Differentiated Practice: The Evolution Professional Nursing JOELLEN

KOERNER,

Differentiated practice identifies and uses three distinct nursing roles to create a comprehensive nursing care delivery system that meets client needs across the health care continuum. Clearly defined associate degree in nursing, bachelor’s of science in nursing, and master’s science in nursing competencies present career opportunities for professional nurses at the bedside providing, integrating, or managlng client care as well as options in management, education, and regulation. An evolutionary paradigm shift required of all nurses is the awareness that each nurse is not the whole of nursing, but rather each nurse contributes to the whole of nursing. A nursing community comprised of dlfferentlated roles that are mutually valued and well integrated will position nursing as a powerful force in meeting the diversity and complexity of health care needs in contemporary society. (Index words: Community; Differentiation; Integration) J Prof Nurs 8:335-341, 1992. Copyright 0 by W.B. Saunders Company The professionalism of nursing will be achieved only through the professlonhood of its members. Margretta Styles

RN,

MS,

FAAN*

the health care continuum. in a manner public,

responsive

the concerns

pectation

force rn rhe health

system of nursing education and licensure, which fails co differentiate the competencies and responsibilities of each type of nurse,

has confused

employer

deep divisions

and created

the public within

and the nursing.

Differentiated practice refers to a philosophy that structures roles and functions of nurses according to education, experience, and competence (Boston, 1990). It recognizes the importance of all roles in creating

the whole community

of professional

nursing

practice. Differentiating practice roles provides the nursing profession with a vehicle to create an integrative nursing care delivery

system

based on client

needs across

*Vice President, Patienr Services, Sioux Valley Hosplcal, Sioux Falls, SD. Address correspondence and reprint request to MS Koerner: Sioux Valley Hospital, 1100 S Euclid Ave, PO Box 5039, Sioux Falls, SD 57117-5039. Copyright 0 1992 by W.B. Saunders Company 8755-7223/92/0806-0007$03.00/O

Journal

of Professsiotzal Nursing,

professional

nurses

to the health care needs of the of the payor,

of nurses will position

Community among

and the career ex-

nursing

care industry

as a powerful

as we approach

reflects

the capacity

individuals-relatedness

the

events in history,

to nature,

for relatedness

to other

people,

to

to the world of ideas, and

to things of the spirit (Palmer, 1988). The feminist concept of community calls for a new way of being in the world,

living in a connected

the universe. caring,

Nurses are familiar

reciprocal,

intuitive.

interactive,

sense with others and with notions organic,

such as

bodily,

We have long been expert ar weaving

and these

behaviors into client care activities. What has been sadly lacking is this form of interaction among ourselves. Nurses (women) have been socialized to serve others and to look out for others’ best interests. A

missing

element

sion for nurses

ROFESSIONALISM REFLECTS the composite character of a particular profession. The current

Using

2 1st century.

(1982)

P

of

in the socialization

process is permis-

to also be SO inclined

towards

them-

selves. Self-awareness must accompany otherawareness if true community is to exist. We must understand

the impact

of our presence

and behaviors

on the group as clearly as we articulate the impact of group behaviors on ourselves and our work if a healthy, growth-producing community is to exist. A true nursing community requires: (1) clearly differentiated professional roles rhar are mutually valued and well integrated to provide the full scope of nursing service, (2) a shared governance model based on concensus-building relationships that move towards a collective vision on behalf of the self and others, and (3) a growth-producing culture that provides information and feedback that fosters autonomy and professional ideology.

The Paradox of Differentiation and Integration Organizations, professions and, individuals of the postindusttial era are faced with conflicting ideas and issues. Fundamentally, a paradox embraces clashing ideas that involve contradictory, mutually exclusive

Vol 8, No 6 (November-December),

1992:

pp 335-341

335

336

JoELLEN

elements

that are present

the same time (Quinn of paradox

& Cameron,

occur more frequently

that are driven complexity,

by increasing

constrained,

Lawrence patterns zations

ferentiation providing greatest efficiently

of information,

evaluated

yet

the work

throughout

the United change

best serve society through

of services education

pro-

study showed that orgam-

by rapid technological

exchange

provided.

Thus,

or inthe dif-

institutions

and health care demonstrated

need for role differentiation carry out their mission

Foundation

to define and

laureate degree nurse (bachelor’s of science in nursing;

yet rigid.

(1967)

by the Kellogg

differentiate

times

This phenomenon

industries

illuminating

affected

formation

flexible

ect funded

1988). Perceptions

that is rich in opportunity

and Lorsch

in major

States. Their

at

in turbulent

amounts

and competition.

duces an environment highly

and that operate equally

KOERNER

to effectively to society.

the and

Paradox-

associate degree nurse (ADN) and bacca-

BSN) competencies nents: provision ment

in three

major

of care (Primm,

1987).

Alliance

in Nursing

their practice

to create advanced

ter’s of science in nursing; system

they designed

quality

satisfaction Santema,

of care,

to

nurse (masFur-

care delivery

nursing

roles to en-

use of resources,

1989; Koerner,

responsibilities

degree

MSN) competencies.

for nurses (Koerner,

An integrated

adapted

competencies

an integrated

based on differentiated

hance

compo-

and manage-

One hospital

the Midwest

thermore,

nursing

of care, communication

and

Bunkers,

career

Nelson,

&

1990).

care delivery system divides the work of client

care across

three

distinct

ically, the factor that separated the strong agencies from those less successful was the degree of integra-

nursing roles: (1) the ADN nurse provides nursing care for clients during a specified work period in

tion found within

structured

the institutions.

a paradox embraces clashing ideas that involve contradictory, mutually exclusive elements . . .

. . .

Within

a differentiated

system,

the danger of frag-

mentation exists as each department nization from its unique perspective.

views the orgaThis same po-

tential exists within the nursing profession as it moves from the old paradigm of “a nurse is a nurse.” Integration within the organization or the profession refers to the degree of collaboration existing among departments or individuals to achieve unity of effort in accomplishing

the goal. Effective integration

on three interrelated

variables:

settings

and/or

where

the policies

health

care are established;

situational

and procedures

environments for provision

(2) the BSN nurse

of inte-

grates health care for clients from preadmission to postdischarge and functions in structured and unstructured geographical and/or situational environments that may not have established

policies and pro-

cedures,

judgement

using independent

nursing

when

integrating health care; and (3) the MSN nurse provides leadership that promotes holistic client/health care outcomes

and functions

in various

time orienta-

tions and settings with dynamic boundaries, using independent nursing judgement based on theory, research, and specialized

knowledge.

Sample competen-

ties include: PROVISION

OF CARE

depends

clear role delineation,

1. ADN:

Monitor

and evaluate

immediate

pa-

a structure for joint decision making around common goals, and autonomy of individuals and groups to act

tient response to nursing and medical treatments. Example: Administer pain medication

based on a common

as appropriate and assess client document clearly.

plan (Batey,

1983).

Differentiated Practice Roles Competence connotes a standard of excellence in performance underlying the ability to be professionally effective. A competency is a performance standard that includes skills, knowledge, talents, and understanding that transcend specific tasks and is guided by a commitment to ethical and scientific principles of standard is the nursing practice. This performance basis for professional accountability. The Midwest AlIiance in Nursing sponsored a proj-

response

and

2. BSN: Monitor, evaluate, and trend patient responses to nursing and medical treatments over hospita1 stay. Example: Inform physician that client has been receiving narcotic medication for 3 days and note frequency of pain medication administration and suggest changes in dose or agent as patient condition indicates. 3. MSN: Analyze delivery systems and client care through the use of theoretical frameworks to promote the delivery of holistic

DIFFERENTIATED

care. Example: Apply man,

337

PRACTICE: AN EVOLUTION

Newman

1986) to identify

response

to pain

findings

and

into long-term

theory (New-

client’s

life pattern

stress,

incorporating

plan for chronic

pain

Implementation structure

that supported

through

role and salary differentiation.

dentialing practice

management.

of this model required professional

was established

along

Implement

to encourage porting port

goal-directed

expression

safe coping

through

during

2. BSN: Facilitate promote

effective

diversion

coping

and

testicular

to

mecha-

changes. Example: Notof coronary disease and

cancer, plan for client teaching diet

. , .

and dialogue. interactions

long-term

nisms and life-style ing family history

on cholesterol

self-examination

while

hospitalized.

and counseling strategies in complex situations. Example: On discovering an at-risk [adolescent

testicular

convene a group of interested

departments

with

hospital

and within

the

itself.

cancer],

nurses and lead

the development of a self-examination program and strategies for its implementation.

the overwhelmingrequest

from staff members was for a class on teamwork and relationship issues. Nursing

administration

classes on discharge system,

3. MSN: Display leadership in assessment, development, and implementation of teaching

population

structure.

of roles and responsibili-

at the interface

and other

practice

peer evaluation

by a male

hospitalization

goal-directed

nursing

with

a crenursing

Example: Sup-

experienced a prolonged

appropriate

management

of needs while sup-

behaviors.

the frustration

adolescent

interactions

practice

Also,

decision-making

Such radical differentiation ties raised challenges

1. ADN:

nursing

system for entry into the corporate

and a shared governance COMMUNICATION

a corporate

and

planning,

finance

a need

anticipated

and

for

the health care delivery management

to support

evolving role competencies. However, when surveyed the overwhelming request from staff members was for a class on teamwork examination

showed

much difficulty

and relationship that

nurses

with the nursing

as they were with interpersonal for integration

fostered

issues.

Closer

were not having

as

role responsibilities

dynamics

and the need

by the change.

Shared Governance Decision-Making Model MANAGEMENT

1. ADN:

Negotiate

The evolution

with the client

to establish

short-term goals that are consistent with the overall plan of care. Example: Monitor the food intake of a newly diagnosed tient

and correlate

insulin

diabetic

administration

pato

2. BSN: Use foresight to negotiate long-term goals with the client in developing a holistic plan of care. Example: If the diabetic is a Native American with cultural dietary preferences, assist with the modification of the dito address

nursing

has paralleled

the growing complexity of the health care delivery system. As medical practice has continued to subspecialize in response to changing information and technological systems, so too is nursing differentiating practice

roles that are essential

to the implementation

of the full spectrum of nursing’s practice responsibilities (Newman, 1990). Empowered decision making

blood sugar levels.

etary teaching preferences.

of professional

these

needs

and

3. MSN: Evaluate system effectiveness and efficiency through monitoring client outcomes. Example: If the diabetic Native American is a pregnant woman, case manage her care on the reservation to assure a healthy for both mother and infant.

outcome

is essential

if the maximum

potential

to be realized. In the author’s ated roles that operate within

of each nurse is

experience differentia shared governance

model of decision making decreases the competition among nurses. A congressional model of governance was established within the Nursing Department, with each unit creating four councils to govern practice: (1) Clinical Practice Council-adopts and/or revises standards of performance, hires practice partners, and manages patient care decisions; (2) Quality Assurance Council-evaluates the standards of practice, creates and supports research and study projects, and man-

338

JoELLEN KOERNER

process; (3) Nursing

ages the peer evaluation ment

Council-manages

fiscal

assurance

equipment

resource

monitoring,

budget,

guides

Manage-

allocation

operates

through

the

self-scheduling

capital

activities,

tice knowing

when to wait and when to move ahead,

when they are centered on guard.

Time

experimenting

and space are essential with alternatives

and guides systems issues that impact unit operations;

the issue and refining

and (4) Nursing

for the group.

cational

Education

needs that support

unit cardiopulmonary other

inservice

budget,

edu-

practice

runs

resuscitation

requirements,

manages

preceptor

tation and cross-training ing student

Council-identifies

activities

recertification

administers

council,

of unit-based

porate decision-making

and supports

serves on the corre-

which is charged activities.

with

The final cor-

body on issues that cannot

be

level is the Nurse

Council, which is composed of the vice for patient services, clinical directors, and

the chair of each department member,

nurs-

including

in the concensus Communal

council.

the vice president model of dialogue

conflict

the whole group

is a public

grows

Each council has equal voice

and decision.

encounter

through

in which

the process of con-

census building by exposing the questionable issue in an arena protected by the compassionate fabric of human caring. The theme of concensus is to value both the process and the product fact that

we become

equally,

whatever

living

out the

we do. In concensus

building, the vision is released, and a gestalt is negotiated that creates a qualitatively different product that what each could create separately. The vision may be altered as it is lived out; thus, the axiom “maintain the vision but embrace In working

toward

that ultimately

concensus

to end or release a vision.

release or eliminate,

Revisiting

the process can be re-energizing

The key to successful ability

the hybrid”

specific changes,

must be honored. each remembers

building

is the

Unless we are able to

we become

blocked

with

forms. To be able to release or end without the next step fully is the challenge

old

knowing

in this process. We on the

next step. If we must know what will happen next, we are limited learning

to that

community

we can imagine.

is to evolve. Learning

ing our power heal,

which

to trust the process is essential

Thus,

if a creative

to end means tak-

seriously-our

power

to love or to abuse,

to create

to harm

or to

or to destroy.

Roberts Rules of Order can be replaced by concensus building in the change process. Thus, nonviolent change occurs as the spiritual and political dimensions of our lives are integrated, different

creating

a qualitatively

community.

A co-consulting

frame of reference

is emerging

in

which each level of practitioner is sought and valued for their unique and timely contribution to the totality of client care. The paradigm shift required of individual

nurses is the awareness

that they are not the

whole of nursing, but that each nurse contributes to nursing practice as a whole (Fig 1). Nurses who were educated and socialized during the “team leading” era appear to have less difficulty with this concept than more recent graduates

socialized

to the primary

nurs-

ing model. Collegial

and collaborative

only when the varied nursing

one can change only oneself.

or

to allow for

selected.

are only really free if we can risk everything

resolved at the unit or department Executive president

the travel

on the unit.

department

standardization

and

issues that arise in orien-

activities,

The chair of each unit council sponding

standards,

and when they are defensive

partnerships

can emerge

roles are understood

and

valued mutually. In a true partnership the power on each side is respected by both, with recognition and

Concensus buiiding

is based

the creative process.

on

Concensus building is based on the creative process. The creative process is nonrational; a norm for experimentation with various methods and approaches allows all community members to connect with their intuitive knowledge. The process is nonlinear; at some level each member already knows what is essential to know. Supportive leadership and small groups best facilitate mutual trust and an ability to work together. Through clear and candid feedback in a supportive environment, all community members prac-

acceptance of separate and combined spheres of activity and responsibility. There is mutual safeguarding of the legitimate interests of each party and a commonality of goals that is recognized by both parties (American Nurses Association, 1980, p. 7). A community that operates on principles of growth and concensus sets the stage for true partnership.

Growth-Producing Culture Land (1973) sees human behavior as a growthdirected activity. “Grow or die” is the imperative of life. A basic drive of the physiological and psychological process is to ingest external materials and convert them into extensions of the self. This activity requires

DIFFERENTIATED

339

PRACTICE: AN EVOLUTION

FORM CBnicaI Practice

Resource Management

Quality Assurance

Education Research

PHD Figtlve 1. Form and function of differentiated practice. (Reprinted with permission of Sioux Valley Hospital, Sioux Falls, SD.)

MSN INTEGRATION (The Healing Web) BSN

nutrition:

food for physiological

growth

and informa-

outside

must

be integrated

if wholeness

is to be

tion for psychological growth. Feedback is the other essential ingredient in an accommodating environ-

achieved.

ment.

context or environmental issues facing both nurses and clients. These practitioners can be a powerful cat-

The cell ingests

its environment

it into like cells. Humankind a cultural

group

and

extends

performs

acts

and transforms the self within that

facilitate

growth of self and others. Both the cell and the human modify their subsequent behavior based on the “feedback” response from the environment.

Advanced

practice

alyst to promote ment.

roles focus more heavily

and support

professional

on the

develop-

Along with expanded role competencies, differentiation calls individual nurses to more deeply internalize a professional ideology. The challenge inherent in this call can best be illustrated in paraphrasing the

. . growth cannot occur independently; it requires interaction and integration between the growing thing and its environment. .

Just as organs

determine

the growth

tures determine the growth within them. When a nurse role within a nursing practice, omy and initiative expressed

of cells, cul-

of the people living assumes a professional the amount of autonis determined by the

corporate culture. A culture establishes the level of information available. Furthermore, culture determines the response of the environment to attempts at using the new growth that the information produces. If the conditions of nutrition and feedback permit new growth, patterns of behavior become responsible and creative. If not, lack of alternatives result in regression to more basic growth patterns. Thus, growth cannot occur independently; it requires interaction and integration between the growing thing and its environment. Nothing grows totally from the inside. Something from the

work of Golding

(1982,

pp.

186-187,

Fig 2):

The typical American Thanksgiving Day Parade is emblematic of nursing in the twentieth century. The gas filled figures of Charlie Brown and Lucy are like the ideologies with which we are enthralled. These oversized figures, grinning, bobbing and swaying in the breeze, dominate the ant-like figures below to whom they are tethered. Little by little the procession with its totemistic figures has become a metaphor for professional nursing; the hurrah for professionalism, collaboration and autonomy. Down empowerment, the street of our common rhetoric they come. They dwarf the nurses who glibly profess these concepts as the driving force for their commitment to nursing and the public they serve. Whether we are in the procession, holding one of the ropes that support our idols or among the crowd on the sidewalk, we all know that to one degree or another-these inflated ideologies inform and nurture our current neuroses. Close examination reveals that many: seek autonomy without assuming the accompanying accountability for ALL decisions and actions; claim professionalism while viewing nursing as a job rather than a career, an integral part of a person’s identity; call for empowerment while tightly controlling client care decisions rather than mutually establishing care goals with the client; desire collaborative relationships with physi-

JoELLEN

340 Differentiated bedside,

practice legitimizes

giving

nursing

authority

skills executed

petence.

Beyond

culture

reward

practice

care industry,

health care environment, legal and regulatory

the profes-

within

institutions

those who educate essential

within

of disdain:

when

making

in their educa-

a new “knowing”

will emerge.

the profession

comments

pathway,

to the

care. As indi-

choices at various junctures

the work of others

and

in a changing

aspect of nursing

tional and experiential

a

and re-

and those committed

begin to plan for a career in nursing,

individual

to

level of com-

at the bedside,

educate nurses to competencies

viduals

financial

of those who create and support

for nursing

the health

the expert at the

at the advanced

nursing

sion is comprised

and

KOERNER

of

The day will arrive

we will

no longer

“She’s no longer

a nurse

hear . .

she left the bedside. ” “How does she know what I do, she is never on the floor. ” “She’s not a very good nurse,

her bath was not done by 1O:OO.” These com-

ments demonstrate a lack of understanding spect for the totality of nursing’s work. As nursing education programs and didactic experience of ADN Figure 2.

Nursing

ideologies.

cians while failing at collegial relationships within the profession itself. At one time or another we have each walked in the procession, held a rope and felt the upward tug of the gas filled balloon. However, a true moral and ethical commitment to professional nursing demands the integration of these ideologies into our personal and professional behaviors and attitudes. We have clearly identified our status as victim of class and gender issues. It is time to move past anger and begin

a healing within the profession. We must demonstrate a collective, identifiable nursing ideology that is exemplified in the practice behaviors of ALL professionals. Only then will we create our rightful place among the ranks of health care professionals.

of or re-

redefine the clinical and BSN students,

and as role models within the health care system become available for role socialization, nursing school graduates will enter the market with differing entry level skills. ADN nurses will function in roles that provide physiological

stabilization

and client comfort. BSN

graduates will also be accountable for care planning, timely prepared discharge, and client education. Advanced-practice doctorate

preparation

level is also becoming

ized for increasingly

complex

at the MSN more highly

roles. Nurses

and

specialentering

postbaccalaureate work will be faced with unprecedented career choices. Those who have an interest in the diagnosis vanced study

and treatment of disease can take adwithin the medical/nursing paradigm

As nurses experience a context for their work that values and supports autonomy, collaboration, and concensus, a professional ideology will flourish, nursing’s work will be more satisfying, and the image of

and graduate as a nurse practitioner, combining ing and medical protocols surrounding client

nursing

paradigm and nursing case management. Nurses who have a deep passion for lifelong learning and the student-teacher relationship will study the principles of education to obtain a master’s or doctoral degree in nursing education and function as a professor. And finally, those nurses with a strong interest in systems, finance, health policy, and politics will gravitate to business and health administration classes, graduating with a master’s degree in business administration or a doctorate in nursing administration (Fig 3). As we begin to reassess our individual and collective career pathways, comments of support and re-

will be enhanced.

Future Considerations Traditionally, nurses entering practice had several career options available to them: they could become a staff nurse in a hospital, nursing home, clinic, or community health setting. Those most expert clinically were often promoted to management positions within these organizations. Others maintained their role at the bedside, being assigned increasingly more complex clients as their expertise grew but receiving little recognition or reward for service rendered.

nurscare.

Those with a deep affinity for nursing practice will obtain an MSN with a specialized focus in the nursing

DIFFERENTIATED

PRACTICE:

341

AN EVOLUTION

Projects of collaboration

between

nursing

education

and service need not be on a large scale to be successful. A joint pilot project committed munity

as its primary

ing. Engaging

in a mutual

herence to a preconceived learning

As the professionhood deeply integrated fessionalism

without

strict ad-

each other,

of linear,

behaviors,

in the new paradigm

com-

undertak-

will assist us all in

process,

Freed of the bondage

(versus goal-directed) treaters

venture outcome

to trust the growth

ourselves.

to building

goal is an honorable

and

goal-driven

we will become

for professional

co-

nursing.

of nursing

leaders become more

and collective,

so too shall the pro-

of nursing

be achieved.

References Admimstration

Figure 3.

The whole of nursing

spect will permeate the profession, improving the image and morale both within and outside the profession. The ADN nurse will be valued as an expert nurse because her patients are comfortable, well monitored and cared for. The BSN nurse will be valued for comprehensive care planning as well as a safe and timely discharge experienced by the client. The nurse manager

will be celebrated

for adequacy

of resources

and information on the unit or the clear understanding of why they are not available. Nursing administrators will be evaluated on the position nursing enjoys within the corporate context, the equity of salaries,

the

presence

of programs

and

projects

that

support and enhance the practice of nursing, and nursing’s relationship with medicine and other departments. The nursing educator will be sought for consultation regarding a theoretical framework or research finding that can be brought

to bear on a current issue facing the

practice. Furthermore, nursing education will be valued for providing well-prepared new graduates to infuse the profession with enthusiasm, talent, and caring. Nursing leadership is called to the creation of a nursing community nurses and individual

that extends beyond individual nursing units, beyond individ-

ual service institutions and schools of nursing, to encompass the totality of nursing. Creating this M-I-DD-L-E-G-R-O-U-N-D (Bunkers & Koerner, 1990) requires application of the principles founded in feminist ideology, adult learning strategies, human development theories, business and administrative principles, systems theories, political and social justice issues, and spirituality.

American Nurses Association. (1980). Nursing: A Social Policy Statement (#NP-63 35M, December). Kansas City, MO: Author. Batey, M. (1983). Structural considerations for the social integration of nursing. In K. E. Barnard, Structure to optcome:Making it work (pp. l-11). Kansas City, MO: American Academy of Nursing. Boston, C. (1990). Introduction. In C. Boston (Ed.), Current issues and perspectives on differentiated practice (AHA Catalog No. 154830: l-5). Chicago: American Organization of Nurse Executives. Bunkers, S., & Koerner, J. (1990). The M-I-D-D-L-EG-R-O-U-N-D: A model for interinstitutional integration. Nursing

Connections, 3( 1).

Golding, W. (1982). A moving target. New York: Farrar, Straus and Giroux. Koerner, J., Bunkers, L., Nelson, B., & Santerna, K. (1989).

Implementing differentiated practice: The Sioux Valley Hospital experience. Journal of Nursing Administvation, 18(6), 13-22. Koerner, J. (1990a). Implications for differentiated practice models for nurse executives. Aspen Advisor fir Nurse Executives, 4(

12). Koerner, J. (1990b).

practice

The relevance of differentiated in today’s environment. In C. Boston (Ed.), Cur-

rent issues and perspectives on differentiated practice (pp. O-O; AHA Catalog No. 154830:35-5 1). Chicago, IL: AONE. Lane, G. L. T. (1973). Grow or die. New York: Dell. Lawrence, P., & Lorsch, J. (1967). Organization and environment: Managing

diffwentiation and integration. Boston: Harvard University Press. Newman, M. A. (1986). Health as expanding consciousness. St Louis, MO: Mosby. Newman, M. A. (1990). Toward an integrative model of professional practice. Journal of Professional Nursing, 6(3):167-173. Palmer, P. J. (1989). Community, conflict and ways of knowing. Change, 5, 20-25. Primm, P. L. (1987). Differentiated practice for ADN-

BSN prepared nurses. Journal of Prof~sional Nursing, 3, 2 18-225. Quinn, R. E., & Cameron, K. S. (1988). Paradox and transformation:

Toward a theory of change in organization and Cambridge, MA: Ballinger. Styles, M. M. (1982). Towards a new empowerment. St. Louis, MO: Mosby.

management.