 1993; Krairiksh & Anthony,
2001). Consequently, clinical nurses experience and competence in participating in group decision making, influencing organizational
processes, and impacting policy is somewhat limited. More frequently nurses are invited to provide input into the decision but are not involved
in making the selection or final choice in the decision that is made (Anthony, 1999; Issel & Anderson, 2001). Generating alternatives, as well
as choosing alternatives, planning implementation, and evaluating results, have been found to be significantly related to satisfaction and
influence (Black & Gregersen, 1997; Issel & Anderson, 2001). Clinical nurses working in Magnet hospitals distinguish between participative
management, which they articulate as providing input or sharing an opinion, and CONP, which they articulate as actually selecting among the
available options regarding practice policies, practice issues, and personnel issues affecting nurses (Kramer & Schmalenberg, 2003b). In other
words, developing skill in generating alternatives and selecting a final choice, coupled with ensuring that there is a structure for both input
and decision making enhances nurses satisfaction and influence.
As a result, investing in teaching nurses about the decision-making process, coaching them through early decision making, and supporting
both successful and unsuccessful decisions will foster an environment for increasing autonomy and also CONP. Expecting nurses to participate
without allowing opportunities to acquire prerequisite skills will result in either frustration or apathy (Hess, 2004). Ensuring that nurses
develop the skills to manage meetings, gather and analyze existing evidence, explore alternatives, and make sound decisions will support
CONP. In this way, nurses will have the knowledge and ability to not only make recommendations but also be empowered to enact decisions.
Nurse leaders, whether in management, clinical, educational, or research positions, can be taught facilitation skills to enhance their ability to
garner discussion that leads to identification of group expertise without dominating the discussion or decision making. Naturally, during
decision making, creative tensions will emerge by exposing differences in perspectives and gaps between organizational visions and current
realities (Burns 2001). Teaching leaders to pose questions that expose assumptions and challenge sacred cows can help to illuminate tensions
and paradoxes, thus ultimately fostering creative new solutions.
In summary, CONP can be increased by strategies that ensure nurse participation in key decisions within the organizational and professional
structure. Establishing the structures and processes for active nurse input and decision making provides the framework for enhancing CONP.
Because many nurses have little such experience, investing in teaching and supporting decision making related to the context of nursing care
is necessary to build competence for CONP.

Role of Nurse Leaders

Nurse managers in particular are instrumental in producing the conditions for autonomy and CONP.

Although leadership can come from any

nurse, designated leaders remain extremely influential for enhancing both autonomy and CONP. Consistently the recommendation is made to
create strong, visible nursing leadership in the nursing department and at the unit level to increase autonomy and CONP (Hinshaw, 2002).
Nurse managers in particular are instrumental in producing the conditions for autonomy and CONP. Manager leadership behaviors have been
shown to influence staff decision-making patterns (Taunton, Boyle, Woods, Hansen, & Bott, 1997). In studies comparing Magnet and nonMagnet hospitals, greater accessibility of nurse leaders, support of autonomous decision making by leaders, and access to work empowerment
structures were found to be the most significant elements accounting for differences in empowerment and job satisfaction (Kramer &
Schmalenberg, 2002; Upenicks, 2003). In a qualitative study, seven staff-nurse focus groups identified and rank ordered the skills needed by
a nurse manager to effectively manage a patient care unit. The top three management skills in descending order were effective
communication, remaining available to staff, and involving staff in decision making (Maceri, 2006). Supervisor support was positively
correlated with nurses reporting more control over their work and higher satisfaction (Hall, 2007). Nurse manager actions, specifically those
encouraging nurses to communicate openly with other healthcare team members, supporting nurses to resolve conflicts, and encouraging
leadership, were associated with increased nurse participation in patient care and conditions of work decisions (Mrayyan, 2004).
In addition to the critical role of the nurse manager, executive leadership is critical to creating an environment that is supportive of autonomy
and CONP. Organizationally, a visionary nurse executive who trusts and values nursing staff is essential for creating the context for high levels
of autonomy and CONP. A chief nurse executive who (a) advocates for a strong, influential nursing presence in the organization; (b) is open
and communicative; and (c) supports participative management is associated with a professional environment that includes autonomous
clinical practice and nursing control over practice (Hinshaw, 2002). Upenieks (2003) reported that when the entire executive team, and not
just the nurse executive, offered support of nursing, a climate was established that endorsed autonomous nursing practice.
Thus, the role of formal nurse leaders is powerful in establishing the context for autonomy and CONP. In contrast to the traditional commandand-control management style that results in stabilization of practices, enhancing autonomy and CONP involves leadership that encourages
and fosters new ideas and innovation. This sort of controlled destabilization has been found to be a characteristic of Magnet facilities (Wolf,
Triolo, & Ponte, 2008). These situations require nurse managers and nurse leaders who value and support their colleagues input and decision

Work Upstream
In addition to addressing autonomy and CONP at the individual and organizational levels, nurses have real opportunities to shape the social,
political, and economic factors that influence their practice within the healthcare system. Whereas nurses describe autonomy in terms of
clinical practice, sociologists describe autonomy as the right of a profession to control its own work free from the influence or power of others
(Freidson, 1988). In other words, nurses use the word autonomy to describe the freedom to make decisions about an individual patient, while
sociologists use the word autonomy to describe the freedom of a profession, such as nursing, to make independent decisions about its body of
knowledge and its work.

Nurses today have the opportunity, even the obligation, to ensure and enhance both autonomy and CONP by influencing social, political, and

economic factors related to their practice.

Nurses today have the opportunity, even the obligation, to ensure and enhance both autonomy

and CONP by influencing social, political, and economic factors related to their practice. Even as the importance of nurses contributions have
become increasingly clear through studies demonstrating that nursing practice impacts the quality of patient outcomes in hospitals, the
underlying technical expertise and unique knowledge needed to influence these outcomes is largely unclear to the public and even to nurses
themselves. In spite of years of desire and demonstration to the contrary, the publics perception of nursing practice is still largely that of a
handmaiden to the physician (Buresh & Gordon, 2001). Although the public highly regards nurses, they do not highly value nurses in terms of
believing that nursing care is equally as important as medical care in contributing to health (Gordon, 2005). Nurses can promote and expand
their autonomy and CONP by publicly identifying their unique expertise in health and patient care in easily understandable terms in a way that
shows the value of their nursing expertise. Nurses need to communicate that their work involves an exclusive knowledge base and skill set
that is different from and even unknown by physicians. This knowledge/skill set includes monitoring of patient and public health status
(surveillance); managing complex, highly technical interventions; integrating and coordinating healthcare services; and providing relevant
education and emotional support in furthering health (Institute of Medicine, 2004).
Lack of clarity about the contribution of nursing may be related to the multiple educational levels and diversity of roles within the profession.
Nurses earning diplomas or associate degrees often do not have content in their curriculum to prepare them to advocate in the social or
political context. Further, the lack of acknowledgement, even within the profession, of the wide range of roles and expertise that constitute
nursing contributes to the devaluing of the work. Although nurses conceptually describe the profession as caring for the individual, family, and
community, nurses often discount colleagues not providing direct patient care by describing them as not real nurses. This negating of
nurses contribution to the managerial, policy, educational, and research components of professional practice diminishes the recognition of the
full contribution of nursing knowledge and expertise (Truth about Nursing, 2006). None-the-less, all nurses have a contribution to make
upstream in the social and political process. For example, novice nurses with entry level degrees can communicate about the role and
responsibility of registered nurses with their individual patients. Colleagues with advanced degrees can serve as primary investigators to
conduct research to demonstrate the impact of nursing practice. All nurses can acknowledge their colleagues contributions in various roles
and practice settings, and thereby assist the public to value the depth and range of the nursing profession in healthcare.

Nurses need to communicate that their work involves an exclusive knowledge base and skill set that is different from and even unknown by


Similarly, nurses can influence the economic and political factors that enable or constrain nurse autonomy and CONP.

Conversations about reforming the United States (U.S.) healthcare system have placed U.S. nurses in a desirable position of having enormous
influence in the dialogue (see the American Nurses Association [2009] webpage health system reform). Certainly decisions about the
economics of healthcare influence the practice environment and degree of autonomy and CONP of nurses. Just as the transition from fee-forservice to prospective payment influenced the context of nursing practice, decisions on future payment structures for healthcare will impact
the practice of nursing. In this climate, nurses need members of their profession to have economic and political prowess to proclaim what is
unique to nursing and negotiate for their professional role (Turkel & Ray, 2000). In this venue, professional nursing associations can have a
powerful impact on promoting autonomy and CONP both by enhancing the skills of nurses and by leveraging a collective response in the
political arena. In addition, appointing and electing nurses to positions with political influence on local, state, and national levels can ensure
that nurses unique expertise is included when decisions that will influence nursing practice are made.

The publication of the original research on Magnet hospitals concluded with a section on the overarching importance of autonomy and CONP
(McClure, Poulin, Sovie, & Wandelt, 1983). Inherent in autonomy and CONP is nurse powernot power to dominate, but power to contribute
uniquely nursing knowledge and expertise to patients and the organization. This power both enriches the practice of nursing and positively
impacts the quality of patient care. Establishing strong structures and processes to enhance nurse autonomy and CONP provides for the
engagement, inclusion, and ownership of nurses over their clinical practice, and thereby enhances the health of the work environment.

Table. Strategies for Enhancing Autonomy and Control Over Nursing

1. Strategies for Enhancing Autonomy
a. Clarify expectations about clinical autonomy
i. Describe expected behaviors
ii. Embed nursing knowledge into clinical practice

iii. Recognize and reward autonomous practice

iv. Role model expected behaviors
v. Coach nurses not demonstrating expected behaviors
vi. Provide manager support for autonomous practice
b. Enhance competence in practice
a. Create a learning environment
b. Enable formal and informal educational
2 Strategies for Enhancing Control Over Nursing Practice
1 Establish participative decision making
Use an organized structure for nurse participation in
decision making
Ensure authority for clinical decision making resides
with direct care nurses
Include nurses on organizational committees
iv. Minimize bureaucracy
v. Support involvement by nurses on committees and
2 Enhance competence in decision making
Teach nurses about the decision-making process
Coach and support nurses through early decisions
Teach facilitation skills to leaders
2 Strategies for both autonomy and CONP
1 Ensure strong nurse leaders
Create strong, visible, nurse leaders
Ensure that nurses in supervisory positions are
encouraging autonomy and CONP
Have executives advocate for influential nursing
iv. Encourage new and innovative ideas
2 Work upstream
Influence social, political, and economic factors
Publicly describe nursings unique expertise and
Acknowledge nurses contributions in all roles and
practice settings
iv. Use political clout of professional organizations and
nurses in leadership roles
Marla J. Weston, PhD, RN
E-mail: Marla.weston@ana.org
Marla J. Weston, a nurse leader with nearly 30 years of diverse management experience in healthcare operations, is the Chief Executive
Officer of the American Nurses Association and the American Nurses Foundation. Dr. Weston graduated with a bachelor of science degree in
nursing from Indiana University of Pennsylvania, a master of science degree in nursing from Arizona State University, and a doctoral degree in
nursing from the University of Arizona, where she received an outstanding dissertation award. For years, her practice, research, and writing
have centered on enhancing autonomy and control over practice in nursing.