POWER AND POLITICS IN NURSING

PRESENTED BY,
Dr. Prof. Rabecca Samson Principal College of Nursing PIMS, Pondichery

INTRODUCTION
Power is ability to control people or things. The aim is to give people more power over their own lives Power politics is referred to a situation in which a country tries to achieve its aims Politics: The activities involved in getting and using power in public life and being to influence decisions that affect a country or society. Political power: it is concerned with power status etc within an organization rather than with the matters of principles

THE POWER OF PROFESSIONAL NURSING PRACTICE: DISCUSSION SESSIONS ABOUT POWER WITH NURSE LEADERS
A study was conducted among nurse leaders. The results are as follows Discussions with nurse leaders were guided by two specific aims: (1) to determine the characteristics of professional nursing power that practicing nurses believe are important at the individual level; and (2) to define strategies to help nurses attain power within their practice. Eleven nurse leaders participated in discussion sessions. The group included a clinical nurse specialist, nurse manager, vice president, program manager, nurse scientist, dean, chief retention officer, and a nurse faculty member. Through a series of questions, the nurse leaders were asked to think about power in the broadest sense and to speak about what power means to them and how it is manifested in their practice and organization. Questions posed to each nurse leader included the following: 1. How do you define power? 2. Define the power dynamics in your organization and how they are different from those found in other organizations that you have practiced in. 3. How do other disciplines and department members view nurses' power in your organization? 4. Are you a powerful nurse? 5. Do you think nurses are perceived as powerful in your organization? 6. What strategies have you seen nurses in your organization use to increase their power? 7. Do you believe that practicing nurses in your organization view the nurse leaders in your organization as powerful? 8. Insights gained through the discussions about what is meant by nursing power and what characterizes a powerful professional nursing practice are summarized below.

CHARACTERISTICS OF NURSING POWER

In responding to our opening question, "How do you define power?" the nurse leaders reflected on their own experiences and those of their nursing colleagues. They observed that the power of the nurse lies in his or her knowledge and expertise related to the technical, analytical, and interpersonal domains of nursing practice. This expertise, they observed, is uniquely interwoven into a collaborative,

interdisciplinary effort focused solely on the patients and families that the nurse and care team serve and with whom they partner. The nursing profession as a whole, they said, establishes power through the practice of individual nurses who are engaged in patient care, administrative leadership, teaching, and research. The actions, behaviors, and comportment of each nurse contribute to or diminish the collective power that the profession of nursing holds in society, within a given organization, and in practice. The nurse leaders' observations regarding power underscored the power of individual nurses and highlighted how the practice of a single individual can impact patients and families, organizations, interdisciplinary colleagues, and the entire nursing profession.

CHARACTERISTICS OF A POWERFUL PROFESSIONAL PRACTICE

Through conversations with nurse leaders, eight characteristics of powerful nursing practice are identified The eight characteristics of powerful nursing practice are the nurse leaders agreed that attaining a BSN is essential, and that more education generally leads to greater power. 1. Nurses with a powerful practice demonstrate professional comportment and recognize the critical nature of presence. The nurse leaders noted that the professional comportment of nurses their behaviors and how they carry themselves is a key component of nursing power. Openness, transparency, authenticity, honesty, and integrity are some of the characteristics that the nurse leaders associated with powerful nurses. 2. The nurse leaders also commented that the way nurses use language, particularly how they refer to themselves, can enhance or detract from their professional image. Nurses in powerful practices consistently acknowledge their own professional status. 3. Nurses with a powerful practice value collaboration and partner effectively with colleagues in nursing and other disciplines. 4. Leading and participating on teams and partnering with others is essential to sound, expert nursing practice and is a critical element of a nurse's power base. 5. Nurses with a powerful practice position themselves to influence decisions and resource allocation. 6. Nurses with a powerful practice strive to develop an impeccable character; to be inspirational, compassionate, and to have a credible, sought-after perspective. 7. Nurses with a powerful practice recognize that the role of the nurse leader is to pave the way for nurses' voices to be heard and to help novice nurses develop into powerful professionals.

8. Nurses with a powerful practice evaluate the power of nursing and the nursing department in organizations they enter by assessing the organization's mission and values and its commitment to enhancing the power of diverse perspectives.

CANADIAN NURSES ASSOCIATION, OTTAWA, ONTARIO, CANADA

Nurses in the 21st century are being called to rise to new levels of practice, including a more influential leadership at senior levels of policy development. Decades of research, good will, and a revolutionary civil rights movement have not resolved the world's staggering health outcome disparities. Nursing has a solution: Many of the most troubling disparities are amenable to effective intervention by the world's nurses through their clinical and policy work. The author challenges nurses to imagine the impact on global health if the elimination of disparities is the core goal of nursing for the 21st century. Moving from individuals and communities to systems levels, nurses must be versed in a range of system-level vital signs that affect policy development including economics, demographics, and access to care. Setting our sights on the elimination of health disparities offers a rallying point around which nursing can coalesce and set human health on a new and more equitable course.

POWER, POLITICS, AND NURSING IN THE UNITED KINGDOM (ABIGAIL MASTERSON, RN, BSC, MN, PGCA)
British politics have undergone a dramatic change as new types of political organizations have emerged in the United Kingdom (UK) and the European Union (EU), yet rarely do nurses receive a mention; they face constant difficulties placing their work on the political agenda. In comparison to the United States, UK nurses are the poor relations when it comes to politics and policy. Knowledge of the political system is vital if nurses are to be effective in influencing policy and the allocation of resources. Many UK nurses are uncomfortable with the idea of politics, seeing it as a distraction from their core purpose of care delivery, but politics affects every aspect of nursing at a macro and micro level HIGH POWER COMMITTEE ON NURSING IN INDIA The retarded development of nursing and nursing profession seems to be mainly due to the fact that no serious thought has been given to this discipline by the government over the years. Timely action on the various reports submitted to the government would have prepared nurses to take care of all areas of health care delivery and would have also avoided multiplication of other categories like occupational therapists, physiotherapists, social worker, health educator etc. All these are doing nursing duties. RECOMMENDATIONS OF HIGH POWER COMMITTEE ON NURSING AND NURSING PROFESSION Policies related to Working conditions of nursing personnel 1. Employment: Uniformity in employment procedures to be made. Recruitment rules are made for all categories of nursing posts. The qualifications and experience required or these be made thought the country.

There should not be a bond for nursing students as some of the states do not give them employment during the stipulated period. Keeping in view of the shortage of nurses in hospitals and community health field states should create posts and appointment these nurses in the appropriate positions. 2. Job description: Job description of all categories of nursing personnel is prepared by the central government to provide guidelines. 3. Working hours : The weekly working hours should be reduced to 4o hrs per week. Straight shift should be implemented in all states. extra working hours to be compensated either by leave or by extra emoluments depending on the state policy .nurses to be given weekly day off and all the gazette holidays as per the government rules. 4. Work load/ working facilities:Nursing norms for patient care and community care to be adopted as recommended by the committee.Hospitals to develop central sterile supply departments, central linen services, and central drug supply system. Group D employees are responsible for housekeeping department.Policies for breakage and losses to be developed and nurses not are made responsible for breakage and losses. 5. Pay and allowances :Uniformity of pay scales of all categories of nursing personnel is not feasible. However special allowance for nursing personnel, ie; uniform allowance, washing, mess allowance etc should be uniform throughout the country. 6. Promotional opportunities: For promotion to the post of ward sister, post basic Bsc Nursing is made an essential qualification. The principle of possessing higher qualification than the category to be supervised, should apply for all levels and categories of nursing personnel in the rural and urban areas. The committee recommends that along with education and experience, there is a need to increase the number of posts in the supervisory cadre, and for making provision of guidance and supervision during evening and night shifts in the hospital. Each nurse must have 3 promotions during the service period. Promotion is based on merit cum seniority.Promotion to the senior most administrative teaching posts is made only by open selection. In cases of stagnation, selection grade and running scales to be given. 7. Career development :-provision of deputation for higher studies after 5 yrs of regular services be made by all states. The policy of giving deputation to 5 -10 % of each category be worked out by each state. Every nursing personnel must have an opportunity to attend at least one refresher course every 2 years. 8. Accommodation :As far as possible, the nursing staff should be considered for priority allotment of accommodation near to work place. Hospitals should not build nurse's hostel for trained nurses.Apartment type of accommodation is built where married/unmarried nurses can be allowed to live. Housing colonies for hospital s must be considered in long run.

9. Transport :During odd hours, calamities etc arrangements for transport must be made for safety and security of nursing personnel. 10. Special incentives:Scheme of special incentives in terms of awards, special increment for meritorious work for nurses working in each state/district/PHC to be worked out. 11. Occupational hazards: Medical facilities as provided by the central govt. by extended by the state govt. to nursing personnel till such times medical services are provided free to all the nursing personnel. Risk allowance to be paid to nursing personnel working in the rural $ urban area. 12. Other welfare services:Hospitals should provide welfare measures like crche facilities for children of working staff, children education allowance, as granted to other employees, be paid to nursing personnel.Additional Facilities For Nurses Working In The Rural Areas.Family accommodation at sub centre is a must for safety and security of ANM's /LHV.Women attendant, selected from the village must accompany the ANM for visits to other villages.The district public health nurse is provided with a vehicle for field supervision.Fixed travel allowance with provision of enhancement from time to time.Rural allowance as granted to other employees is paid to nursing personnel.

NURSING EDUCATION
Nursing education to be fitted into national stream of education to bring about uniformity, recognition and standards of nursing education. The committee recommends that; There should be 2 levels of nursing personnel - professional nurse (degree level) and auxiliary nurse (vocational nurse). Admission to professional nursing should be with 12 yrs of schooling with science. The duration of course should be 4 yrs at the university level. admission to vocational /auxiliary nursing should be with 10 yrs of schooling .The duration of course should be 2 yrs in health related vocational stream. All school of nursing attached to medical college hospitals is upgraded to degree level in a phased manner. All ANM schools and school of nursing attached to district hospitals be affiliated with senior secondary boards. Post certificate BSc Nursing degree to be continued to give opportunities to the existing diploma nurses to continue higher education. Master in nursing programme to be increased and strengthened. Doctoral programmes in nursing have to be started in selected universities. Central assistance be provided for all levels of nursing education institutions in terms of budget( capital and recurring) Up gradation of degree level institutions be made in a phased manner as suggested in report. Each school should have separate budget till such time is phased to degree/vocational programme. The principal of the school be the drawing and the disbursing officer. Nursing personnel should have a complete say in matters of selection of students. Selection is based completely on merit. Aptitude test is introduced for selection of candidates.

All schools to have adequate budget for libraries and teaching equipments. All schools to have independent teaching block called as School Of Nursing with adequate class room facilities, library room, common room etc as per the requirements of INC. Adequate accommodations are provided to students. A maximum of 3 students to share a room. Rooms to be furnished with light, study table , chair etc. Adequate dining room, toilets and bathrooms facilities to be provided in each hostel as per norms recommended. Students should learn under supervision in the wards. Tutors/clinical instructors must go to the ward with students. Students should not be used for the service of the hospital. Community nursing experience should be as per INC requirements. Necessary transport and accommodation at PHC be made available for safety, security and meaningful learning of students. INC requirements for staffing the schools and meeting the minimum requirements are followed by all schools as these are statutory requirements. Specialty courses at post-graduate level be developed at certain special centers of excellence eg; AIIMS. Institutes like National Institute of Health and Family welfare, RAK College of Nursing and several others may develop courses on nursing administration for senior nursing leading to doctorate level. Provision for higher training abroad and exchange programmes is made.

CONTINUING EDUCATION AND STAFF DEVELOPMENT

Definite policies of deputing 5-10% of staff for higher studies are made by each state. Provision for training reserve is made in each institution. Deputation for higher study is made compulsory after 5 yrs. Each nursing personnel must attend 1 or 2 refresher course every year. Necessary budgetary provision be made, A National Institute for Nursing Education Research and Training needs to be established like NCERT, for development of educational technology, preparation of textbooks, media, / manuals for nursing.

NURSING SERVICES: HOSPITALS/INSTITUTIONS (URBAN AREAS) Definite nursing policies regarding nursing practice be available in each institution .These policies include: a) Qualification/recruitment rules b) Job description/job specifications c) Organizational chart of the institutions d) Nursing care standards for different categories of patients.

Staffing of the hospitals should be as per norms recommended. District hospitals /non teaching hospitals may appoint professional teaching nurses in the ratio of 1:3 as soon as nurses start qualifying from these institutions. Students not to be counted for staffing in the hospitals Adequate supplies and equipments, drugs etc be made available for practice of nursing. The committee strongly recommends that minimum standards of basic equipment needed for each patient be studied , norms laid down and provided to enable nurses to perform some of the basic nursing functions . Also there should be a separate budget head for nursing equipment and supplies in each hospitals/ PHC. The NS and PHN should be a member of the purchase and condemnation committee. Nurses to be relieved from non -nursing duties. Duty station for nurses is provided in each ward. Necessary facilities like central sterile supplies, linen, drugs are considered for all major hospitals to improve patient care. Also nurses should not be made to pay for breakage and losses. All hospitals should have some systems for regular assessment of losses. Provision of part time jobs for married nurses to be considered. (min 16-20hrs/week) Re-entry by married nurses at the age of 35 or above may also be considered and such nurse be given induction courses for updating their knowledge and skills before employment. Nurses in senior positions like ward sisters, Asst. nursing superintendents, Deputy NS; N.S must have courses in management and administration before promotions. Nurses working in speciality areas must have courses in specialities. Promotion opportunities for clinical specialities like administrative posts are considered for improving quality nursing services. The committee recommends that Gazetted ranks be allowed for nurses working as ward sister and above (minimum class II gazetted). Similarly the post of Health Supervisor (female) is allowed gazetted rank and district public health nurse be given the status equal to district medical/ health officers.

Community nursing services Appointment of ANM/LHV to be recommended. ANM/LHV promoted to supervisory posts must undergo courses in administration and management. Specific standing orders are made available for each ANM/LHV to function effectively in the field. Adequate provision of supplies, drugs etc are made. Recording system be simplified. Posts of public health nurses and above are given gazetted status.

Norms recommended for nursing service and education hospital setting. Nursing Supdt -1: 200 beds (hospitals with 200 or more beds).

Dy. Nsg. Supdt. - 1: 300 beds ( wherever beds are over 200) Asst. Nsg . Supdt - 1: 100 Ward sister/ward supervisor - 1:25 beds 30% leave reserve Staff nurse for wards -1:3 ( or 1:9 for each shift ) 30% leave reserve For nurses OPD and emergency etc - 1: 100 patients ( 1 bed : 5 out patients) 30% leave reserve For ICU -1:1(or 1:3 for each shift) 30% leave reserve For specialised depts such as operation theatre, labour room etc- 1: 25 30% leave reserve.

Community nursing services 1 ANM for 2500 population ( 2 per sub centre) 1 ANM for 1500 population for hilly areas 1 health supervisor for 7500 population( for supervision of 3 ANM's) 1 public health nurse for 1 PHC ( 30000 population to supervise 4 Health Supervisors ) 1 Public Health Nursing Officer for 100000 population ( community health centre) 2 district public health nursing for each district. Teaching staff for schools/colleges of Nsg as per INC 1 Nurse Teacher to 10 students for post graduate programmes.

NURSING LEGISLATION INC and state nursing council acts be amended to provide for control by INC on states nursing councils. Provision of more nurse members. Provision for regulation of nursing education standards by timely inspections and follow up. Provision of maintaining of minimum standards of nursing practice Provision of regulation for nursing care standards in private nursing homes. Provision for regulation for private nursing bureaus and practice by unqualified nurses. Provision of approval of INC before opening a SON or CON. Provision of renewal of registration every 5 yrs. Provision of independent practice of nursing by nurses.

INC to set up a national examination system in about 10 yr time to regulate standards of nursing education.

Also, the positions up to the DADG level are proposed to be at the office of the Directorate General of Health Services. The positions below the level of DADG are to exist at the institutions governed by the central govt. The Principal, College Of Nursing will be equal to the rank of ADG (N) and will be eligible for promotion to the post of DDG (N)/ Addl. (N). The salary scales and structure of the staff of colleges of nursing will be as per norms of INC and the UGC.

ORGANISATION OF NURSING SERVICES The position and status of nursing personnel working in the directorates need up gradation and expansion of the nurse to enable the nurses to participate in policy making and decision making. Total nursing components, i.e., nursing education, nursing service and community nursing should be under the control of nursing personnel at all the levels. I.e. At centre, state and district level. At every level adequate provision of budget should be made for development of nursing profession. The organizational structure recommended for centre, state and district level is as follows. Each ADG level nurse to deal with continuing education /research component for specialized areas. Selection to these posts is made on merit and not by seniority alone. Nurses appointed these posts must have courses in administration, management and fiscal management.

It was observed that nurses are not involved in making policies that govern their status and practice. They are invariably excluded from the govt bodies that decide these policies. Most of the decisions concerning nursing care and nurses are made by other people, usually physicians without the benefit of professional input from by nurses. It is possible that this situation is the direct result of lack of appropriate status accorded to the nursing staff. Nearly 97% of nursing staff are in group "c "category and their status are too low. Does Health Have to Be Political? Health is a very political area because health is expensive The allocation of resources often becomes a very political decision very influential in influencing local decisions and laws. Health is profoundly political because It is a collection of resources unequally distributed in society Its social determinants are critical to well-being and are politically determined, It is recognized by many as a fundamental right, It has been intertwined with economic, social, and political systems, Growth requires political debate and consensus Over the past five years, the World Health Organization and other groups have actively engaged the question What is health? A large part of this thought process has involved defining what health is not. It is not the health care system. It is not the reactive elimination of

disease. It is not a simple commodity to be weighed against all other commodities in society. It is different from these things, and more than these things. Health is a Preferred State of Being is universal and common to the people of the world, independent of geography, race, income, gender, and culture. Health is an active state of wellbeing that encompasses mind, body and spirit It is the capacity to reach ones full human potential, and, on a larger scale, a nations potential for development. Dr. Gro Brundtland, former director-general of the World Health Organization, wrote in the World Health Report 2000 that The objective of good health is twofold goodness and fairness; goodness being the best attainable average level; and fairness, the smallest feasible differences among individuals and groups. 1

Two major components of health reform : 1-Changes in policy 2- changes in the structure and processes of health system and organization politics refers to a process of influencing the allocation of scarce resources ( Leavitt & Mason,1998 ) . strategies to accomplish goals often involve political action and policy development . In political interactions , participants must have something to bring to the table Opportunities created through networking : backbone of success in policy and politics . The four spheres of political action: No matter where you are, in the workplace; in your community; working with your professional organizations, or in the government there are public policy issues that you can address. Where nurses are not active in policy, otherssuch as legislators, insurers, or other provider groups are speaking on our behalf. If you look at the stages of public policy development, you will see that the process is very similar to the nursing process. Identifying important problems. This is the first step in providing focus for the public policy agenda. Placing a problem on the policy agenda. One must consider whether the problem or issue represents AACNs mission, vision and values or is particularly important in the health policy arena. Formulating possible options. Address the problem by considering direct or indirect means to influence health care decisions. Direct approach is influencing of policy makers through the membership, and Indirect is educating the public and professionals to influence policy and policy makers.

Policy decisions. Adopting a particular policy enhances the image and objectives of AACN that promote healthy, healing, humane and ethical environments in the advancement of quality critical care. AACN communicates its policy goals and objectives so the membership will be aware of its strategic goals and can be part of the outcome of implementation. Policy Implementation. Implementing the selected policy requires both the organization and its membership to recognize the issues and objectives and take action to ensure implementation across the membership. Access will be provided to motivational or inspirational programs, and programs will be made available for development of basic and advanced skills. Policy Evaluation. Evaluating the policy has to be an ongoing effort to make sure the policy is achieving desired outcomes

Plan an event Although a face-to-face meeting provides the best opportunity to have discussion about health policy and nursing issues, it is often not possible. The letter is the most popular means of contact with a congressional office. In the letter State your purpose, be courteous and to the point, include key information. Use examples, stories, and statistics to get your point across. Address only one issue per letter, use your own stationery, keep the letter to one page, and be sure to sign your name and include RN. Complete guidelines for communicating with your legislator are in the Public Policy manual. Letters to the editor, or opinion editorial, can be very effective tools in communicating with the legislator (they read the news) and the public. Share your organizations opinions with a publications readers. . Look for an opportunity to fit your topic into your local radio stations schedule. When you call, keep your message short, focused, and insightful. Use AACN talking points and position papers. Plan anything from a charitable fundraiser to a community health fair to capture the media and your elected officials attention. It doesnt have to be extravagant, but make it something that will appeal to the media, and be sure to invite your elected official and his/her staff.

The Seat of Political Power in Health is shifting As these trends play out and the definition of health continues to evolve, we will see the seat of political power in health continues to shift. It will move away from paternalism toward partnership. It will move away from individual care models to team approaches. And it will move away from intervention toward prevention. It will embrace evidence-based clinical care but incorporate educational and social missions as well. It will move away from hospitals and outpatient care sites toward home settings. And it will move away from thought elites toward patients and their care teams.

Health Care the most important characteristics of a health care system are: Quality Cost Access What is Politics? The process of influencing how limited resources are allocated. The Four Spheres of Political Influence Community is the sphere that supports and embraces all the others. Like Workplace, Organizations

, Government

Is it Policy or is it Politics? Policy: The Policy Process, Policy Frameworks, Actual Legislative Bills and Amendments Politics: Lobbying, Power and Money ,Also referred to as The Game OPPORTUNITY: Mining the Possibilities, SEEKING OPPORTUNITIES, SEIZING OPPORTUNITIES Nursing professionals need to understand the sources of power and patterns in politics to effectively promote health and prevent disease in a culturally effective way. SEEING OPPORTUNITIES As the contemporary health care context becomes increasingly politicized , Nurses political competence will be vital to improving the health of the public at individual and collective levels. Political skills will also be crucial in improving the health care system , maintaining a strong profession , and bringing nursing values convincingly into policy formation . Motivation for this growth relates to our commitment to influence the determinants of health ,advocate for clients ,contribute substantively in the creation of our health care system ,and position nursing for its optimal role in delivery of care

Why Get Involved Politically? Nurses have in-depth knowledge of the strengths and weaknesses of our health care system The Voice of Nursing: Nursing cannot be seen as a significant health care profession unless it is visible and vocal in connection with all the major health care issues of our time. How can nurses find their voice? Realize that no one but nurses can truly inform the public about nursing., Every nurse should make public communication and education about nursing an integral part of his or her nursing work.Nurses must overcome the internal obstacles that silence them.KEEP IN MIND One of the penalties for refusing to participate in politics is that you end up being governed by your inferiors.

Plato GET POLITICAL The future of nursing depends on YOU! Power Voice Vision Action the development of leadership skills is a major priority for top- level nursing in health systems undergoing major changes . Think Act LOCAl GLOBAL