Current research would indicate that traditional, prescribed role behaviors have been deeply internalized by many mainstream nurses, with consistent performance of these behaviors preventing any real formation of progressive attitudes or more autonomous actions (Weiss & Remen, 1983). Over the years, nurses have been educated to fear generating controversy or taking risks, and instead to rely on those in "authority" to make correct decisions (Blackwood, 1979; Gluck & Charter, 1980; Grissum, 1976; Grubb, 1979; Hutchings & Colburn, 1979). While many educators have taken definitive stands against such approaches, others have not. Yet it is the educator who holds a crucial and influential position through which to mobilize nurses toward fuller realization of their potential. Education for autonomy and responsibility, more than any other kind of education, may enable nurses to maximally use their expertise and to feel actualized as members of the nursing profession.
However, it is no simple task to successfully transform role behaviors which have been a foundation of a profession for years. A dual approach of role education and role experimentation is essential if nurses are to acquire the knowledge and skill they need. The Figure shows a model for role transformation and indicates the key positions which education and experimentation hold in the role transformation process.
As seen in the model, role education addresses itself to the belief systems held by nurses. Its aim is to facilitate the knowledge and awareness of individual nurses regarding the deeply held attitudinal patterns they have assumed. In complementary fashion, role experimentation attempts to modify habitual patterns of deferent behavior by encouraging nurses to test out new behaviors.
Inherent in this joint education/experimentation approach is the design to 1 ) stimulate awareness and readiness to learn, 2) make learning concrete and relevant to the work environment, 3) offer opportunities to apply information in simulated situations so that feedback and support can be given if difficulties arise, and 4) require the learner to try out new behaviors in the actual work setting so that assistance can be provided when barriers to using new role behaviors are encountered. Such an approach allows the learner to more easily internalize new roles since it encourages graduated change and gives continued mentorship during the inevitable difficulties encountered in role transition.
In addition, a systematic, experimental approach to learning these roles affords concrete and readily apparent results, yielding opportunities for self-critique, feedback and readjustment of one's behavior to achieve desired ends (Bandler & Grinder, 1975; Fishbein & Ajzen, 1975; Hutchings & Colburn, 1979). Consequently, there is greater potential to dramatically influence the self-perception and attendant attitudes of the individual as well as the behaviors of others in the individual's environment.
The lack of role education and experimentation has been a major factor in the debilitation of nursing power in health care delivery. The role transformation process seeks to systematically increase nursing readiness to assume more power in health care, for it is a nurse's state of readiness which determines her governance potential (that is, the ability to control the course of nursing and influence the conduct of ongoing health care activities). Our governance potential, in turn, decides the degree of impact which we will have on the cost, quality, and direction of health care. As shown in the Figure, the process is ultimately a cyclic one whereby nursing impact also affects governance potential which affects each nurse's individual belief and behavior systems. Without external intervention to transform ongoing belief and behavior systems, the cyclic process continues to perpetuate a nurse with less than adequate potential and minimal impact. Via role education and experimentation, the cycle can be broken and new patterns can emerge.
ROLE TRANSFORMATION PROCESS
Existing nursing attitudes and behaviors (Weiss and Remen, 1983) would indicate that role transformation needs to occur in five major areas: 1) Defining and Articulating the Nursing Domain, 2) Legitimizing the Nursing Profession, 3) Communicating in Professional rather than Non-professional Modes, 4) Negotiating Collaborative Roles, and 5) Cultivating the Organizational Network.
Defining and Articulating the Nursing Domain
Students and experienced nurses alike must be provided with opportunities to critically examine the scope of their nursing expertise so that they can clarify for themselves the unique areas of knowledge and skill which are the direct outcome of professional nursing education (Brunner & Singer, 1979). There is a growing body of literature within the profession which offers an effective foundation for outlining the substance of the nursing domain (Donaldson & Crowley, 1978; Fawcett, 1981). Common assumptions and misconceptions regarding physicians' and nurses' skills should be openly discussed so that nurses can begin to clearly differentiate their own skills from those of physicians. This is especially important since numerous spheres of professional overlap have recently emerged in health care.
For example, as major diagnostic and treatment decisions become increasingly computerized and the importance of supportive, facilitati ve care is recognized, physicians are identifying patient education, health promotion, and psychosocial aspects of care to be major components of their practice. This change is most visible in the gradually shifting priorities for medical student education (Fine & Themen, 1977; Herman, 1975; Hudson & Giacalone, 1975; Mumford & Wikler, 1976; Ward & Stein, 1975). As nurses, we must be able to clarify and assert our existing spheres of practice as well as those emerging spheres which we are best prepared to manage by reason of our unique expertise. If we cannot, the scope of nursing practice will be narrowly defined by others and nurses' unique skills will continue to go unrecognized.
Through exposure to operative models and simulated practice, we must teach our students and colleagues to articulate the nursing domain to others and to educate both patients and health professionals as to their functions and competencies in health care. Skills of articulation include the ability to discuss with patients and physicians how they mutually view each other's responsibilities and to differentiate for others responsibilities which can be shared from those which are uniquely nursing.
Patients, in particular, generally have little understanding of the nurse's educational background or decision-making skills. They assume that the physician possesses superior knowledge in all health-related matters and that the nurse's sole function is to carry out physicians' orders (Weiss, 1981). It behooves us to teach nurses how to use their time with patients to counteract these distortions. For example, one important aspect of patient education is to help the patient gain a realistic understanding of the skills which various professionals hold. Only with an accurate picture of nursing expertise can patients appropriately turn to the nurse for professional advice and recommendations.
Legitimizing the Nursing Profession
Equally as important as the ability to articulate the nursing domain is one's ability to convey a nursing image conducive to expanded authority and responsibility. To successfully communicate such an image, nurses need first to recognize ways in which they may invalidate both themselves and the profession. With this awareness as a base, they can begin to practice instead the use of professional, legitimation strategies.
Nursing's historical struggle for recognition can be viewed as a tremendous resource to this validation process, for it represents a valuable "muscle toning" experience through which internal strength and many talents for survival have been acquired. We must assist students and colleagues in using this talent reservoir, bringing forth the basic self-trust which they may have deeply buried. It is this inherent confidence to which others in the work environment must be exposed since the power to create a legitimate image of the profession depends to a great extent on the nature of nurses' interaction with others (Kalisch, 1979).
Although a nurse may not consciously experience a sense of inner self-assuredness, a confident behavioral approach can do much to improve her image (Dyer, 1977; Scheele, 1979; Sher, 1979; Weiss, 1981). For instance, nurses need to openly communicate the individual contributions they make to the health care team. In the context of ongoing discussion, they should make a point of commenting on various approaches they have successfully used or different programs or techniques they may have initiated. We often see such behavior as egocentrism when, in fact, it serves as an effective educational tool for strengthening the power base of the individual nurse as well as the profession.
Nurses should also be taught to initiate discussions with physicians in topical areas where the nurse has strong intellectual expertise. By discussing content which is clearly in the nurse's domain, there is the opportunity to assume the role of educator with the physician instead of the more commonly assumed roles of learner or assistant. Legitimation of the profession necessitates that individual nurses learn how to realistically identify those areas of skill which are their greatest assets, and negotiatefor positions where these skills can be used. Concomitantly, each nurse must know how to assess areas of minimal competence and avoid performing in arenas where these skills are required. If steps are not taken to place oneself in appropriate competence arenas, the nurse will be observed and evaluated on a weak foundation of knowledge and ineptly executed skills. Negative stereotypes of the profession will then continue to be reinforced.
To further prevent thèse negative stereotypes, we can teach students and colleagues to publicly uphold the profession of nursing rather than demeaning either the profession's or their own status. Any comments about the problems and inadequacies within the profession are better reserved for debate with other nurses; for non-nurses are never privy to a complete information base and may interpret pejorative comments as a full set of facts upon which to evaluate the profession.
Communicating in Professional Rather than Non-Professional Modes
The ability to employ professional communication as an integral part of nursing role behavior goes hand in hand with legitimation of the profession. Nurses need to learn how to assess their own modes of communication, and use those modes which elicit perceptions of them as a colleague and an authoritative professional (Hargraeves, 1980; Sovie, 1980).
Fundamental to professional communication is the active sharing of professional opinions with physicians and patients. Strategies for offering opinions must be taught and practiced with emphasis on using a cognitive, knowledge-based communication style when interacting with those in the work environment. Regardless of their potential validity, suggestions based on personal feeling or intuitive impression have done much to diminish the nurse's credibility in the eyes of the medical world (Hargraeves, 1980; McClure, 1978; Weiss & Remen, 1983). Nurses can be taught instead to present their ideas in a thoughtful and empirical manner, substantiating recommendations with a detailed rationale and factual supporting data.
The nature of professional communication also requires that nurses learn to screen their own words and gestures so as not to convey any quality of subservience when relating to physicians or administrators. For example, the formality of an interchange between nurse and physician should always be equalized. If a physician calls a nurse by her first name, the overture should be returned by addressing the physician by his first name (e.g., "John") rather than as "Dr." Otherwise, the nurse is subtly but assuredly placed in a subordinate position.
As well as modifying the characteristics of their communication, nurses should be taught to increase the frequency of their contributions to patient care decisions. They can demonstrate their skills and abilities through more active participation in discussions of patient care with physicians and other professionals. Such participation implies that nurses consistently provide opinions about diagnoses and treatment, openly speak to physicians about any of their orders which seem inappropriate, and be present at significant health care events (such as informed consent) so that the nurse's information base and opportunities for ongoing, immediate input are increased. These types of involvement, though often not invited, will ultimately lead to a greater role in the more power laden zones of health care.
Negotiating for Collaborative Roles
There is little likelihood that use of professional communication will substantially influence our governance potential unless we can effectively define and adjust our roles in relation to others. Role relationships in the health care system can be likened to a hanging mobile, with each of its pieces delicately balanced, dependent upon one another for continuing homeostasis. If one part of the mobile becomes heavier, or is jostled in some way, the entire mobile is influenced. A rejuggling, a period of chaos, a struggle to again acquire stasis must then occur.
Analogous to the mobile, nurses' role experimentation will cause temporary upheaval within health care relationships, requiring sensitive negotiation if new behaviors are to be permanently integrated into the existing structure. It is our responsibility, therefore, to teach negotiation, a threefold process involving role empathy, role clarification and role assertion.
Role empathy indicates an awareness and interest in the perspectives and needs of others in the work environment, interest based on integrity and fairness as well as concern for ones own territorial advantage. While nurses are quite skilled in empathizing with patient need and motivation, the use of empathy with professional colleagues is rare (Friedrich, et al., 1979; Kaiisch, 1971; Weiss, 1977). Once nurses learn to hypothesize about physicians' or administrators' perceptions of nursing role experimentation, they can respond more intelligently and sensitively to any resistance or anger shown toward their changing behavior.
Role clarification is a process which elucidates mutual expectations and merited degrees of entitlement and responsibility in role relationships. Clarification involves a) the identification of ground rules for allocation of responsibility on the health care team, b) specification of diverse expertise on an individual basis, c) resolution of differences of opinion regarding responsibilities, and d) delineation of mutually acceptable roles in the health care relationship. Successful role clarification relies on such fundamental approaches as the following: checking out all personal assumptions about others in the health care relationship, clarifying and qualifying what is said to others, asking others to clarify their own confusing or contradictory messages, making opportunities to acquire the viewpoints of others, and providing feedback to others on their views (Farrell, et al., 1977; Satir, 1972). Mastering each of these behaviors is essential to effective negotiation with those in the work environment, for they enable the nurse to decrease ambiguity in existing role expectations and further the resolution of any conflicts which result from disparate expectations.
Role assertion is the direct exercise of authority or influence regarding one's role in the work environment. Without assertion, role empathy and role clarification could result in the compromise of nursing standards. While compromise does have a place in role negotiation, it would appear to be a significant factor in debilitating current nursing roles. Historically, we have tended to compromise our need to be recognized for nursing skills which are credited to physicians and for the scope of expertise which we could potentially provide. In some cases, we have compromised our ethics in order to survive the political milieu of the health care system. Indeed, research has shown compromise to be the most common mode used by nurses in managing their differences with others (Weiss, 1981).
Role assertion can allow nurses to reach beyond the need to compromise and expand the traditional parameters of their present roles. It enables them to define responsibility more flexibly, and spontaneously assume responsibilities which are appropriate to their expertise. Role assertion provides the base for introducing a more autonomous nursing role into an unresponsive environment, including the ability to change one's approach when efforts to establish greater governance are rebuffed.
The combination of role empathy, role clarification, and role assertion yields a balanced repertoire of negotiation skills, including those which invoke forceful, instrumental use of self as well as those which entail receptivity and responsiveness to the needs and contributions of others. The use of this threefold process can effectively resolve role conflicts which emerge and result in a more mutually acceptable allocation of health care responsibility.
Cultivating the Organizational Network
Role education and experimentation in other areas will prove futile unless nurses also learn how to cultivate the organizational network in which they work. Cultivation skills include both the ability to recognize institutional factors which inhibit us from being influential members of the health care team as well as the ability to utilize organizational resources to maximize our governance potential.
To further these ends, students and colleagues can be taught strategies for identifying and fostering rapport with key individuals who can affect their progress toward greater nursing governance. These key contacts should represent a heterogeneous expanse, including nursing, medicine, hospital administration and other professional groups. Certain volunteers, support staff or health care consumers may also be vital inclusions to a network, having more impact on the distribution of resources than might be expected.
A systematic and ongoing dialogue with one's contacts is essential, for they provide a conduit to needed information and other resources which strengthen a nurse's power base. Working with the network requires that nurses sufficiently prepare themseves with well thought out, researched proposals or questions before approaching contacts, that they be selective in what and how much they share with whom, that they ask for support when needed and accept offers of assistance when given, that they ask for only one favor or consideration at a time, that they make requests specific, and that they follow up on leads, advice and information which are provided (Scheele, 1979), The nurse must also recognize the need to keep the network well informed regarding ongoing activities and to identify all benefits and risks of any proposed role changes. Acquiring the critique, suggestions and support of network members will build their level of readiness prior to any direct attempts at change.
We also need to emphasize the importance of such factors as the timing of interchanges with the network, hidden contracts underlying communication with network members, and the situational environment where interchanges occur. For instance, establishing a time and location conducive to egalitarian, productive dialogue is essential; otherwise the nurse may find that important conversations occur under stressful, rushed or less than optimum conditions. Efforts must be made to regulate these factors since they are fundamental to successful achievement of influence.
In addition to establishing a network of individuals, nurses need to be taught to seek out and assure participation on institutional policy-making bodies which affect their work environment (Aiken, 1981; Johnson, 1981; Longest, 1974). Since invitations to participate on these bodies will rarely be proffered, initiative needs to be taken to identify consequential committees and boards, to make interest in membership known, and to monitor the committee's activities until successful input is achieved. Presence as an observer of the group's effort will improve a nurse's potential for entree to eventual membership. As well as demonstrating commitment to participation, the observer role creates opportunities for contact with committee members who will have influence in determining a nurse's suitability for the policy-making body.
Whether in the context of one's individual network or on policy-making bodies, nurses need to learn strategies for developing and maintaining reciprocity within the organization (Phillips, 1979). Via reciprocity, contacts know which of their policies and issues they can count on the nurse to support in return for championing her causes. Achieving this kind of trust with key figures who influence the work environment can only be accomplished through a conscious choice to make these resources a significant part of our ongoing communication in the work world. It is the cultivation of the sociopolitical network which will allow the individual nurse and nursing as a profession to fully and successfully grow.
Enduring Role Transformation
Nurse educators can contribute significantly to the role transformation of mainstream nursing by providing opportunities for education and experimentation in the five areas just described. However, it is important to recognize that, initially, role transformation may produce more costs than benefits to nurses, for the barriers to change are great and the risks significant. As our students and colleagues assume new attitudes and experiment with new role behaviors, they will need substantial support in coping with alterations in their own self-perceptions as well as the natural resistance to change from within the delivery system. In addition, as they achieve more influence in health care transactions, nurses must also adapt to a greater onus of responsibility, for increased rights and power will concomitantly bring intensified obligation, accountability and liability.
It is at this crucial transitional juncture where there will be the greatest temptation to succumb to old behaviors. As educatore, we play a vital role in helping those who are learning new behaviors to see that by regressing to more familiar, more comfortable and less controversial patterns of behavior, they will forfeit the opportunity to strengthen their own governance potential and the profession's ultimate influence within health care.
Now is the time for nurses to achieve a more primary, more dominant and more recognized status in the health care relationship. It is time for nurses to embody a system of beliefs and behaviors which truly reflect their preparation. It is time for nurses to further the humane use of power by claiming more influence in the ongoing distribution of health care resources. More than ever before, it is time for nurse educators to move the profession forward by modeling and facilitating role transformation for both the student and the normative nurse.
We are what we are; and if we are to become anything more, now is the time to begin.
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