Beyond Rhetoric to Role Accountability

Beyond Rhetoric to Role Accountability A Practical and Professional Model of Practice Maria Williams O’Rourke, RN, DNSc, FAAN, CHC

It is important to project a clear image of the professional registered nurse (RN) role to increase awareness of the value of nursing practice. A clear image will show the role authority, responsibility, accountability, and autonomy of the RN in a manner that demonstrates the impact on generating positive outcomes for patients. Numerous recommendations have been made as to how best to create models that structure and organize our work within a professional practice framework, each having its own focus of attention.1-3 This article describes the importance of the professional role in care delivery and offers a useful and sensible strategy for how to use a data-driven, professional, role development program to ensure competence, foster practice excellence, reward staff, and assist with the development and maintenance of a highly functioning professional workforce.

WHAT IS A PROFESSIONAL PRACTICE MODEL? Brennan et al4 identified 11 key factors that compose a professional practice model, including continuity of care, participation in management, collaboration, leadership, learning environment, nurses’ role, staffing, communication, specialization, orientation of temporary staff, and group commitment. All are necessary and important components of a professional practice model. I believe that the most important factor is the concept of the professional role, its authority, responsibility and accountability.5 The professional role takes center stage because it is the key decision maker and driver of the practice, which is codified in scope of practice. This powerful authority requires 28 Nurse Leader

the individual in a professional role to demonstrate competence in key obligations as described by Brennan. An organization that supports this kind of professional role behavior, and then builds the infrastructure to support the role, promotes practice excellence, and creates systems to reward this role obligation, can be said to have a professional model of practice that moves beyond rhetoric. This becomes important work for nurse leaders. Because role competence is a predictor of performance, making sure nurses at all levels of the organization have a clear and complete understanding of the professional role and related obligations is essential. How we perform in our role is a reflection of how define it. Each and every day nurse leaders work to ensure that patients receive the best possible care in a safe, high quality, effective, and efficient manner. A practical way to address this is through a clearly defined professional model of practice. In this model, role accountability, professional standards of practice, code of ethics, and scope of practice serve as the overarching explanation for expected professional role behavior,6, 7 a role that by design can change the course of events in a patient’s life. June 2006

PATIENTS’ VIEW OF THE PROFESSIONAL NURSE Patients understand the importance of the RN role and have a deep respect for the nursing profession. This view of nursing by the public is born out by the 2005 Gallup poll. 8 The survey once again placed nursing in the number one position as the profession that the public could count on to be honest and ethical. As nurse leaders this is an important and refreshing accolade, and one that speaks to the heart of our profession’s commitment to provide the highest quality care to the American public. The survey addresses the decision-making role of the RN because these decisions must be based on ethics and honesty. We have earned that respect by staying true to the core ethical values9 and standards of the practice.10 A recent article by Curtain11 on solving ethical dilemmas underscores the important ethical obligation we have as professional nurses to recommend to patients that they use the hospital’s ethics committee to sort out their options and decide on the best possible course of action. This kind of action by the RN is viewed as helping the patient get assistance from the experts. Professional accountability such as this makes our role visible by demonstrating to others that our primary commitment is to the patient, whether an individual, family, group, or community. Because we are seen as honest and ethical, the duty to provide care through role- and standards-based practice and the most up to date best evidence takes center stage. The public’s accolade also underscores the importance of the professional as teacher. Nurse leaders can find ways to show how the work of nursing is a major contributor to improving patient outcomes. Many times the value of the professional RN and the related practice is below the radar. This situation places a special obligation on nurse leaders to demonstrate the value of the professional RN in relation to improving outcomes. It helps the public, physicians, other team members, and those who would desire to be professional nurses understand the impact of the nurse’s behavior on generating positive outcomes for patients and ensuring patient safety.

CARING FOR THE SAFETY OF THE PATIENT—THE PROFESSIONAL ROLE IN PRACTICE In a professional model of practice, role competence is linked to outcomes. The title “Beyond Rhetoric to Role Accountability” brings home this point. An important thesis, validated throughout my years of practice, is that if you want to improve the standard of care, then you must improve the standard of practice. Improving the standard of practice is based on one’s understanding of professional role authority, responsibility, and accountability. A key article by Aiken et al,12 which documents the valuable part that nurses play in morbidity and mortality reduction, put the issue on the front page and was supported further by Blegen and Goode.13 Lankshear et al14 adds that more emphasis on how our practice produces positive efJune 2006

fects on patient outcomes is needed as we continue to address this issue of patient safety. Questions about whether the work environment supports the efforts of nurses to practice in a professional model and provide quality care has been explored.15-18 Another issue that requires focused attention on the need for a professional model is governance of practice.19 This clinical governance model addresses the key professional obligation to monitor and evaluate practice. 20,21 This concept is still underdeveloped. However, the recent resurgence of interest in Magnet designation, in which issues related to the environment of care and professional practice are addressed, is a hopeful sign for the future. But despite major positive changes that have improved the delivery of care, the high profile report by the Institute of Medicine in 1999 indicates that all is not well in health care.22 This report citied nearly 100,000 deaths annually as a result of medical errors. Many practitioners and hospital management teams were not surprised by the figure, which suggests a level of understanding of the issues that contribute to the situation. I consider role accountability an important key variable.6 Since the report, many collaborative initiatives have been launched by hospitals and states who are striving to better understand the nature and occurrence of adverse events and implement interventions that reduce the incidence of adverse events. An important addition to the work on patient safety is the 2003 Institute of Medicine report “Health Profession Education: A Bridge to Quality.”23 This report focuses on professional education and the need to develop strategies for restructuring clinical education. The report concludes that doctors, nurses, pharmacists, and other health professionals are not being adequately prepared to provide the highest quality and safest medical care possible, and there is insufficient assessment of their ongoing proficiency. It recommends that students and working professionals develop and maintain proficiency in five core areas: delivering patient-centered care, working as part of interdisciplinary teams, practicing evidence-based medicine, focusing on quality improvement, and using information technology. It goes on to support and reinforce the need to return to our core values and renew, reconfirm, and remember the principles upon which a profession is built and from which the powerful decision- making authority of the professional role is derived. It is interesting to note that these recommendations align with the tenets of a profession that have long been held as the basis for action within a profession.23,24 These tenets include a service orientation based on ethics, a body of knowledge to be used in practice with the necessary training to master the knowledge and skill, and the monitoring and evaluating of practice to professional standards. These tenets form the basis of a professional model of practice and must be in clear view at all times.6 The Joint Commission on Accreditation of Health Organizations (JCAHO)25 picked up this theme in 2005 and 2006 by focusing attention on the need to communicate in a more standardized way to improve practitioner-to-practi-

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tioner communication. The promotion of this practice speaks directly to our professional obligation to engage in interdisciplinary thinking and collaboration,26 the purpose of which is to transfer knowledge and information about the patient and the patient’s condition. Labeling this as a communication issue undermines the complexity and skill needed to complete this transaction in a manner that produces timely, reliable, and valid information. Several organizations were well on their way to dealing with this issue from an interdisciplinary professional practice model before these 2006 JCAHO goals were set.27-30 Recent publicity on “failure to rescue” has focused attention on the need to examine the cause of this situation. Silber et al31 defined the concept in 1992 as “death after adverse occurrence.” Clark et al32-34 add their definition, which is “the proportion of patients who die among those who experience complications, taking into account the best set of variables to control known patient safety risk.” This introduces the concept of controlling for patient risk. In doing so, Clark ties the concept to professional role competence and evidence-based practice. It is important for nurse leaders to look carefully at the depth and breadth of knowledge that the staff has about the patient’s condition. This knowledge, coupled with our observing and monitoring function, demonstrates that nurses can play a significant part in reducing the need for rescue by anticipating potential risk. In this context, the rapid response team, a recently introduced strategy to rapidly bring resources to a patient situation when care demands exceed available resources at the point of care, would only be used when patient situations were highly unpredictable and not because the practitioner did not have sufficient knowledge to anticipate the event. Another patient safety initiative related to a professional model of practice is the Institute for Healthcare Improvement “Save a 100K Lives Campaign35 as a strategy to help make health care safer and more effective for all patients and make certain that hospitals achieve the best possible outcomes. The key strategy closely aligns with the basic intent of a professional model of practice. Their desire is to “change the skills, attitudes, and knowledge of the workforce, both in the ongoing development of young professionals and in life-long education, so as to reduce profession-specific silos that limit collaborative effort for the well-being of patients…and seek to improve joy in work, and to help all who work in health care to become better able to help improve care.” Leaders carry significant influence in recognizing that building an organization that supports a professional model of practice is a patient safety and quality of care issue that will move us from rhetoric to role accountability.

DEVELOPMENT OF THE PROFESSIONAL Professional development has long been supported within the profession. My interest in professional development36 is related to promoting the need for all educational programs to include socialization to the generic professional role and then, based on that understanding, apply 30 Nurse Leader

the principles to the goal of nursing. This foundation is used to support professional RN role development and socialization from the perspective of the powerful position of the RN as a decision maker on the interdisciplinary team. For students, professional role development and socialization must begin the day they start their professional education; when they begin to learn, internalize, and adopt the behaviors associated with a profession. I have worked with organizations that understand this basic principle, respect and treasure the work of nursing, promote interdisciplinary collaboration, understand the evidence base for practice, and recognize the need to control and monitor practice, all of which are key requirements for a professional practice model that is practical and fosters role accountability.7 My emphasis continues to be on professional role development and socialization that addresses role competence based on the tenets of a profession, scope of practice, and standards rather than skill competence or clinical practice competence both of which are dependent on role competence. This approach to development assures that practitioners understand both the substance and process of nursing.37 McClure,38 in her article on the educational preparation of nursing, makes a compelling argument for why service has a vested interest in both the substance and process of the education of nurses. She indicates that service has the ultimate responsibility to set standards, and that includes standards related to staff knowledge and skill. Her clarity on the issues brings home the point that role development and socialization start at the point of entry and continue throughout a person’s career. To be effective leaders, all who practice must be well versed in the generic professional role behaviors to promote a professional model of practice that emulates and rewards these behaviors when providing care.

HOW TO BUILD A PROFESSIONAL PRACTICE MODEL To ensure a role- and standards-based approach to professional role development and to help find ways to focus on the central concept in a professional model of practice, I have developed a formal program based on this professional framework and used to guide professional role development in a systematic and data driven manner. The framework includes the four core role components of self direction and decision making, evidence-based practice, role-based transfer of knowledge, and role-based provision of care. When the leadership team is well versed about the generic professional role and its related responsibility, they can use it as a key for developing a competent work force. This is true for educators, preceptors, and management. The manager role is designed to determine whether the workforce is upholding these rules and regulations when providing care. They must know how to “Manage to the Standard” based on an understanding of the generic professional role and related expectations. Senior leadership can take steps to help the clinical leadership team engage in the necessary professional role development.39 This helps to reconfirm and reground the team’s understanding June 2006

Table 1. Generic Baccalaureate Students Category

Total

Not Familiar

Novice

Beginner

Intermediate Expertise

Somewhat Advanced

Extremely Advanced

Self Direction

165

3.64%

29.09%

38.18%

27.27%

1.82%

0.00%

Using Theory

150

6.67%

37.33%

36.00%

20.00%

0.00%

0.00%

Transferring Knowledge

240

5.83%

27.92%

35.83%

26.67%

3.75%

0.00%

Providing Care

300

3.67%

33.67%

39.00%

22.33%

1.33%

0.00%

of role- and standards-based practice. A key strategy is to use a data-driven professional role development program that produces a development plan designed to guide ongoing professional role development through a system of feedback and reinforcement needed to achieve higher levels of expertise. To that end, a Professional Role Development and Role Socialization Program (Program) provides such an opportunity for comprehensive approach to professional development. It is an intensive educational program that provides core content about the professional role and its application to the professional registered nurse role, strategic planning, and a professional role assessment experience. It provides a consistent approach to role- and standards-based practice and to the appropriate use of the professional RN role within an interdisciplinary team. It is used for the role development of managers, charge nurses, clinical nurse specialists, educators, preceptors, new graduates, professional staff, faculty, and students. The program is based on the O’Rourke Professional Practice Model (PPM), which includes two key models: the O’Rourke Model of the Professional Role that describes the key components of professional role, and the O’Rourke Stability of Patient Condition & Professional Practice Decision-Making Process Model that defines the professional role decision-making process used to help recover the patient and manage patient care activities. Together these models clarify professional role accountability, support the professional role as a key decision maker on the team, and uphold the pivotal decision making role that the professional RN plays on the interdisciplinary team. In addition, the program uses the O’Rourke Professional Role Development Guide (PRDG), a data driven tool that delineates the role expectations associated with the professional role and serves as a learning needs assessment and development plan to guide progressive development. In this way, role development is approached in a systematic manner. The program sets the stage for development of the leadership team such that the agenda to develop a competent and sustainable workforce can more forward. It introduces a systematic way to identify the learning needs associated with the professional role and its development. In the end the clinical team must own its role accountability to ensure that care is provided in a manner that is based on its legal and professional role. June 2006

This program clarifies the decision-making and critical thinking authority of the professional role based on scope of practice. Traditionally, management has used the job description and performance evaluation to address practice performance. Most job descriptions simply refer to “upholding the standards,” and few clearly spell out what that means. As a result managers are unable to be precise in their feedback to staff about how to meet the practice standard. These traditional tools leave management with an incomplete or inconsistent way to evaluate professional role competence and then tie it to performance. When used consistently and systematically, PRDG helps develop and sustain a highly functioning professional staff and leadership team that is role and standards based. This program supports the concepts and principles found in the Forces of Magnetism and when used facilitates the journey toward Magnet designation. Through this program, individuals in the management/clinical leadership role achieve a better understanding of the generic RN role, which is needed if they are to fulfill their obligation as managers to evaluate standards based practice. The primary goals include increasing understanding of the professional role and role expectations based on scope of practice and professional standards. This back-to-basics approach and increasing skill in the use of a defined professional role development tool (PRDG) for the purpose of self development leads to professional role competence, increasing understanding of role competence as the foundation for leadership and clinical practice and increasing understanding of the link between professional role competence and outcomes. The following five tables describe the level of role expertise of several key positions and show the varying levels of role expertise that can exist within an organization or student cohort. All participants were instructed in the O’Rourke Program core content. The data generated from the role assessment is used to guide the development and socialization process in a manner that reinforces role- and standards-based practice.

Generic Baccalaureate Students Table 1 represents data from 15 self-assessments completed by generic baccalaureate students. The frequency distribution indicates that even when students are taught in a consistent manner, variation in their learning and understanding can occur. The data generated from

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Table 2. Advance Practice Students Category

Total

Not Familiar

Novice

Beginner

Intermediate Expertise

Somewhat Advanced

Extremely Advanced

Self Direction

484

2.07%

24.79%

30.37%

26.86%

13.43%

2.48%

Using Theory

440

3.86%

24.32%

39.32%

24.09%

5.91%

2.50%

Transferring Knowledge

704

6.82%

20.60%

27.70%

24.72%

15.77%

4.40%

Providing Care

880

2.73%

20.23%

37.16%

26.25%

10.23%

3.41%

Table 3. New Graduates Category

Total

Not Familiar

Novice

Beginner

Intermediate Expertise

Somewhat Advanced

Extremely Advanced

Self Direction

484

3.31%

43.06%

40.91%

10.33%

1.65%

0.21%

Using Theory

440

5.45%

49.09%

39.77%

5.45%

0.23%

0.00%

Transferring Knowledge

704

5.40%

40.77%

37.93%

12.78%

2.84%

0.28%

Providing Care

880

2.61%

44.66%

39.55%

11.59%

1.36%

0.23%

Table 4. Preceptors Category

Total

Not Familiar

Novice

Beginner

Intermediate Expertise

Somewhat Advanced

Extremely Advanced

Self Direction

517

1.55%

2.71%

13.93%

33.66%

35.40%

12.77%

Using Theory

470

6.17%

2.98%

27.02%

37.23%

21.28%

5.32%

Transferring Knowledge

752

2.66%

1.33%

15.16%

35.64%

32.58%

12.63%

Providing Care

940

0.53%

1.06%

13.94%

35.21%

33.40%

15.85%

this program was used by faculty members to further clarify and reconfirm students’ perceptions of their professional role behavior.

through individuated learning plans. The data was used by staff development/educators and preceptors to clarify and reconfirm the new graduate’s perceptions of their professional role behavior.

Advanced Practice Students Table 2 represents data from 44 self-assessments completed by students enrolled in an advanced practice program leading to a master’s degree in nursing. This frequency distribution indicates that educational preparation and practice experience prior to entering a program of study may vary. The data provided a useful way to ensure that discussions related to the professional role by students and faculty were based on a common reference point that displayed the full range of behaviors associated with the professional role and its decision-making authority.

New Graduates Table 3 represents self-assessments of 44 new graduates primarily from associate degree programs. This distribution indicates that, even when taught in a consistent manner, levels of expertise vary and must be addressed 32 Nurse Leader

Preceptors Table 4 represents self-assessments of 44 preceptors who were assigned to coach and precept new graduates. This distribution indicates that variation in levels of expertise is present and must be addressed through individuated learning plans. The data was used by staff development/educators and preceptors to clarify and reconfirm their own understanding of professional role behavior.

Nurse Managers Table 5 represents self-assessments of 12 clinical nurse leaders in an acute care setting. This distribution also indicates that, even when taught in a consistent manner, levels of expertise vary and must be addressed through individualized learning plans. This program is a practical and effective way to generate role data that helps reduce variation in the understanding June 2006

Table 5. Managers Category

Total

Not Familiar

Novice

Beginner

Intermediate Expertise

Somewhat Advanced

Extremely Advanced

Self-direction

132

0.00%

0.00%

8.33%

25.00%

46.97%

19.70%

Using Theory

120

0.00%

4.17%

14.17%

37.50%

38.33%

5.83%

Transferring Knowledge

192

0.52%

2.60%

5.73%

28.13%

45.31%

17.71%

Providing Care

240

0.00%

0.42%

6.25%

30.42%

48.33%

14.58%

the expectations associated with the professional role within a professional model of practice. These profiles of professional role expertise show that variation exists. This data provides the opportunity for generating professional development plans and helps define more clearly the learning needs associated with increasing role expertise.

9.

10. 11. 12.

CONCLUSION A professional model of practice is a practical way, beyond rhetoric, to structure the learning needs of nurses. Through a professional role development and role socialization program, staff will be motivated and rewarded for effectively using their role in the service of the patient. This model requires an understanding of and support for the generic professional role. Therefore, to sustain this learning process, we must reward managers who build environments that support the professional role and reward educators who teach the professional role to strive for higher levels of practice excellence. In this way, all our roles can come together as a dynamic force that helps build and sustain a workforce that is role and standards based and helps us stay true to our professional commitment to provide the best care to our patients.

13.

References

19.

1.

2.

3.

4.

5.

6.

7.

8.

Massaro T, Monroe D, Schisler L, White R, et al. A professional practice model: two key components. Nurs Manage 1996;27(9):43-48. Nevidjon B, Erickson J. The nursing shor tage: solutions for the shor t and long term. Online Journal of Issues in Nursing 2001 Jan 31. Available at: www.nursingworld.org/ojin/ topic14/tpc14_4.htm. Accessed 2006 March 13. Wolf GA, Hayden M, Bradle, JA. The transformational model for professional practice: a system integration focus. J Nurs Admin 2004;34(4):180-185. Brennan PF, Anthony M, Jones J, Kahana E. Nursing practice models: implications for IS design. J Nurs Admin 1998;28(10): 26-31. O’Rourke M. Professional issues and development in psychiatric nursing. In: Pothier P, editor. Psychiatric nursing: a basic text. Boston (MA): Little Brown; 1980. O’Rourke MW. Generic professional behaviors: implications for the CNS role. Clinical Nurse Specialist 1989;3(3): 128-132. O’Rourke MW. Rebuilding a professional practice model: the return of role based practice accountability. Nurse Admin Q 2003;27(2):95-105. The Gallup Poll. Honesty and ethics in professions 2005. Available at poll.gallup.com/contnet/default.aspx?ci=1654. Accessed Februar y 26, 2006.

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14.

15.

16.

17.

18.

20. 21. 22. 23. 24.

25.

26.

American Nurses Association. Code of ethics for nurses with interpretive statements. 4th ed. Silver Spring (MD): ANA Nursebooks; 2005. American Nurses Association. Nursing: scope and standards of practice. Silver Spring (MD): ANA Nursebooks; 2004. Curtain L. Patients’ rights: In whose best interest? Healthcare Traveler 2005;12(11):14-16. Aiken LH, Smith H, Lake E. Lower Medicare mortality among a set of hospitals known for good nursing care. Med Care 1994;32:771-787. Blegen MA, Goode CJ, Reed L. Nurse staffing and patient outcomes. Nursing Research 1998;47(1):43-50. Lankshear AJ, Sheldon TA, Maynard A. Nurse staffing and health outcomes: a systematic review of the international research evidence. Adv Nurs Science 2005;28(2):163-174. O’Rourke MW, Thompson C. Building a strong clinical practice system: the case for an interdisciplinary professional practice model. Presented at: Tomorrow’s Nursing Workforce: Practice Solutions for Success. Forum on Health Care Leadership; Nashville, (TN) August 7-10, 2004. Hinshaw AS, Atwood JR. Nursing staff turnover, stress and satisfaction: models, measures, and management. Ann Rev Nurs Res 1983;1:333-353. Kangas SK, Kee C, Mckee-Waddle R. Organizational factors, nurses, job satisfaction and patient satisfaction with nursing care. J Nurs Admin 1999;29(1);32-34. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout and job dissatisfaction. JAMA 2002;288(16):1987-1993. O’Rourke MW, Davidson PM. Governance of practice and leadership: implications for nursing leadership. In: Daly J, Speedy S, Jackson D, editors. Nursing leadership Sydney: Churchill Livingstone; 2004: 327-343. Larson MS. The rise of professionalism: a sociological analysis. Berkeley (CA): University of California Press: 1977. Pointer DD. Hospitals and professionals: a changing relationship. Hospitals 1976;50:117-121. Institute of Medicine. To err is human Washington (DC): National Academies Press; 2001. Institute of Medicine. Health Professions Education: a bridge to quality Washington (DC): National Academies Press; 2003. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st centur y. Washington (DC): National Academies Press; 2001. Joint Commission for the Accreditation of Health Care Organizations. Special report: 2005 Joint Commission National Patient Safety Goals: Practical Strategies and Helpful Solutions for Meeting These Goals. Available at: www.jcrinc.com/subscribers/ perspectives.asp?durki=7704. Accessed February 26, 2006. O’Rourke MW. Who holds the keys to the future of health care? Nurse Week 1996;(8):1-2.

Continued on page 44

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Rhetoric to Role Accountability Continued from page 33 27. O’Rourke M. Professional practice and collaboration for care team redesign. Nursing Horizons. 1994 Dec, Long Beach Memorial Medical Center, Division of Nursing. 28. O’Rourke M, Goeppinger S. Interdisciplinary professional practice: Good for patients, good for business. Presented at the American Academy of Nursing Annual Conference; San Diego, (CA); November 2-4, 2000. 29. O’Rourke MW, Bucher R. Improving the quality of the clinical conversation: a commitment to patient safety. Presented at: American Nurses Association 2004 Biennial Convention; Minneapolis (MN); June 25-30, 2004. 30. O’Rourke MW, Bucher R. Improving the quality of the clinical conversation: a commitment to patient safety. Presented at: Queens Medical Center Patient Safety Conference; Honolulu, (HI); February 28, 2004. 31. Silber JH, Williams SV, Krakauer H, Schwartz JA. Hospital and patient characteristics associated with death after surgery: a study of adverse occurrence and failure to rescue. Medical Care 1992;30:615-629. 32. Clarke SP, Aiken LH. Failure to rescue. Am J Nurs 2003;103(1); 42-47. 33. Aiken LH, Clarke SP, Cheung RB, Sloane DM, Silber JH. Educational levels of hospital nurses and surgical patient mortality. JAMA 2003;290(12):1617-1623. 34. Clarke SP. Failure to rescue: lessons from missed opportunities in care. Nurs Inquiry 2004;11(2):67-71. 35. Berwick DM, Calkins DR, McCannon CJ, Hackbarth AD. The 100,000 lives campaign. JAMA 2006;295(3):324-327. 36. O’Rourke M. California nursing practice act: a model for implementation., San Francisco, Calif: California Nurses Association; 1976. 37. O’Rourke M. Expert power: the basis for political strength. New York: National League for Nursing; 1980. 38. McClure ML. The nursing leader and nursing education: a case for patient advocacy. Nurs Leader 2005;3(2):29-32. 39. O’Rourke MW, Jones BA, White C, Segura A. Striving for the highest RN role performance: implications for professional RN role accountability, authority, and patient safety. Presented at: the Association of California Nurse Leaders Annual Program; Culver City (CA); February 5-7, 2006.

Maria Williams O’Rourke, RN, DNSc, FAAN, CHC, is president and CEO of Maria W. O’Rourke Inc., her consulting firm that specializes in professional role development, management and education services. She can be reached at [email protected]. 1541-4612/2006/ $ See front matter Copyright 2006 by Mosby Inc. All rights reserved. doi:10.1016/j.mnl.2006.04.011

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