546413
research-article2014
NSQXXX10.1177/0894318414546413Nursing Science QuarterlyDonohue-Porter / Leading-Following Perspectives
Leading-Following Perspectives
The Creative Élan of Nursing Theory: Indispensable to Leadership
Nursing Science Quarterly 2014, Vol. 27(4) 330–335 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0894318414546413 nsq.sagepub.com
Patricia Donohue-Porter, RN; PhD1
Abstract The author discusses how nursing theoretical knowledge contributes to nursing leadership and how the use of nursing theory can build confidence in nurse leaders in all settings, drawing on examples from selected theorists’ work. It is suggested that when nursing theory is not fully valued by the profession, not only knowledge is lost but also the language that helps nurses to lead. However, the vision and the voice of nursing theory will allow nurses to lead with creativity and to tap into innovation that facilitates contributions to healthcare. To be firmly, intellectually, and enthusiastically grounded in one’s disciplinary knowledge sets the stage to being able to lead effectively. Four aspects of leadership are addressed: clinical, interdisciplinary, nursing education, and interpersonal nursing. Our accumulated nursing theories can help nurse leaders to meet contemporary healthcare challenges by providing answers that help to focus on improvement, patient-centered care, critical reflection, and caring. Keywords creativity, leadership, nursing theory, vision Early in my career as a clinical nurse specialist in diabetes, I was asked to give a Medical Grand Rounds presentation at a large medical center in New York City. I was invited by a physician several months in advance of the presentation and as the weeks went by he would check in with me, confirming that I would be using a theoretical base for this upcoming presentation similar to ones he had heard in my previous presentations. He said he had been struck by my use of nursing theory at diabetes conferences and wanted to make sure that my plan was to do so at the upcoming Grand Rounds. It was, and I let him know what to expect. When I arrived at the event, a kind but blunt, endocrinology Fellow who had been assigned to escort me told me that there had been much negative discussion about the idea of a nurse giving Grand Rounds, even though she was theoretical, and that the Chief of Medicine had been emphatic that the invitation should never have been given to a nurse. During the presentation I described diabetic patient care and education in light of Peplau’s (1952) levels of anxiety, Orem’s self-care management (2001), and Leininger’s (1991) attention to cultural details. The setting was (in reflecting back) somewhat stressful but the presentation went well and I felt confident, with great vigor and enthusiasm, because I was guided by a foundation of nursing theory. I had been used to excellent interprofessional collaborations, which are often the norm in the interdisciplinary setting of diabetes education but I felt that, in this particular presentation, theory helped me to distinctly show the contribution nurses brought to patient education and self-management. I offer this personal narrative to set the
stage for my assertion that nursing theoretical knowledge contributes to nursing leadership just as it contributes to nursing practice. The use of nursing theory can build creative confidence in nurse leaders in all settings; here I give examples of selected theorists’ works. I will close with describing how nursing theory helps to meet contemporary leadership challenges.
Voice and Vision of Nursing Theory Years have gone by and my leadership roles have shifted from clinical practice to nursing education, but the nursing theories that I have respected, used, and taught continue to be foundational to my nursing essence. I always use nursing theory in my classes and I often teach classes in advanced nursing theory. In those classes I begin with the writings of nurse theorists in relation to the profession, even before describing the details of their theories. To me, our nurse theorists write about the nursing profession and its advancement in ways that can awaken a commitment to nursing in students and a vitality that becomes central to dialogue and reflection in the classroom. I call these writings about the nursing 1
Associate Professor and Director, Adelphi University
Contributing Editor: F. Beryl Pilkington, RN, PhD, Associate Professor, School of Nursing, York University, HNES 345, 4700 Keele St., Toronto, Ontario, Canada M3J 1P3. Email: [email protected]
Downloaded from nsq.sagepub.com at University of New England on June 9, 2015
331
Donohue-Porter / Leading-Following Perspectives profession the voice of nursing theory. The voice represents how theorists describe their view of both our profession and the elegance of nursing practice. These voices are then coupled with the visions of the theorists as detailed in each of their specific theories. The visions are the processes of the nursing theories that allow us to care more effectively in any situation that requires nursing expertise. For me, as nursing theory integration into practice becomes less widely used and understood, I fear that we face a parallel loss of the words of the nursing theorists, how they vividly describe what nurses do and what nursing is. When nursing theory is not fully valued by professionals we lose not only knowledge but also the language that helps nurses to lead. Fewer nurses may become followers of particular theorists since there is less exposure. When nurses do follow a particular theorist they may be criticized as disciples, something that Baumann (2012) points out as a response that lacks appreciation for the breadth of unique theoretical work of these contributors to nursing knowledge.
Creative Élan Using the full force of both the vision and the voice of nursing theory allows nurses to lead with what Parse (2011) calls “creative élan”—a force and vigor that taps into innovation and facilitates marked contributions to healthcare. She uses this term in describing how the act of holding up a mirror may be used as a metaphor for glimpsing personal truths for fleeting moments (Parse, 2011, p. 169). When holding up the mirror to reflect upon personal meaning of the humanbecoming leading-following model, three processes of intimate contemplating, cautiously discerning, and wisely endeavoring are in place. The reflective glance in the mirror searches for creative élan as possibilities are envisioned around leading-following (Parse, 2011, p. 170). I will continue to use this term to demonstrate how creative élan born of nursing theory influences nursing leadership. A mastery of both nursing theory and knowledge of the descriptions of nursing that nurse theorists have given to us over the decades helps leaders to develop confidence and enthusiasm for the profession. Confidence, enthusiasm, vigor, and vivacity are components of élan. A manner of energetic confidence characterizes a leader. To be firmly, intellectually, and enthusiastically grounded in one’s disciplinary knowledge sets the stage to being able to lead effectively.
Creativity Fuels Nursing Theory and Leadership The contributions of nursing theory to education, research, administration, and professional practice have been long recognized (Fawcett & Desanto-Madeya, 2013; Meleis, 2007). Yet, increasing distress in response to the present marginalization of nursing theory is well-documented (Florczak,
2011; Karnick, 2012). I contend that the role of nursing theory belongs in any examination of nursing leadership. I believe that the work of nurse theorists, both their writings about what nursing is as well as the substance of the theories themselves are prime exemplars of creativity. Yet creativity is not understood by examining the works of creative individuals in isolation but by understanding the interactions among those individuals and others they influence (Csikszentmihalyi, 2007). Central to leading-following is nurses responding to the creative work of nursing theory. Each kind of nurse leader benefits from the contribution of nursing theory. Clinical leaders may be relying exclusively on resources to support evidence-based practice, quality, and safety. These components are essential, but processing these practice initiatives can be enriched by theorizing about nursing through reflection on nursing theory. Educators, too, may be presenting curriculum that meets standards for examinations and fulfills benchmarks but underutilizes the reflective and dialogical practices of theorizing through a nursing lens. Administrators who are called to leadership may be unaware of all the resources available for them in the field of nursing theory. Importantly, new graduates or early career nurses may be transitioning into complex nursing practice without viewing nursing theoretical foundations as integral to the essence of nursing, and without benefiting from knowledge of these theories to help them lead successfully.
Aspects of Leadership My discussion here focuses on four aspects of leadership: clinical, interdisciplinary, nursing education, and interpersonal nursing, demonstrating how creative élan born of nursing theory can improve care for our patients, build bridges across disciplines, demonstrate vitality for the profession for students, and strengthen nursing interrelationships.
Clinical Leadership: Improving Care for Patients In order to be effective in leading nursing practice one needs to be familiar with the disciplinary focus of nursing. A central unifying focus for the discipline has been offered: facilitating humanization, meaning, choice, quality of life, and healing in living and dying (Willis, Grace & Roy, 2008). Without confidence in the focus of the discipline of nursing, the leader in a clinical setting can unwittingly bow to the competing demands of others. In order to advocate for excellence in patient care the leader needs to use contemporary knowledge of specific nursing theoretical guides for patient care. The leader must at the same time view every practice situation as having the potential to stimulate theoretical thinking. The visions of nursing theory exist to improve clinical care. The wide array of studies based on the adaptation model of Callista Roy gives theoretical foundation and clinical
Downloaded from nsq.sagepub.com at University of New England on June 9, 2015
332
Nursing Science Quarterly 27(4)
application to leaders everywhere. The model’s application has given rise to knowledge development strategies of multiple types and has wide global influence (Roy, 2014). Her world-wide guidance and mentoring to nursing clinicians and researchers parallels Parse’s (2008) leading-following model. But it is Roy’s voice, too, that resonates with leadership for nurses. In her commentary on Nightingale in the commemorative edition of Notes on Nursing, Roy (1992) recalled with “absolute awe” that Nightingale would immediately use everything at her disposal to relieve suffering, not waiting for proof of effectiveness (p. 65). Roy followed that example by taking risks in every turn of her developing theory, charting a course that was unknown at its beginning and always improving nursing science, particularly advancing neuroscience nursing. Clinical nurses can benefit by reading the reaction Roy had to Nightingale so that leading is illuminated. They can see that reflecting back on the voice of Nightingale can give us examples of the risk-taking central to nurse leadership. Dorothea Orem’s work offers clinical models of selfmanagement with an emphasis on patient education (Orem, 2001). Her theory assists diabetes educators and others facing global, contemporary health challenges. In addition to forging theoretical connections, Orem speaks to the essence of what nurses provide through their care. Her description of “nursing agency” (p. 133), its powers and capabilities, transforms the way we view the actions of the clinical nurse, actions that are not task-oriented but born of education and intellectual expertise. The need for tasks and technology is not devalued but added to the actions of a theoretical leader. Swanson’s caring theory (2006), rooted in the clinical problems of undiagnosed grief during miscarriage, has come to be seen as a superior way to fully practice caring in the clinical setting. Her voice as a nurse scholar and leader reminds us that caring is central to discussions of best practices in clinical leadership. In developing her theory of caring, Swanson (2006) establishes the primacy of caring that helps other nurses to articulate what can be contributed to healthcare. Her five basic processes of caring: knowing, being with, doing for, enabling, and maintaining belief and her multiple scholarly projects that investigate caring-based interventions provide a vision for nurse leaders so that they may articulate that caring is not an abstract concept but central to nursing. In each of these exemplars, the vision and voice of nurse theorists unite. The vision is the theoretical framework, the model, and the information that nurses can use to improve patient care. The voice, too, of these theorists is equally important in leading the profession. Lazenby (2013) recently implored nurses to focus on what is at the center of their profession, the human. In calling for an appreciation of the role of the humanities in nursing practice he asserted that he is speaking of the “human experience of nurses and of the people whom they aid through their inclusive, sympathetic, imaginative acts” (p. 13). We may
better accomplish the performance of such acts if we are fueled by the creative thinkers of our past and present generations, our nurse theorists. Ideas generated by the nurse theorists exist to stimulate discussion and debate in clinical practice and serve to improve care.
Interdisciplinary Leadership: Building Bridges Across Disciplines Bleich (2014) has recently described the essence of leadership, recognizing that nursing has at times been underfunctioning for a variety of reasons and pointing out that we often “use our intellectual capacity silently” (p. 7). Our important intellectual capacity is based on theory as well as clinical content and theorizing can help the nurse to advance to a higher level of cognitive reasoning that breaks such a silence. Building bridges across disciplines becomes possible when our intellectual capacity is extended through theory. Meleis (2007), as a nurse scholar, guides us to improved practice through offering her work on transitions. Her work on transitions demonstrated how we can better care for patients in a variety of changing aspects of life experiences. But Meleis also guides us, as leaders, to examine where we stand in our discipline in terms of a secure ownership of our theoretical foundation so we may more effectively partner with other disciplines. Meleis challenges us with broad disciplinary questions: “What does it mean to have a disciplinary domain and perspective and how do we preserve that core of the discipline as we become more interdisciplinary?” (Meleis, 2007, p. 526). These questions need reflection and answers as we move to a welcome pattern of interprofessional collaboration. Leininger (1991) commented on her own intellectual work in relation to Nightingale, noting that that she, too had advanced nursing science, studying human caring from a transcultural and anthropologic perspective. By using these unique perspectives, Leininger role-modeled leadership across disciplines for nurse leaders. She commended nurses for having liberated themselves from a limited focus on diseases and for having moved to understand the nature of human caring. She presented nursing as a profession of activism and choice. She saw herself as a leader offering one of the most significant contributions to nursing of the 20th century, the study of caring from the transcultural perspective. She pointed out that she had met many unrecognized nurse leaders in far corners of the world. After meeting these global leaders she refined her definition of leadership with central elements of creativity, persistence, commitment, and vision (Leininger, 1991, p. 37). Studying nursing theories in depth stimulates confidence in our disciplinary focus and openness in thinking patterns and reflective strategies that elevates interprofessional collaboration. The theorists can help shape a view of nursing in the world that allows nurses to refine, challenge, and
Downloaded from nsq.sagepub.com at University of New England on June 9, 2015
333
Donohue-Porter / Leading-Following Perspectives integrate theories into their own leadership style. Without the strength of understanding what has philosophically grounded the nursing profession, confusion about the role of nursing, its contribution, and existence is threatened (Florczak, 2011). This threat is very real, particularly to doctoral students who are future leaders and need to develop a deep appreciation of nursing theory. They will be serving in the interprofessional arena and will need the strongest background possible to succeed in creating nursing contributions to solving complex problems.
Nursing Education Leadership: The Vitality of the Profession Students need to know that nursing theory has a history. The theoretical development is a source of pride for the profession. Nursing students particularly need to be aware that themes like evidence-based practice, innovation science, patient-centered care, and cultural competence are not at all new for nurses. They have been central to the practice of nursing and education of students since Nightingale but may not have been defined or pronounced as important as they are today. We have been warned that nurses often embrace each nursing practice advance as something completely new without recognizing how these advances were born out of a trajectory of professional nursing knowledge. This leads to consistently underestimating the progress of nursing (Nelson & Gordon, 2004). These authors challenge nurses to honor all of the past contributions of nursing as we progress and advance. We have diminished theory by its very absence in so many arenas today and we must incorporate its past as we use it in the present to lead into the future. Visioning the future has been identified as an element of nurse faculty leadership (Horton-Deutsch et al., 2014). This visioning also needs a connection to our past that cannot be offered as purely a historical review of milestones. Connections provide for realistic yet treasured contact with previous generations of leaders in a field. Nurse theorists’ wisdom shown through their vivid descriptions of what nursing is and what nurses do portrays generations of intellectual activity in the discipline. What better way to increase critical thinking, promote clinical reasoning, and advance argumentation, critique, and challenges than to offer nursing theories to students for discussion. This leads to pride, passion, and a sense of personal responsibility for contributing to one’s profession. It also leads students to view nursing as a scholarly profession. When theory is introduced and addressed early in the curriculum as foundational, students recognize a trajectory of education that includes the doctoral degree and more naturally develop a desire for lifelong learning. Demonstrating the vitality of the profession to our students is essential as they begin their journey of leadership. If nurse faculty “bury the importance of nursing theory to practice,” as Karnick (2012, p. 34) writes, we will be left with
students without both the ideas and verve that have been in place in the intellectual discipline of nursing. A passion for nursing has been identified as one of several common characteristics of exemplary nurse leaders (Anonson, Walker, Arries, Maposa, Telford & Berry, 2014). This passion has to be carefully cultivated by nursing education leaders who choose curriculum that introduces students to nursing theory and theorists with clarity and creativity. Passion for the profession feeds creative élan. Locsin (2005) has helped to identify how technological competence is an expression of caring in nursing. This can be referenced by nursing education leaders when instructing students about contemporary views of technology. He guides us to the purpose of technological competency in nursing and acknowledges the wholeness of persons as a focus of nursing. His work can be shared with students from the first time they are introduced to the technological tasks inherent in our profession so they can lead through these experiences, choosing not to allow technology to overshadow their focus. Beck’s research and knowledge development in the area of postpartum depression provide the theoretical path to understanding a time of great sorrow and need for patients. Her scholarly work can open the eyes of nursing students to an experience that is not easily accessible to them. In another way, Beck’s writings and her specific choice of words are just as important as the theory itself in demonstrating nursing leadership. In choosing the title: Birth trauma: In the eye of the beholder Beck (2004) gives a clear message that she respects what individuals determine to be traumatic to them, the patients’ perspectives. This example can be used to demonstrate patient-centered care and for students to be directly tied to learning contemporary aspects of caring through the work of a nurse scholar. There are strategies to expose nursing students to the vitality of the nurse theorists. For instance, particular publications can be chosen that display the interdisciplinary strength of Nightingale, complementing her leadership in nursing science. Students can read her letters collected and themed to display her persistence in activism for global health (Harper, Davey & Fordham, 2014). Incorporation of a biographical description that targets great leadership such as the legacy of Hildegard Peplau can also be used to initiate discussion (Haber, 2000), and texts such as that of Hills and Watson (2011) that are dedicated to infusing a curriculum with caring theory can be excellent resources for stimulating nursing education leadership.
Interpersonal Nursing: Strengthening Nursing Interrelationships In a qualitative metasynthesis of leadership development, Galuska (2012) found the relationship factor to be of importance. Significant relationships in three areas: with the nursing manager, with the undermining or bolstering role of
Downloaded from nsq.sagepub.com at University of New England on June 9, 2015
334
Nursing Science Quarterly 27(4)
colleagues, and with mentors who guided growth in leadership, had an impact on the growth of leadership competencies. Nurse theorists such as Parse and Watson who emphasize respect and reverence for the interpersonal nature of nurses’ connectedness can help nurse leaders understand more about development of a culture of leadership. These same nurse theorists give nurse leaders the language and conceptualizations to face the unknown. As clinical leaders, nurses encounter suffering each day and can turn to the works of the nurse theorists to help explain the essence of patient-nurse encounters and human potential in relationships. When existential nurse theorists use creative metaphors nurses may struggle with interpretation but need to be encouraged to continue to study the metaphors. Metaphors often require time and reflection to be fully understood but can lead to an increased appreciation of interrelationships. Sumner’s (2012) communicative work introduces guidelines and guideposts for the moral development that improves communication. In meeting current practice demands for knowledge translation nurses are expected to communicate well with one another, patients, and teams. Sumner views communication as moral caring in nursing, emphasizing how interactive discourse takes place between two equal human beings: nurse and patient. The vulnerability of persons as they are exposed in communication is demonstrated with the caution that this vulnerability requires the moral component of “considerateness” (p. 20). In a recent practice change of returning the intershift report back to the bedside, the use of Sumner’s work helped to add a strong nursing theoretical orientation to a quality and safety nurse-led initiative where nurses stated that they felt empowered by using scholarly works to accomplish the important goal of being patientcentered (Thomas & Donohue-Porter, 2011). A leader who values the respect involved in the dyadic nature of leading-following is one who makes connections. Watson (2010) points out to us the way Nightingale made connections, between and among all aspects of the “self, other, humanity, the environment, nature, and the cosmos as a means of learning, understanding, and connecting health, caring and healing” (p. 107). We know that leading into the future requires much self-reflection. The nurse theorists and their theories help individual leaders in nursing to think deeply, gather multiple perspectives, acknowledge complexity in situations, stimulate creativity and determine the focus of nursing care, all critical skills to lead nursing in the 21st century.
(p. 170). The community of nurse theorists has as much to tell us about leadership as they advance knowledge. They need us to listen and we need to be open to their writings in a different way, to look in their direction and at their direction. They are animating practice; they are illuminating values. They are allowing us to mirror their creative processes. Each time nurses dismisses nursing theory as not useful for practice they are smashing the mirror and missing the opportunity for intellectual growth, stimulating discourse, and an elevated and enriched path to improved patient care. They are missing the opportunity to follow and to lead. At times, we as nurses hold up the mirror for each other as we pass through phases of leading and following and this metaphor can bring us to the realization that often our colleagues need the help of each other to reflect back their excellence in leadership.
Using the Mirror for Reflecting not Discarding
Declaration of Conflicting Interests
Parse (2011) emphasizes that holding up a mirror for reflection may seem a solitary act but clarifies that the solitude is not aloneness, “it is connecting-separating with the choirs of voices alive in the history of who one is as community”
Meeting Leadership Challenges Nursing theory is essential for nursing leadership, a part of practice, research, and education. Within the last four years, critical questions have been raised across the United States that demand a nursing leadership response. In practice, the Institute of Medicine’s (2010) The Future of Nursing report recommended opportunities for nurses to assume leadership positions and to serve as full partners in healthcare redesign and improvement. The Interprofessional Education Collaborative Expert Panel (2011) identified patientcentered care as a major goal of interprofessional collaborative practice. Nursing theories have historically centered on the patient, and nurses must take the lead in interdisciplinary collaboration. In nursing education, Benner, Sutphen, Leonard and Day (2010) critically analyzed contemporary nursing education and asked how we may better teach for salience. Finally, and of great importance, nurses need to lead each other in meeting these challenges with civility and care in their own interactions with each other and with patients. We have the answers to these challenges within our accumulated nursing theories that help us to focus on the challenges of improvement, patient-centered care, critical reflection, and caring. There are creative ways in our nursing theories to formulate answers to complex questions for the future of nursing. Nurse theorists will help us to continue asking the essential questions that will guide nurse leaders to improve care. Nursing leadership will only grow stronger and more secure when using nursing theory as a creative force.
The author declared no potential conflicts of interest with respect to the authorship and/or publication of this article.
Funding The author received no financial support for the authorship and /or publication of this article.
Downloaded from nsq.sagepub.com at University of New England on June 9, 2015
335
Donohue-Porter / Leading-Following Perspectives References Anonson, J., Walker, M., Arries, E., Maposa, S., Telford, P., & Berry, L. (2014). Qualities of exemplary nurse leaders: Perspectives of frontline nurses. Journal of Nursing Management, 22, 127-136. Baumann, S. (2012). Making a meaningful contribution to nursing theory. Nursing Science Quarterly, 25, 155-159. Beck, C. (2004). Birth trauma: In the eyes of the beholder. Nursing Research, 53, 28-35. Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. The Carnegie Foundation for the Advancement of Teaching. San Francisco: Jossey- Bass. Bleich, M. (2014). The essence of leadership. Journal of Continuing Education in Nursing, 45, 6-7. Csikszentmihalyi, M. (2009). Creativity: Flow and the psychology of discovery and invention. New York: HarperCollins Publishers. Fawcett, J., & Desanto-Madeya, S. (2013) Contemporary nursing knowledge: Analysis and evaluation of nursing models and theories (3rd ed.). Philadelphia: F. A. Davis. Florczak, K. (2011). Angst for nursing theory. Nursing Science Quarterly, 24, 311. Galuska, L. (2012). Cultivating nursing leadership for our envisioned future. Advances in Nursing Science, 35, 333-345. Haber, J. (2000). Hildegarde E. Peplau: The psychiatric nursing legacy of a legend. Journal of the American Psychiatric Nurses Association, 6, 56-62. Harper, D., Davey, K., & Fordham, P. (2014). Leadership lessons in global nursing and health from The Nightingale Letter Collection at the University of Alabama at Birmingham. Journal of Holistic Nursing, 32, 44-53. Hills, M., & Watson, J. (2011). Creating a caring science curriculum: An emancipatory pedagogy for nursing. New York: Springer Publishing Company. Horton-Deutsch, S., Pardue, K., Young, P., Morales, M., Halstead, J., & Pearsall, C. (2014). Becoming a nurse faculty leader: Taking risks by doing the right thing. Nursing Outlook, 62, 89-96. Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, DC: Interprofessional Education Collaborative. Karnick, P. (2012). Seeing the forest through the trees. Nursing Science Quarterly, 25, 34-35.
Lazenby, M. (2013). On the humanities of nursing. Nursing Outlook, 61, E9-E14. Leininger, M. (Ed). (1991). Culture care diversity & universality: A theory of nursing. New York: National League for Nursing Publications. Locsin, R. (2005). Technological competency as caring in nursing: A model for practice. Indianapolis: Sigma Theta Tau International. Meleis, A. (2007). Theoretical nursing: Development and progress. Philadelphia: Lippincott Williams & Wilkins. Nelson, S., & Gordon, S. (2004). The rhetoric of rupture: Nursing as a practice with a history? Nursing Outlook, 52, 255-261. Nightingale, F. (1859/1992). Notes on nursing: What it is and what it is not [Commemorative edition with commentaries by contemporary nursing leaders]. Philadelphia: J. B. Lippincott Company. Orem, D. (2001). Nursing: Concepts of practice. St. Louis: Mosby. Parse, R. (2008). The humanbecoming leading-following model: Nursing Science Quarterly, 21, 369-375. Parse, R. (2011). Humanbecoming leading-following: The meaning of holding up the mirror. Nursing Science Quarterly, 24, 169-171. Peplau, H. (1952). Interpersonal relations in nursing. A conceptual frame of reference for psychodynamic nursing. New York: G.P. Putnam’s Sons. Roy, C. (1992). Commentary. In F. Nightingale, Notes on nursing: What it is and what it is not (Commemorative edition) (pp. 6372). Philadelphia: J.B. Lippincott. Roy, C. (2014). Generating middle range theory: From evidence to practice. New York: Springer. Sumner, J. (2012). Communication as moral caring in nursing: The moral construct of caring in nursing as communicative action. International Journal for Human Caring, 16(2), 20-27. Swanson, K. (2006). Kristen M. Swanson: A program of research on caring. (pp. 351-360). In M. Parker (Ed.), Nursing theories and nursing practice. Philadelphia: F. A. Davis. Thomas, L., & Donohue-Porter, P. (2011). Blending evidence and innovation: Improving intershift handoffs in a multihospital setting. Journal of Nursing Care Quality, 27, 116-125. Watson, J. (2010). Florence Nightingale and the enduring legacy of transpersonal human caring-healing. Journal of Holistic Nursing, 28(1), 107-108. Willis, D., Grace, P., & Roy, C. (2008). A central unifying focus for the discipline: Facilitating humanization, meaning, choice, quality of life, and healing in living and dying. Advances in Nursing Science, 31, E28-E40.
Downloaded from nsq.sagepub.com at University of New England on June 9, 2015
research-article2014
NSQXXX10.1177/0894318414546413Nursing Science QuarterlyDonohue-Porter / Leading-Following Perspectives
Leading-Following Perspectives
The Creative Élan of Nursing Theory: Indispensable to Leadership
Nursing Science Quarterly 2014, Vol. 27(4) 330–335 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0894318414546413 nsq.sagepub.com
Patricia Donohue-Porter, RN; PhD1
Abstract The author discusses how nursing theoretical knowledge contributes to nursing leadership and how the use of nursing theory can build confidence in nurse leaders in all settings, drawing on examples from selected theorists’ work. It is suggested that when nursing theory is not fully valued by the profession, not only knowledge is lost but also the language that helps nurses to lead. However, the vision and the voice of nursing theory will allow nurses to lead with creativity and to tap into innovation that facilitates contributions to healthcare. To be firmly, intellectually, and enthusiastically grounded in one’s disciplinary knowledge sets the stage to being able to lead effectively. Four aspects of leadership are addressed: clinical, interdisciplinary, nursing education, and interpersonal nursing. Our accumulated nursing theories can help nurse leaders to meet contemporary healthcare challenges by providing answers that help to focus on improvement, patient-centered care, critical reflection, and caring. Keywords creativity, leadership, nursing theory, vision Early in my career as a clinical nurse specialist in diabetes, I was asked to give a Medical Grand Rounds presentation at a large medical center in New York City. I was invited by a physician several months in advance of the presentation and as the weeks went by he would check in with me, confirming that I would be using a theoretical base for this upcoming presentation similar to ones he had heard in my previous presentations. He said he had been struck by my use of nursing theory at diabetes conferences and wanted to make sure that my plan was to do so at the upcoming Grand Rounds. It was, and I let him know what to expect. When I arrived at the event, a kind but blunt, endocrinology Fellow who had been assigned to escort me told me that there had been much negative discussion about the idea of a nurse giving Grand Rounds, even though she was theoretical, and that the Chief of Medicine had been emphatic that the invitation should never have been given to a nurse. During the presentation I described diabetic patient care and education in light of Peplau’s (1952) levels of anxiety, Orem’s self-care management (2001), and Leininger’s (1991) attention to cultural details. The setting was (in reflecting back) somewhat stressful but the presentation went well and I felt confident, with great vigor and enthusiasm, because I was guided by a foundation of nursing theory. I had been used to excellent interprofessional collaborations, which are often the norm in the interdisciplinary setting of diabetes education but I felt that, in this particular presentation, theory helped me to distinctly show the contribution nurses brought to patient education and self-management. I offer this personal narrative to set the
stage for my assertion that nursing theoretical knowledge contributes to nursing leadership just as it contributes to nursing practice. The use of nursing theory can build creative confidence in nurse leaders in all settings; here I give examples of selected theorists’ works. I will close with describing how nursing theory helps to meet contemporary leadership challenges.
Voice and Vision of Nursing Theory Years have gone by and my leadership roles have shifted from clinical practice to nursing education, but the nursing theories that I have respected, used, and taught continue to be foundational to my nursing essence. I always use nursing theory in my classes and I often teach classes in advanced nursing theory. In those classes I begin with the writings of nurse theorists in relation to the profession, even before describing the details of their theories. To me, our nurse theorists write about the nursing profession and its advancement in ways that can awaken a commitment to nursing in students and a vitality that becomes central to dialogue and reflection in the classroom. I call these writings about the nursing 1
Associate Professor and Director, Adelphi University
Contributing Editor: F. Beryl Pilkington, RN, PhD, Associate Professor, School of Nursing, York University, HNES 345, 4700 Keele St., Toronto, Ontario, Canada M3J 1P3. Email: [email protected]
Downloaded from nsq.sagepub.com at University of New England on June 9, 2015
331
Donohue-Porter / Leading-Following Perspectives profession the voice of nursing theory. The voice represents how theorists describe their view of both our profession and the elegance of nursing practice. These voices are then coupled with the visions of the theorists as detailed in each of their specific theories. The visions are the processes of the nursing theories that allow us to care more effectively in any situation that requires nursing expertise. For me, as nursing theory integration into practice becomes less widely used and understood, I fear that we face a parallel loss of the words of the nursing theorists, how they vividly describe what nurses do and what nursing is. When nursing theory is not fully valued by professionals we lose not only knowledge but also the language that helps nurses to lead. Fewer nurses may become followers of particular theorists since there is less exposure. When nurses do follow a particular theorist they may be criticized as disciples, something that Baumann (2012) points out as a response that lacks appreciation for the breadth of unique theoretical work of these contributors to nursing knowledge.
Creative Élan Using the full force of both the vision and the voice of nursing theory allows nurses to lead with what Parse (2011) calls “creative élan”—a force and vigor that taps into innovation and facilitates marked contributions to healthcare. She uses this term in describing how the act of holding up a mirror may be used as a metaphor for glimpsing personal truths for fleeting moments (Parse, 2011, p. 169). When holding up the mirror to reflect upon personal meaning of the humanbecoming leading-following model, three processes of intimate contemplating, cautiously discerning, and wisely endeavoring are in place. The reflective glance in the mirror searches for creative élan as possibilities are envisioned around leading-following (Parse, 2011, p. 170). I will continue to use this term to demonstrate how creative élan born of nursing theory influences nursing leadership. A mastery of both nursing theory and knowledge of the descriptions of nursing that nurse theorists have given to us over the decades helps leaders to develop confidence and enthusiasm for the profession. Confidence, enthusiasm, vigor, and vivacity are components of élan. A manner of energetic confidence characterizes a leader. To be firmly, intellectually, and enthusiastically grounded in one’s disciplinary knowledge sets the stage to being able to lead effectively.
Creativity Fuels Nursing Theory and Leadership The contributions of nursing theory to education, research, administration, and professional practice have been long recognized (Fawcett & Desanto-Madeya, 2013; Meleis, 2007). Yet, increasing distress in response to the present marginalization of nursing theory is well-documented (Florczak,
2011; Karnick, 2012). I contend that the role of nursing theory belongs in any examination of nursing leadership. I believe that the work of nurse theorists, both their writings about what nursing is as well as the substance of the theories themselves are prime exemplars of creativity. Yet creativity is not understood by examining the works of creative individuals in isolation but by understanding the interactions among those individuals and others they influence (Csikszentmihalyi, 2007). Central to leading-following is nurses responding to the creative work of nursing theory. Each kind of nurse leader benefits from the contribution of nursing theory. Clinical leaders may be relying exclusively on resources to support evidence-based practice, quality, and safety. These components are essential, but processing these practice initiatives can be enriched by theorizing about nursing through reflection on nursing theory. Educators, too, may be presenting curriculum that meets standards for examinations and fulfills benchmarks but underutilizes the reflective and dialogical practices of theorizing through a nursing lens. Administrators who are called to leadership may be unaware of all the resources available for them in the field of nursing theory. Importantly, new graduates or early career nurses may be transitioning into complex nursing practice without viewing nursing theoretical foundations as integral to the essence of nursing, and without benefiting from knowledge of these theories to help them lead successfully.
Aspects of Leadership My discussion here focuses on four aspects of leadership: clinical, interdisciplinary, nursing education, and interpersonal nursing, demonstrating how creative élan born of nursing theory can improve care for our patients, build bridges across disciplines, demonstrate vitality for the profession for students, and strengthen nursing interrelationships.
Clinical Leadership: Improving Care for Patients In order to be effective in leading nursing practice one needs to be familiar with the disciplinary focus of nursing. A central unifying focus for the discipline has been offered: facilitating humanization, meaning, choice, quality of life, and healing in living and dying (Willis, Grace & Roy, 2008). Without confidence in the focus of the discipline of nursing, the leader in a clinical setting can unwittingly bow to the competing demands of others. In order to advocate for excellence in patient care the leader needs to use contemporary knowledge of specific nursing theoretical guides for patient care. The leader must at the same time view every practice situation as having the potential to stimulate theoretical thinking. The visions of nursing theory exist to improve clinical care. The wide array of studies based on the adaptation model of Callista Roy gives theoretical foundation and clinical
Downloaded from nsq.sagepub.com at University of New England on June 9, 2015
332
Nursing Science Quarterly 27(4)
application to leaders everywhere. The model’s application has given rise to knowledge development strategies of multiple types and has wide global influence (Roy, 2014). Her world-wide guidance and mentoring to nursing clinicians and researchers parallels Parse’s (2008) leading-following model. But it is Roy’s voice, too, that resonates with leadership for nurses. In her commentary on Nightingale in the commemorative edition of Notes on Nursing, Roy (1992) recalled with “absolute awe” that Nightingale would immediately use everything at her disposal to relieve suffering, not waiting for proof of effectiveness (p. 65). Roy followed that example by taking risks in every turn of her developing theory, charting a course that was unknown at its beginning and always improving nursing science, particularly advancing neuroscience nursing. Clinical nurses can benefit by reading the reaction Roy had to Nightingale so that leading is illuminated. They can see that reflecting back on the voice of Nightingale can give us examples of the risk-taking central to nurse leadership. Dorothea Orem’s work offers clinical models of selfmanagement with an emphasis on patient education (Orem, 2001). Her theory assists diabetes educators and others facing global, contemporary health challenges. In addition to forging theoretical connections, Orem speaks to the essence of what nurses provide through their care. Her description of “nursing agency” (p. 133), its powers and capabilities, transforms the way we view the actions of the clinical nurse, actions that are not task-oriented but born of education and intellectual expertise. The need for tasks and technology is not devalued but added to the actions of a theoretical leader. Swanson’s caring theory (2006), rooted in the clinical problems of undiagnosed grief during miscarriage, has come to be seen as a superior way to fully practice caring in the clinical setting. Her voice as a nurse scholar and leader reminds us that caring is central to discussions of best practices in clinical leadership. In developing her theory of caring, Swanson (2006) establishes the primacy of caring that helps other nurses to articulate what can be contributed to healthcare. Her five basic processes of caring: knowing, being with, doing for, enabling, and maintaining belief and her multiple scholarly projects that investigate caring-based interventions provide a vision for nurse leaders so that they may articulate that caring is not an abstract concept but central to nursing. In each of these exemplars, the vision and voice of nurse theorists unite. The vision is the theoretical framework, the model, and the information that nurses can use to improve patient care. The voice, too, of these theorists is equally important in leading the profession. Lazenby (2013) recently implored nurses to focus on what is at the center of their profession, the human. In calling for an appreciation of the role of the humanities in nursing practice he asserted that he is speaking of the “human experience of nurses and of the people whom they aid through their inclusive, sympathetic, imaginative acts” (p. 13). We may
better accomplish the performance of such acts if we are fueled by the creative thinkers of our past and present generations, our nurse theorists. Ideas generated by the nurse theorists exist to stimulate discussion and debate in clinical practice and serve to improve care.
Interdisciplinary Leadership: Building Bridges Across Disciplines Bleich (2014) has recently described the essence of leadership, recognizing that nursing has at times been underfunctioning for a variety of reasons and pointing out that we often “use our intellectual capacity silently” (p. 7). Our important intellectual capacity is based on theory as well as clinical content and theorizing can help the nurse to advance to a higher level of cognitive reasoning that breaks such a silence. Building bridges across disciplines becomes possible when our intellectual capacity is extended through theory. Meleis (2007), as a nurse scholar, guides us to improved practice through offering her work on transitions. Her work on transitions demonstrated how we can better care for patients in a variety of changing aspects of life experiences. But Meleis also guides us, as leaders, to examine where we stand in our discipline in terms of a secure ownership of our theoretical foundation so we may more effectively partner with other disciplines. Meleis challenges us with broad disciplinary questions: “What does it mean to have a disciplinary domain and perspective and how do we preserve that core of the discipline as we become more interdisciplinary?” (Meleis, 2007, p. 526). These questions need reflection and answers as we move to a welcome pattern of interprofessional collaboration. Leininger (1991) commented on her own intellectual work in relation to Nightingale, noting that that she, too had advanced nursing science, studying human caring from a transcultural and anthropologic perspective. By using these unique perspectives, Leininger role-modeled leadership across disciplines for nurse leaders. She commended nurses for having liberated themselves from a limited focus on diseases and for having moved to understand the nature of human caring. She presented nursing as a profession of activism and choice. She saw herself as a leader offering one of the most significant contributions to nursing of the 20th century, the study of caring from the transcultural perspective. She pointed out that she had met many unrecognized nurse leaders in far corners of the world. After meeting these global leaders she refined her definition of leadership with central elements of creativity, persistence, commitment, and vision (Leininger, 1991, p. 37). Studying nursing theories in depth stimulates confidence in our disciplinary focus and openness in thinking patterns and reflective strategies that elevates interprofessional collaboration. The theorists can help shape a view of nursing in the world that allows nurses to refine, challenge, and
Downloaded from nsq.sagepub.com at University of New England on June 9, 2015
333
Donohue-Porter / Leading-Following Perspectives integrate theories into their own leadership style. Without the strength of understanding what has philosophically grounded the nursing profession, confusion about the role of nursing, its contribution, and existence is threatened (Florczak, 2011). This threat is very real, particularly to doctoral students who are future leaders and need to develop a deep appreciation of nursing theory. They will be serving in the interprofessional arena and will need the strongest background possible to succeed in creating nursing contributions to solving complex problems.
Nursing Education Leadership: The Vitality of the Profession Students need to know that nursing theory has a history. The theoretical development is a source of pride for the profession. Nursing students particularly need to be aware that themes like evidence-based practice, innovation science, patient-centered care, and cultural competence are not at all new for nurses. They have been central to the practice of nursing and education of students since Nightingale but may not have been defined or pronounced as important as they are today. We have been warned that nurses often embrace each nursing practice advance as something completely new without recognizing how these advances were born out of a trajectory of professional nursing knowledge. This leads to consistently underestimating the progress of nursing (Nelson & Gordon, 2004). These authors challenge nurses to honor all of the past contributions of nursing as we progress and advance. We have diminished theory by its very absence in so many arenas today and we must incorporate its past as we use it in the present to lead into the future. Visioning the future has been identified as an element of nurse faculty leadership (Horton-Deutsch et al., 2014). This visioning also needs a connection to our past that cannot be offered as purely a historical review of milestones. Connections provide for realistic yet treasured contact with previous generations of leaders in a field. Nurse theorists’ wisdom shown through their vivid descriptions of what nursing is and what nurses do portrays generations of intellectual activity in the discipline. What better way to increase critical thinking, promote clinical reasoning, and advance argumentation, critique, and challenges than to offer nursing theories to students for discussion. This leads to pride, passion, and a sense of personal responsibility for contributing to one’s profession. It also leads students to view nursing as a scholarly profession. When theory is introduced and addressed early in the curriculum as foundational, students recognize a trajectory of education that includes the doctoral degree and more naturally develop a desire for lifelong learning. Demonstrating the vitality of the profession to our students is essential as they begin their journey of leadership. If nurse faculty “bury the importance of nursing theory to practice,” as Karnick (2012, p. 34) writes, we will be left with
students without both the ideas and verve that have been in place in the intellectual discipline of nursing. A passion for nursing has been identified as one of several common characteristics of exemplary nurse leaders (Anonson, Walker, Arries, Maposa, Telford & Berry, 2014). This passion has to be carefully cultivated by nursing education leaders who choose curriculum that introduces students to nursing theory and theorists with clarity and creativity. Passion for the profession feeds creative élan. Locsin (2005) has helped to identify how technological competence is an expression of caring in nursing. This can be referenced by nursing education leaders when instructing students about contemporary views of technology. He guides us to the purpose of technological competency in nursing and acknowledges the wholeness of persons as a focus of nursing. His work can be shared with students from the first time they are introduced to the technological tasks inherent in our profession so they can lead through these experiences, choosing not to allow technology to overshadow their focus. Beck’s research and knowledge development in the area of postpartum depression provide the theoretical path to understanding a time of great sorrow and need for patients. Her scholarly work can open the eyes of nursing students to an experience that is not easily accessible to them. In another way, Beck’s writings and her specific choice of words are just as important as the theory itself in demonstrating nursing leadership. In choosing the title: Birth trauma: In the eye of the beholder Beck (2004) gives a clear message that she respects what individuals determine to be traumatic to them, the patients’ perspectives. This example can be used to demonstrate patient-centered care and for students to be directly tied to learning contemporary aspects of caring through the work of a nurse scholar. There are strategies to expose nursing students to the vitality of the nurse theorists. For instance, particular publications can be chosen that display the interdisciplinary strength of Nightingale, complementing her leadership in nursing science. Students can read her letters collected and themed to display her persistence in activism for global health (Harper, Davey & Fordham, 2014). Incorporation of a biographical description that targets great leadership such as the legacy of Hildegard Peplau can also be used to initiate discussion (Haber, 2000), and texts such as that of Hills and Watson (2011) that are dedicated to infusing a curriculum with caring theory can be excellent resources for stimulating nursing education leadership.
Interpersonal Nursing: Strengthening Nursing Interrelationships In a qualitative metasynthesis of leadership development, Galuska (2012) found the relationship factor to be of importance. Significant relationships in three areas: with the nursing manager, with the undermining or bolstering role of
Downloaded from nsq.sagepub.com at University of New England on June 9, 2015
334
Nursing Science Quarterly 27(4)
colleagues, and with mentors who guided growth in leadership, had an impact on the growth of leadership competencies. Nurse theorists such as Parse and Watson who emphasize respect and reverence for the interpersonal nature of nurses’ connectedness can help nurse leaders understand more about development of a culture of leadership. These same nurse theorists give nurse leaders the language and conceptualizations to face the unknown. As clinical leaders, nurses encounter suffering each day and can turn to the works of the nurse theorists to help explain the essence of patient-nurse encounters and human potential in relationships. When existential nurse theorists use creative metaphors nurses may struggle with interpretation but need to be encouraged to continue to study the metaphors. Metaphors often require time and reflection to be fully understood but can lead to an increased appreciation of interrelationships. Sumner’s (2012) communicative work introduces guidelines and guideposts for the moral development that improves communication. In meeting current practice demands for knowledge translation nurses are expected to communicate well with one another, patients, and teams. Sumner views communication as moral caring in nursing, emphasizing how interactive discourse takes place between two equal human beings: nurse and patient. The vulnerability of persons as they are exposed in communication is demonstrated with the caution that this vulnerability requires the moral component of “considerateness” (p. 20). In a recent practice change of returning the intershift report back to the bedside, the use of Sumner’s work helped to add a strong nursing theoretical orientation to a quality and safety nurse-led initiative where nurses stated that they felt empowered by using scholarly works to accomplish the important goal of being patientcentered (Thomas & Donohue-Porter, 2011). A leader who values the respect involved in the dyadic nature of leading-following is one who makes connections. Watson (2010) points out to us the way Nightingale made connections, between and among all aspects of the “self, other, humanity, the environment, nature, and the cosmos as a means of learning, understanding, and connecting health, caring and healing” (p. 107). We know that leading into the future requires much self-reflection. The nurse theorists and their theories help individual leaders in nursing to think deeply, gather multiple perspectives, acknowledge complexity in situations, stimulate creativity and determine the focus of nursing care, all critical skills to lead nursing in the 21st century.
(p. 170). The community of nurse theorists has as much to tell us about leadership as they advance knowledge. They need us to listen and we need to be open to their writings in a different way, to look in their direction and at their direction. They are animating practice; they are illuminating values. They are allowing us to mirror their creative processes. Each time nurses dismisses nursing theory as not useful for practice they are smashing the mirror and missing the opportunity for intellectual growth, stimulating discourse, and an elevated and enriched path to improved patient care. They are missing the opportunity to follow and to lead. At times, we as nurses hold up the mirror for each other as we pass through phases of leading and following and this metaphor can bring us to the realization that often our colleagues need the help of each other to reflect back their excellence in leadership.
Using the Mirror for Reflecting not Discarding
Declaration of Conflicting Interests
Parse (2011) emphasizes that holding up a mirror for reflection may seem a solitary act but clarifies that the solitude is not aloneness, “it is connecting-separating with the choirs of voices alive in the history of who one is as community”
Meeting Leadership Challenges Nursing theory is essential for nursing leadership, a part of practice, research, and education. Within the last four years, critical questions have been raised across the United States that demand a nursing leadership response. In practice, the Institute of Medicine’s (2010) The Future of Nursing report recommended opportunities for nurses to assume leadership positions and to serve as full partners in healthcare redesign and improvement. The Interprofessional Education Collaborative Expert Panel (2011) identified patientcentered care as a major goal of interprofessional collaborative practice. Nursing theories have historically centered on the patient, and nurses must take the lead in interdisciplinary collaboration. In nursing education, Benner, Sutphen, Leonard and Day (2010) critically analyzed contemporary nursing education and asked how we may better teach for salience. Finally, and of great importance, nurses need to lead each other in meeting these challenges with civility and care in their own interactions with each other and with patients. We have the answers to these challenges within our accumulated nursing theories that help us to focus on the challenges of improvement, patient-centered care, critical reflection, and caring. There are creative ways in our nursing theories to formulate answers to complex questions for the future of nursing. Nurse theorists will help us to continue asking the essential questions that will guide nurse leaders to improve care. Nursing leadership will only grow stronger and more secure when using nursing theory as a creative force.
The author declared no potential conflicts of interest with respect to the authorship and/or publication of this article.
Funding The author received no financial support for the authorship and /or publication of this article.
Downloaded from nsq.sagepub.com at University of New England on June 9, 2015
335
Donohue-Porter / Leading-Following Perspectives References Anonson, J., Walker, M., Arries, E., Maposa, S., Telford, P., & Berry, L. (2014). Qualities of exemplary nurse leaders: Perspectives of frontline nurses. Journal of Nursing Management, 22, 127-136. Baumann, S. (2012). Making a meaningful contribution to nursing theory. Nursing Science Quarterly, 25, 155-159. Beck, C. (2004). Birth trauma: In the eyes of the beholder. Nursing Research, 53, 28-35. Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. The Carnegie Foundation for the Advancement of Teaching. San Francisco: Jossey- Bass. Bleich, M. (2014). The essence of leadership. Journal of Continuing Education in Nursing, 45, 6-7. Csikszentmihalyi, M. (2009). Creativity: Flow and the psychology of discovery and invention. New York: HarperCollins Publishers. Fawcett, J., & Desanto-Madeya, S. (2013) Contemporary nursing knowledge: Analysis and evaluation of nursing models and theories (3rd ed.). Philadelphia: F. A. Davis. Florczak, K. (2011). Angst for nursing theory. Nursing Science Quarterly, 24, 311. Galuska, L. (2012). Cultivating nursing leadership for our envisioned future. Advances in Nursing Science, 35, 333-345. Haber, J. (2000). Hildegarde E. Peplau: The psychiatric nursing legacy of a legend. Journal of the American Psychiatric Nurses Association, 6, 56-62. Harper, D., Davey, K., & Fordham, P. (2014). Leadership lessons in global nursing and health from The Nightingale Letter Collection at the University of Alabama at Birmingham. Journal of Holistic Nursing, 32, 44-53. Hills, M., & Watson, J. (2011). Creating a caring science curriculum: An emancipatory pedagogy for nursing. New York: Springer Publishing Company. Horton-Deutsch, S., Pardue, K., Young, P., Morales, M., Halstead, J., & Pearsall, C. (2014). Becoming a nurse faculty leader: Taking risks by doing the right thing. Nursing Outlook, 62, 89-96. Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, DC: Interprofessional Education Collaborative. Karnick, P. (2012). Seeing the forest through the trees. Nursing Science Quarterly, 25, 34-35.
Lazenby, M. (2013). On the humanities of nursing. Nursing Outlook, 61, E9-E14. Leininger, M. (Ed). (1991). Culture care diversity & universality: A theory of nursing. New York: National League for Nursing Publications. Locsin, R. (2005). Technological competency as caring in nursing: A model for practice. Indianapolis: Sigma Theta Tau International. Meleis, A. (2007). Theoretical nursing: Development and progress. Philadelphia: Lippincott Williams & Wilkins. Nelson, S., & Gordon, S. (2004). The rhetoric of rupture: Nursing as a practice with a history? Nursing Outlook, 52, 255-261. Nightingale, F. (1859/1992). Notes on nursing: What it is and what it is not [Commemorative edition with commentaries by contemporary nursing leaders]. Philadelphia: J. B. Lippincott Company. Orem, D. (2001). Nursing: Concepts of practice. St. Louis: Mosby. Parse, R. (2008). The humanbecoming leading-following model: Nursing Science Quarterly, 21, 369-375. Parse, R. (2011). Humanbecoming leading-following: The meaning of holding up the mirror. Nursing Science Quarterly, 24, 169-171. Peplau, H. (1952). Interpersonal relations in nursing. A conceptual frame of reference for psychodynamic nursing. New York: G.P. Putnam’s Sons. Roy, C. (1992). Commentary. In F. Nightingale, Notes on nursing: What it is and what it is not (Commemorative edition) (pp. 6372). Philadelphia: J.B. Lippincott. Roy, C. (2014). Generating middle range theory: From evidence to practice. New York: Springer. Sumner, J. (2012). Communication as moral caring in nursing: The moral construct of caring in nursing as communicative action. International Journal for Human Caring, 16(2), 20-27. Swanson, K. (2006). Kristen M. Swanson: A program of research on caring. (pp. 351-360). In M. Parker (Ed.), Nursing theories and nursing practice. Philadelphia: F. A. Davis. Thomas, L., & Donohue-Porter, P. (2011). Blending evidence and innovation: Improving intershift handoffs in a multihospital setting. Journal of Nursing Care Quality, 27, 116-125. Watson, J. (2010). Florence Nightingale and the enduring legacy of transpersonal human caring-healing. Journal of Holistic Nursing, 28(1), 107-108. Willis, D., Grace, P., & Roy, C. (2008). A central unifying focus for the discipline: Facilitating humanization, meaning, choice, quality of life, and healing in living and dying. Advances in Nursing Science, 31, E28-E40.
Downloaded from nsq.sagepub.com at University of New England on June 9, 2015
