- Email: [email protected]
Enhancing nursing leadership: Through policy, politics, and strategic alliances
Enhancing Nursing Leadership Through Policy, Politics, and Strategic Alliances There are a number of key professional nursing roles within New Zealand in which the incumbents are in a position to influence policy, either as individuals or by being in strategic alliances with others. Strategic alliances between key professional leaders in different nursing roles can help the profession by directly influencing policy development and implementation. This form of policy entrepreneurship is an important component of professional leadership.
Frances Hughes, DNurs, RN, Jan Duke, PhD, RN, Anita Bamford, DNurs, RN, and Cheryle Moss, PhD, RN In this article, we explore leadership in three key professional arenas: government through the role of the chief nurse, practice through the role of the director of nursing (DON), and education through the role of head of a nursing school. Through enactment of entrepreneurship in the policy arena and strategic alliances among varying sectors, these incumbents advance professional agendas and practice in their everyday roles.
LEADERSHIP AND INFLUENCE Leadership and influence are core competencies for all three leadership roles. The role of the chief nurse within a country is important politically and practically to provide information, mediate among various interest groups, and refine practical health strategies and policy. When working strategically as a policy entrepreneur, the chief nurse influences the development of activities that help the emergence of critical ideas, expertise, and proposals well ahead of time. For the chief nurse to generate change and develop new concepts, it is critical to strategize and to influence others and events within different levels of organizational structures. This includes working both externally and internally in government to create links and “couple up” streams, creating a softening-up 24 Nurse Leader
process and preparing the environment through cooperative alliances. This is done so that proposals may gradually become supported. Such proactivity, Oliver and Paul-Shaheen1 argue, not only uses opportunities but also creates agenda items. The chief nurse scans the environment for opportunities to determine when certain proposals may be more likely to be viewed more seriously than others, taking advantage of right timing or, as Kingdon2 would say, when the window is open. Kingdon recognizes that, characteristically, policy entrepreneurs’ resources include “their longevity, their expertise, the pattern of their relationships with interest groups.”2 As a nurse, public servant, and policy entrepreneur, the chief nurse offers important advice to the ministry and government and is also key to the implementation of policy that affects and influences nurses and nursing.
DIRECTORS DONs are primarily charged with influencing care within particular health care organizations. This organizational role is about finding new ways to provide professional leadership that is nonhierarchical and vested in elevating nurses’ professional work. Leadership as a DON is about assessing the practice environment to determine either reApril 2006
sistance or receptiveness to change. At the same time, effective strategies are developed that are congruent with this assessment. The DON represents the nursing component of health care at the corporate level and has input into such activities as the quality improvement council, strategic planning, finance, risk management, human resources, and other projects and programs of the corporate leadership team. In a typical district health board (DHB) within New Zealand, the DON provides expert advice on nursing to the chief executive, clinical directors, and business managers. Critical aspects of leadership in this role are the ability to bring wisdom and expertise to enhance practice within the DHB and to effectively support and influence broader development of nursing practice within the profession and health care services. To achieve these effectively, DONs need functional and strategic national and international links. Working with this juxtaposition of internal and external influences requires an artful understanding of how to use power, how to draw knowledge and insight from others, and how to read and influence the possibilities in the moment.
SCHOOLS Like the chief nurse and DON, the role of head of school of nursing is also one of strategic importance and influence. Located within educational institutions such as universities, the head of a school is charged with meeting educational and research imperatives of the profession and ministerial directives as well as those of the tertiary educational provider. Heads of schools must be able to operate within the values and professional imperatives of the nursing practice discipline while adhering to traditional university values and processes. The heads of schools are thus positioned to offer leadership to the profession from within the university. They must legitimize emerging nursing discourse within the current academic discourse and negotiate the extension of boundaries for the necessary growth and development within both the practice and university environment. A necessary component of this work is the leadership to negotiate professional imperatives, culture, and discourse. The heads of schools must position their school to be a key contributor to the profession and generate influence sufficient to support the developments of other schools and sectors. It is necessary that the head of a school exert influence in professional policymaking and implementation. This ensures that the educational institution’s requirements will meet the needs of the profession. Achieving this often requires cooperation between the key sectors within the nursing community, educators within the university and polytechnic sectors, nurse executives, the nursing council, professional associations, and other bodies. These sectors are often required to work strategically and collectively with the head of school to convince politicians, policymakers, and public servants of the merits of change and to help April 2006
the academic community deliver on the educational initiatives important for improved health outcomes. As illustrated, these three leadership roles demonstrate similar imperatives for valid policy entrepreneurship. They use similar strategic alliances to achieve effective professional development and influence from within their spheres of practice. For strategic alliances to work effectively, those in critical leadership roles in government, practice, and education also need to recognize and value the different viewpoints and spheres of influence of members within the alliance.
POLICY ENTREPRENEURSHIP AND STRATEGIC ALLIANCES Policy entrepreneurship has been described by Kingdon2 as somewhat akin to surfing, which involves timing, placement, and creation of momentum to ride and drive forward. Policy entrepreneurs need to be able to use a wide range of choices and practices to create and move agenda items. These individuals must generate necessary links and relationships among issues, problems, policy possibilities, and political forces and streams. It is necessary to watch for windows of opportunity to gain control over resources, control information, and gain access to pivotal people. Strategic windows occur only for limited periods, and to notice and use them requires critical skill in environmental scanning and using one’s professional capabilities strategically and cooperatively.3 Policy entrepreneurs play a major part in waiting and watching for the right time to attach solutions to problems, identify constraints, and take advantage of politically propitious events. According to Kingdon,2 policy entrepreneurs generate links between “streams” and action: good ideas require advocacy, problems need solutions, and political moments of opportunity need incentives and welldeveloped proposals. The policy entrepreneur is able to shift and move around in these different streams so as to further significant and strategic interests and issues. As Kingdon2 identifies, “Policy entrepreneurs bring several key resources into the fray: their claim to a hearing, their political connections and negotiating skills, and their sheer persistence.” Kingdon also says, “Without the presence of an entrepreneur, the linking of the streams may not come together. Good ideas lie fallow for lack of an advocate. Problems are unsolved for lack of a solution. Political events are not capitalized for the lack of inventive and developed proposals.” Oliver and Paul-Shaheen1 agree with Kingdon2 and describe how policy entrepreneurs “exhibit a wider horizon of choice” and influence policy streams through taking advantage of the ambiguity of policy by offering proposals as a “plausible solution.” Policy entrepreneurs also impact the political stream by influencing interest groups and political parties when changes in national mood are occurring. Kingdon2 highlights that the chances of items moving higher on an agenda are enhanced considerably by the presence of a skillful entrepreneur. Oliver and Paul-Shaheen1 go even further and
Nurse Leader 25
directly recognize that because of Oliver and Paul-Shaheen1 reIt is important to let go of searched in six U.S. states the factors their effective political and practical personal agendas and that create the right environments for processes, policy entrepreneurs manage to create agenda items. personal power differen- policy innovation and change. They concluded that “the critical factor Reflecting on our roles and practices, tials to generate stronger these states shared in common was the authors of this article agree that leadskilled committed leadership from polership in nursing does require and use platforms within and icy entrepreneurs.” Leadership is the these political and practical skills and between groups. key characteristic of the policy entrethat much strategic work is achieved by preneur, which “is needed to recogthe regular and effective engagement of nize opportunities for change” and to “organize the policy entrepreneurship. Each of us could identify multiple development of options to ameliorate the most pressing instances in which change and desired development inproblems.” volved working the context, influencing and responding to Again, we agree with these authors, but we also recogpolitical opportunities, enrolling people, generating possibilinize that policy entrepreneurship involves the formation ties, seizing ideal moments, and prying open spaces to creand use of strategic alliances as processes in the develate a better and stronger ground for action. opment and achievement of change. In a practical way, As a group, we generated and learned a number of such leadership is about having a clear grasp of what is practice maxims; these include “keep to the vision while possible. It is about motivating others to join in the efworking on the parts,” “keep the ball in the air and the fort to create and use opportunities for development. Efgame going,” and “there is more than one way to skin a fective alliances recognize the significance of the greater cat.” We also stressed with each other the need to work good and work toward that end. Leadership generates politically and practically with these powerful tools for and influences policy and practical outcomes and in the change and implementation plans. This requires a critical process generates and involves strategic alliances. conscience, moral responsibility, and respect for justice We have argued our beliefs about the construct, and fairness. processes, and centrality of policy entrepreneurship and In considering the surfing analogy we concluded that, strategic alliances to the effective exercise of professional in everyday practice, we enroll others to assist the forward leadership within key nursing roles. In the following secmomentum. We form strategic coalitions consisting of the tion, we draw this to a conclusion with consideration of right people at the right time in the right way and for the implications and further developments that need to occur. right reasons to generate movement and development. These strategic coalitions involve keeping to the vision THE IMPORTANCE OF POLICY while working on the parts and evolving the vision to keep ENTREPRENEURSHIP TO NURSING progressing, often in incremental steps. We had each expeIn our exploration, we found that policy entrepreneurrienced successful moments and outcomes using entrepreship was critical to effective leadership within our roles, neurial skills and working strategically with others to and we experienced relative ease and confidence in create and move political and practical platforms forward. identifying ways this phenomenon works. This ease and We had also experienced failures where agendas were clarity are likely indices of the strength of the phenomedropped, opportunities were not seized, and coalitions na within our practice and of our local theorizing in had failed to unite. As a group, we explored our beliefs practice.4 Yet there has been very little published in about how successful strategic alliances work. Strategic alnursing in relation to the art, skill, and relevance of poliliances often meant using some or all of the key players in cy entrepreneurship. different positions and in different ways; sometimes it inGiven the strength of this aspect within our everyday volved swapping the leader. When working in various secpractice, nurses in leadership and policy roles will likely tors, we acknowledged the varying role and sector have either confirming or other insights into the practice differences, strengths, and spheres of influence. and centrality of policy entrepreneurship for effective In acting as enrolled players for strategic coalition, we practice and professional development. This signals the recognized aspects that contributed to success, including need for more detailed investigation of the phenomenon the importance of facilitating rather than blocking as a reof policy entrepreneurship, particularly in relation to sponse to situations and people’s agendas. It is important nursing leadership. We believe also that the relevance of to let go of personal agendas and personal power differenstrategic alliances in the functioning of policy entrepretials to generate stronger platforms within and between neurship needs further investigation and elucidation. the groups. Other critical elements include being prepared to swap and change batons and baton holders while negoCONCLUSION tiating political and practical moments; keeping the The exercise of leadership from a position of power and process alive and sustaining continuity over time, across influence is critical to the development of nursing practice. sectors, and between people; and acknowledging the imNurses who have occupied critical leadership roles in govportance of sharing knowledge and recognizing different ernment (as chief nurse), in practice (as director of nursperspectives from different spheres of influence. 26 Nurse Leader
April 2006
ing), and in education (as head of school) identify some key features of their work practice environments and the skills they consider central to policy entrepreneurship. We conclude that policy entrepreneurship and the use of strategic alliances are critical to the exercise of leadership, that it is important for nurses to discuss how they create and influence policy development and ongoing change in the profession, and that this area of professional practice needs further theorizing and investigation. References 1.
2. 3. 4.
Oliver TR, Paul-Shaheen P. Translating ideas into actions: entrepreneurial leadership in state health care reforms. J Health Politics Policy Law 1997;22:722-788. Kingdon JW. Agendas, alternatives and public policies. New York: Harper Collins; 1995. Hughes FA. Role for the government chief nurse in policy and the profession. Nurs Health Policy Review 2002;1(2):11-14. Moss CA. Moral-in-practice: a hermeneutic exploration of nurses’ choices-in-action during acts of care [unpublished doctoral thesis]. Lismore, New South Wales, Australia: Southern Cross University; 2004.
Bibliography Aiken L. Health policy and nursing practice. New York: McGraw-Hill; 1981. Aiken LH, Clarke SP, Sloane DM. Hospital restructuring: does it adversely affect care and outcomes? J Nurs Admin 2000;30(10):457-465. Andreoli K, Musser LA, Otto DA. Health policy in nursing curriculum. J Nurs Education 1987;26(6):239-243. Antrobus S, Kitson A. Nursing leadership: influencing and shaping health policy and nursing practice. J Adv Nurs 1999;29(3):746753. Bamford AF. Leadership for culture change: generating new growth from old. [unpublished doctoral dissertation]. Sydney New South Wales, Australia: University of Technology Sydney; 2004. Beyers M. The executive nurse in a corporate culture. In: Beyers SR. The executive nurse: leadership for new health care transitions. Albany (NY): Delmar Publishers; 1997. p. 2-13. Buerhaus PI. Teaching health care public policy. Nurs Health Care 1992;3(6):304-309. Buerhaus PI, Needleman J. Policy implications of research on nurse staffing and quality of care. Policy Politics Nurs Pract 2001;1:5-15. Buerhaus PI, Needleman J, Mattke S, Stewart M. Strengthening hospital nursing. Health Affairs 2002;21(3):123-132. Cohen S, Mason D, Kovner C, Leavitt J, Pulcini J, Sochalski J. Stages of nursing’s political development: where we’ve been and where we ought to go. Nurs Outlook 1996;22(6):259-266. Cohen SS, Milone-Nuzzo P. Learning. Adv Nurs Sci 2001;23(3):28-40. Fagin CM. When care becomes a burden: diminishing access to adequate nursing. New York: Millbank Memorial Fund; 2001. Ferguson V. Over view of the concepts of power, politics and policy in nursing. In: Wieczorek RR, editor. Power, politics and policy in nursing. New York: Springer Publishing Company; 1985. p. 5-21. Gebbie KM, Wakefield M, Kerfoot K. Nursing and health policy. J Nurs Scholarship 2000;32(3):307-315. Hughes FA. Health policy and nursing: closer relationship required. Nurs Praxis New Zealand 2001 Nov:23-27. Hughes FA. Chief nursing officers: who are they and what do they do? Int Nurs Rev 2002;49:129-130. Leavitt JK, Cohen SS, Mason DJ. Political analysis and strategies. In: Mason D, Leavitt JK, Chaffee MW. Policy and politics in nursing and health care. St Louis (MO): Saunders: 2002. Maslin-Prothero S, Masterton A. Power, politics and nursing in the United Kingdom. Policy Politics Nurs Pract 2002;3(2):108-117.
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Mason D, Dodd CJ, Glickstein B. Role of media in influencing policy: getting the message across. In: Mason D, Leavitt J, Chaffee M. Policy and politics in nursing and health care. 4th ed. St Louis: Saunders; 2002. Mason D, Leavitt J, Chaffee M. Policy and politics in nursing and health care. 4th ed. St Louis (MO): Saunders; 2002. Mechanic D, Reinhard SC. Contributions of nurses to health policy: challenges and opportunities. Nurs Health Policy Rev 2002;1(1):7-15. Misener TR, Alexander JW, Blaha AJ, Clarke PN, Cover CM, Felton GM, et al. National Delphi study to determine competencies for nursing leadership in public health. Image: J Nurs Scholarship 1997;29(1):47-51. Mundinger MO, Kane RL, Lenz ER, Totten AM, Wei-Yann T, Cleary PD, et al. Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial. JAMA 2000;283:59-68. Rafferty AM. Nursing policy and nationalization of nursing: the representation of crisis and the crisis of representation. In: Robinson J, Gray A, Elkan R, editors. Policy issues in nursing. Buckingham: Open University Press; 1992. p. 68-83. Schön DA. The reflective practitioner: how professionals think-in-action. San Francisco: Basic Books; 1983. Sochalski J. Nursing shortage redux: turning the corner on an enduring problem. Health Affairs 2002;21:157-163.
Frances Hughes, DNurs, RN, is director of the Centre for Mental Health Research, Policy and Service Development, a professor at the University of Auckland, and the former chief advisor on nursing to the New Zealand Ministry of Health. She can be reached at [email protected]. Jan Duke, PhD, RN, is a professor and head of the Graduate School of Nursing and Midwifery at Victoria University of Wellington in New Zealand. Anita Bamford, DNurs, RN, is a lecturer in health care practice at the Auckland University of Technology and the former Director of Nursing for the Capital and Coast District Health Board of New Zealand. Cheryle Moss, PhD, RN, is an associate professor and research coordinator for the Graduate School of Nursing and Midwifery at the Victoria University of Wellington in New Zealand.
1541-4612/2006/ $ See front matter Copyright 2006 by Mosby Inc. All rights reserved. doi:10.1016/j.mnl.2006.01.001
Nurse Leader 27
Frances Hughes, DNurs, RN, Jan Duke, PhD, RN, Anita Bamford, DNurs, RN, and Cheryle Moss, PhD, RN In this article, we explore leadership in three key professional arenas: government through the role of the chief nurse, practice through the role of the director of nursing (DON), and education through the role of head of a nursing school. Through enactment of entrepreneurship in the policy arena and strategic alliances among varying sectors, these incumbents advance professional agendas and practice in their everyday roles.
LEADERSHIP AND INFLUENCE Leadership and influence are core competencies for all three leadership roles. The role of the chief nurse within a country is important politically and practically to provide information, mediate among various interest groups, and refine practical health strategies and policy. When working strategically as a policy entrepreneur, the chief nurse influences the development of activities that help the emergence of critical ideas, expertise, and proposals well ahead of time. For the chief nurse to generate change and develop new concepts, it is critical to strategize and to influence others and events within different levels of organizational structures. This includes working both externally and internally in government to create links and “couple up” streams, creating a softening-up 24 Nurse Leader
process and preparing the environment through cooperative alliances. This is done so that proposals may gradually become supported. Such proactivity, Oliver and Paul-Shaheen1 argue, not only uses opportunities but also creates agenda items. The chief nurse scans the environment for opportunities to determine when certain proposals may be more likely to be viewed more seriously than others, taking advantage of right timing or, as Kingdon2 would say, when the window is open. Kingdon recognizes that, characteristically, policy entrepreneurs’ resources include “their longevity, their expertise, the pattern of their relationships with interest groups.”2 As a nurse, public servant, and policy entrepreneur, the chief nurse offers important advice to the ministry and government and is also key to the implementation of policy that affects and influences nurses and nursing.
DIRECTORS DONs are primarily charged with influencing care within particular health care organizations. This organizational role is about finding new ways to provide professional leadership that is nonhierarchical and vested in elevating nurses’ professional work. Leadership as a DON is about assessing the practice environment to determine either reApril 2006
sistance or receptiveness to change. At the same time, effective strategies are developed that are congruent with this assessment. The DON represents the nursing component of health care at the corporate level and has input into such activities as the quality improvement council, strategic planning, finance, risk management, human resources, and other projects and programs of the corporate leadership team. In a typical district health board (DHB) within New Zealand, the DON provides expert advice on nursing to the chief executive, clinical directors, and business managers. Critical aspects of leadership in this role are the ability to bring wisdom and expertise to enhance practice within the DHB and to effectively support and influence broader development of nursing practice within the profession and health care services. To achieve these effectively, DONs need functional and strategic national and international links. Working with this juxtaposition of internal and external influences requires an artful understanding of how to use power, how to draw knowledge and insight from others, and how to read and influence the possibilities in the moment.
SCHOOLS Like the chief nurse and DON, the role of head of school of nursing is also one of strategic importance and influence. Located within educational institutions such as universities, the head of a school is charged with meeting educational and research imperatives of the profession and ministerial directives as well as those of the tertiary educational provider. Heads of schools must be able to operate within the values and professional imperatives of the nursing practice discipline while adhering to traditional university values and processes. The heads of schools are thus positioned to offer leadership to the profession from within the university. They must legitimize emerging nursing discourse within the current academic discourse and negotiate the extension of boundaries for the necessary growth and development within both the practice and university environment. A necessary component of this work is the leadership to negotiate professional imperatives, culture, and discourse. The heads of schools must position their school to be a key contributor to the profession and generate influence sufficient to support the developments of other schools and sectors. It is necessary that the head of a school exert influence in professional policymaking and implementation. This ensures that the educational institution’s requirements will meet the needs of the profession. Achieving this often requires cooperation between the key sectors within the nursing community, educators within the university and polytechnic sectors, nurse executives, the nursing council, professional associations, and other bodies. These sectors are often required to work strategically and collectively with the head of school to convince politicians, policymakers, and public servants of the merits of change and to help April 2006
the academic community deliver on the educational initiatives important for improved health outcomes. As illustrated, these three leadership roles demonstrate similar imperatives for valid policy entrepreneurship. They use similar strategic alliances to achieve effective professional development and influence from within their spheres of practice. For strategic alliances to work effectively, those in critical leadership roles in government, practice, and education also need to recognize and value the different viewpoints and spheres of influence of members within the alliance.
POLICY ENTREPRENEURSHIP AND STRATEGIC ALLIANCES Policy entrepreneurship has been described by Kingdon2 as somewhat akin to surfing, which involves timing, placement, and creation of momentum to ride and drive forward. Policy entrepreneurs need to be able to use a wide range of choices and practices to create and move agenda items. These individuals must generate necessary links and relationships among issues, problems, policy possibilities, and political forces and streams. It is necessary to watch for windows of opportunity to gain control over resources, control information, and gain access to pivotal people. Strategic windows occur only for limited periods, and to notice and use them requires critical skill in environmental scanning and using one’s professional capabilities strategically and cooperatively.3 Policy entrepreneurs play a major part in waiting and watching for the right time to attach solutions to problems, identify constraints, and take advantage of politically propitious events. According to Kingdon,2 policy entrepreneurs generate links between “streams” and action: good ideas require advocacy, problems need solutions, and political moments of opportunity need incentives and welldeveloped proposals. The policy entrepreneur is able to shift and move around in these different streams so as to further significant and strategic interests and issues. As Kingdon2 identifies, “Policy entrepreneurs bring several key resources into the fray: their claim to a hearing, their political connections and negotiating skills, and their sheer persistence.” Kingdon also says, “Without the presence of an entrepreneur, the linking of the streams may not come together. Good ideas lie fallow for lack of an advocate. Problems are unsolved for lack of a solution. Political events are not capitalized for the lack of inventive and developed proposals.” Oliver and Paul-Shaheen1 agree with Kingdon2 and describe how policy entrepreneurs “exhibit a wider horizon of choice” and influence policy streams through taking advantage of the ambiguity of policy by offering proposals as a “plausible solution.” Policy entrepreneurs also impact the political stream by influencing interest groups and political parties when changes in national mood are occurring. Kingdon2 highlights that the chances of items moving higher on an agenda are enhanced considerably by the presence of a skillful entrepreneur. Oliver and Paul-Shaheen1 go even further and
Nurse Leader 25
directly recognize that because of Oliver and Paul-Shaheen1 reIt is important to let go of searched in six U.S. states the factors their effective political and practical personal agendas and that create the right environments for processes, policy entrepreneurs manage to create agenda items. personal power differen- policy innovation and change. They concluded that “the critical factor Reflecting on our roles and practices, tials to generate stronger these states shared in common was the authors of this article agree that leadskilled committed leadership from polership in nursing does require and use platforms within and icy entrepreneurs.” Leadership is the these political and practical skills and between groups. key characteristic of the policy entrethat much strategic work is achieved by preneur, which “is needed to recogthe regular and effective engagement of nize opportunities for change” and to “organize the policy entrepreneurship. Each of us could identify multiple development of options to ameliorate the most pressing instances in which change and desired development inproblems.” volved working the context, influencing and responding to Again, we agree with these authors, but we also recogpolitical opportunities, enrolling people, generating possibilinize that policy entrepreneurship involves the formation ties, seizing ideal moments, and prying open spaces to creand use of strategic alliances as processes in the develate a better and stronger ground for action. opment and achievement of change. In a practical way, As a group, we generated and learned a number of such leadership is about having a clear grasp of what is practice maxims; these include “keep to the vision while possible. It is about motivating others to join in the efworking on the parts,” “keep the ball in the air and the fort to create and use opportunities for development. Efgame going,” and “there is more than one way to skin a fective alliances recognize the significance of the greater cat.” We also stressed with each other the need to work good and work toward that end. Leadership generates politically and practically with these powerful tools for and influences policy and practical outcomes and in the change and implementation plans. This requires a critical process generates and involves strategic alliances. conscience, moral responsibility, and respect for justice We have argued our beliefs about the construct, and fairness. processes, and centrality of policy entrepreneurship and In considering the surfing analogy we concluded that, strategic alliances to the effective exercise of professional in everyday practice, we enroll others to assist the forward leadership within key nursing roles. In the following secmomentum. We form strategic coalitions consisting of the tion, we draw this to a conclusion with consideration of right people at the right time in the right way and for the implications and further developments that need to occur. right reasons to generate movement and development. These strategic coalitions involve keeping to the vision THE IMPORTANCE OF POLICY while working on the parts and evolving the vision to keep ENTREPRENEURSHIP TO NURSING progressing, often in incremental steps. We had each expeIn our exploration, we found that policy entrepreneurrienced successful moments and outcomes using entrepreship was critical to effective leadership within our roles, neurial skills and working strategically with others to and we experienced relative ease and confidence in create and move political and practical platforms forward. identifying ways this phenomenon works. This ease and We had also experienced failures where agendas were clarity are likely indices of the strength of the phenomedropped, opportunities were not seized, and coalitions na within our practice and of our local theorizing in had failed to unite. As a group, we explored our beliefs practice.4 Yet there has been very little published in about how successful strategic alliances work. Strategic alnursing in relation to the art, skill, and relevance of poliliances often meant using some or all of the key players in cy entrepreneurship. different positions and in different ways; sometimes it inGiven the strength of this aspect within our everyday volved swapping the leader. When working in various secpractice, nurses in leadership and policy roles will likely tors, we acknowledged the varying role and sector have either confirming or other insights into the practice differences, strengths, and spheres of influence. and centrality of policy entrepreneurship for effective In acting as enrolled players for strategic coalition, we practice and professional development. This signals the recognized aspects that contributed to success, including need for more detailed investigation of the phenomenon the importance of facilitating rather than blocking as a reof policy entrepreneurship, particularly in relation to sponse to situations and people’s agendas. It is important nursing leadership. We believe also that the relevance of to let go of personal agendas and personal power differenstrategic alliances in the functioning of policy entrepretials to generate stronger platforms within and between neurship needs further investigation and elucidation. the groups. Other critical elements include being prepared to swap and change batons and baton holders while negoCONCLUSION tiating political and practical moments; keeping the The exercise of leadership from a position of power and process alive and sustaining continuity over time, across influence is critical to the development of nursing practice. sectors, and between people; and acknowledging the imNurses who have occupied critical leadership roles in govportance of sharing knowledge and recognizing different ernment (as chief nurse), in practice (as director of nursperspectives from different spheres of influence. 26 Nurse Leader
April 2006
ing), and in education (as head of school) identify some key features of their work practice environments and the skills they consider central to policy entrepreneurship. We conclude that policy entrepreneurship and the use of strategic alliances are critical to the exercise of leadership, that it is important for nurses to discuss how they create and influence policy development and ongoing change in the profession, and that this area of professional practice needs further theorizing and investigation. References 1.
2. 3. 4.
Oliver TR, Paul-Shaheen P. Translating ideas into actions: entrepreneurial leadership in state health care reforms. J Health Politics Policy Law 1997;22:722-788. Kingdon JW. Agendas, alternatives and public policies. New York: Harper Collins; 1995. Hughes FA. Role for the government chief nurse in policy and the profession. Nurs Health Policy Review 2002;1(2):11-14. Moss CA. Moral-in-practice: a hermeneutic exploration of nurses’ choices-in-action during acts of care [unpublished doctoral thesis]. Lismore, New South Wales, Australia: Southern Cross University; 2004.
Bibliography Aiken L. Health policy and nursing practice. New York: McGraw-Hill; 1981. Aiken LH, Clarke SP, Sloane DM. Hospital restructuring: does it adversely affect care and outcomes? J Nurs Admin 2000;30(10):457-465. Andreoli K, Musser LA, Otto DA. Health policy in nursing curriculum. J Nurs Education 1987;26(6):239-243. Antrobus S, Kitson A. Nursing leadership: influencing and shaping health policy and nursing practice. J Adv Nurs 1999;29(3):746753. Bamford AF. Leadership for culture change: generating new growth from old. [unpublished doctoral dissertation]. Sydney New South Wales, Australia: University of Technology Sydney; 2004. Beyers M. The executive nurse in a corporate culture. In: Beyers SR. The executive nurse: leadership for new health care transitions. Albany (NY): Delmar Publishers; 1997. p. 2-13. Buerhaus PI. Teaching health care public policy. Nurs Health Care 1992;3(6):304-309. Buerhaus PI, Needleman J. Policy implications of research on nurse staffing and quality of care. Policy Politics Nurs Pract 2001;1:5-15. Buerhaus PI, Needleman J, Mattke S, Stewart M. Strengthening hospital nursing. Health Affairs 2002;21(3):123-132. Cohen S, Mason D, Kovner C, Leavitt J, Pulcini J, Sochalski J. Stages of nursing’s political development: where we’ve been and where we ought to go. Nurs Outlook 1996;22(6):259-266. Cohen SS, Milone-Nuzzo P. Learning. Adv Nurs Sci 2001;23(3):28-40. Fagin CM. When care becomes a burden: diminishing access to adequate nursing. New York: Millbank Memorial Fund; 2001. Ferguson V. Over view of the concepts of power, politics and policy in nursing. In: Wieczorek RR, editor. Power, politics and policy in nursing. New York: Springer Publishing Company; 1985. p. 5-21. Gebbie KM, Wakefield M, Kerfoot K. Nursing and health policy. J Nurs Scholarship 2000;32(3):307-315. Hughes FA. Health policy and nursing: closer relationship required. Nurs Praxis New Zealand 2001 Nov:23-27. Hughes FA. Chief nursing officers: who are they and what do they do? Int Nurs Rev 2002;49:129-130. Leavitt JK, Cohen SS, Mason DJ. Political analysis and strategies. In: Mason D, Leavitt JK, Chaffee MW. Policy and politics in nursing and health care. St Louis (MO): Saunders: 2002. Maslin-Prothero S, Masterton A. Power, politics and nursing in the United Kingdom. Policy Politics Nurs Pract 2002;3(2):108-117.
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Frances Hughes, DNurs, RN, is director of the Centre for Mental Health Research, Policy and Service Development, a professor at the University of Auckland, and the former chief advisor on nursing to the New Zealand Ministry of Health. She can be reached at [email protected]. Jan Duke, PhD, RN, is a professor and head of the Graduate School of Nursing and Midwifery at Victoria University of Wellington in New Zealand. Anita Bamford, DNurs, RN, is a lecturer in health care practice at the Auckland University of Technology and the former Director of Nursing for the Capital and Coast District Health Board of New Zealand. Cheryle Moss, PhD, RN, is an associate professor and research coordinator for the Graduate School of Nursing and Midwifery at the Victoria University of Wellington in New Zealand.
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