Walk the Talk: Promoting Control of Nursing Practice and a Patient-Centered Culture

How clinical nurses can operationalize the walk aspect of the talk, the values and beliefs inherent in control of nursing practice and a patient-centered culture.To “walk the talk”—putting values into action, leading by example, practicing what you preach—is a best practice related to 2 of the 8 attributes or work processes identified by staff nurses as essential to a healthy work environment. These 2 attributes, control of nursing practice and a culture in which concern for the patient is paramount, are the focus of this article. Another commonality of these 2 essential attributes is that they are the only 2 of the 8 that have as many departmental/hospital-wide implications as they do unit-focused implications. Nurses cannot control practice or engage in activities related to a patient-centered culture at the unit level unless parallel sanction and endorsement for these activities exist at the organizational level. After clarifying and illustrating the walk-the-talk metaphor and the constructs control of nursing practice and shared governance, we present the results of research that pertain to control of nursing practice and a patient-centered culture. We then suggest ways in which clinical nurses can operationalize the walk aspect of the talk, the values and beliefs inherent in control of nursing practice and a patient-centered culture.The cultural metaphor walk the talk is not new, but its use in both popular and professional literature and in everyday colloquial usage is increasing.1,2 In the study that provided the data for this article, the term was freely used by all—staff nurses, managers, physicians, and other professionals—in all hospitals and in all regions of the United States. It was used in conjunction with 3 of the 8 essentials of a healthy work environment: nurse manager support, control of nursing practice, and a patient-centered culture. The following 2 examples illustrate use of this metaphor with respect to a patient-centered culture and control of nursing practice. The first excerpt from a 2001 staff nurse interview3 illustrates the metaphor with respect to culture.The second example illustrates use of the walk-the-talk metaphor in the control of nursing practice. One of the study hospitals that had been invited to participate in the structure-identification studies declined because of a busy schedule of upcoming activities. A week after the invitation was declined, the investigator was informed that the administrative group had been hasty in their decision and that the request was being sent to the shared governance research council for disposition. The council contacted the investigators, sought additional information, endorsed the study, and expedited the institutional review board’s review process. The chief nursing executive explained that the council structure was still relatively new and that nurses and administrators were still learning how to make decisions together, how to walk the talk and “practice what we preach.”4In the spring and summer of 2006, we conducted a nationwide study4–7 in 8 strategically selected magnet hospitals. The purpose of the study was to ascertain the organizational structures and leadership practices that staff nurses identify as necessary for a healthy work environment, specifically, structures and practices that promote control of nursing practice and a patient-centered culture. To achieve this purpose, we needed to elicit the answers from staff nurses working in patient-centered cultural environments with confirmed control of nursing practice. The Essentials of Magnetism (EOM),8–10 a tool used to measure the extent to which staff nurses confirm that they have healthy work environments, has subscales to measure control of nursing practice and patient-centered culture as well as the other 6 essentials. It has been administered to staff nurses in hundreds of hospitals, mostly magnet hospitals, since its development in 2003. The results of these EOM evaluations were used to select the hospital sample for this study.We selected the 8 magnet hospitals, according to the 8 census-tract regions of the United States, that had the highest or second-highest EOM scores. To obtain the interview sample, we selected the clinical units with the highest EOM scores within each hospital. The “experts” that we interviewed on these units consisted of 244 staff nurses nominated by their peers and managers, 105 nurse managers, and 97 physicians nominated by staff nurses or managers. The number of staff nurses interviewed varied by the size of the unit but usually consisted of 2 or 3 staff nurses, 1 nurse manager, and 1 physician per unit. We interviewed the chief operating officer, the chief nursing officer, and 4 to 6 representatives from professional departments such as respiratory therapy, physical therapy, dietary, and pharmacy in each hospital to obtain the perspectives of these personnel of the nursing department and the degree of interdepartmental collaboration. We also conducted “participant-observation,” a qualitative research technique,11,12 in all central and unit council meetings during the 4-day on-site visit.The American Nurses Credentialing Center, which governs magnet designation, refers to control of nursing practice as “shared” or “unit-based” decision making related to an environment in which administrators use a participative management style.13 The Institute of Medicine,14 in the institute’s delineation of 5 evidence-based management practices needed for a healthy work environment, define it as “involving workers in decision making pertaining to work design and work flow.” Staff nurses in magnet hospitals define control of nursing practice as a work process through which nurses at all levels in the organization have input and make decisions on issues of importance that affect nurses, the context of nursing practice at unit, departmental, and hospital levels, and the quality of patient care provided.15 The input includes access to power and exchange of information, views, and judgments; the decision making is interdependent and shared; and the issues of importance include practices, standards, policies, and selection of equipment.Nurses wrote of control of nursing practice as follows:Staff nurses in both the United States15,16 and Canada,17 now4,18,19 and in the past,20 concur with well-established precepts of a profession in distinguishing between clinical autonomy and control of nursing practice. Clinical autonomy is individual, patient-centered decision making with the patient as the primary and often sole beneficiary. In much of the nursing literature,18,19 clinical autonomy and control of nursing practice are combined, referred to simply as decision making, and are discussed as though they were the same attribute. The American Association of Critical-Care Nurses standards for maintaining and sustaining a healthy work environment21 group the 2 dimensions of autonomy under a single standard, effective decision making, but particularly note the principle of unique and combined spheres of practice that is so critical in selecting the appropriate type of decision making: independent or interdependent. Control of practice, articulated by Flexner22 almost 100 years ago in his characteristics of a profession, is the self-regulation and self-determination of professional issues, practices, and standards by professionals. The following excerpt from an interview with a staff nurse illustrates the application of this definition to nursing. (All excerpts in this article are from interviews with staff nurses unless noted otherwise. NM indicates excerpts from interviews with nurse managers; MD, excerpts from interviews with physicians.)As in any form of self-regulation or self-determination, a structure is needed to facilitate smooth and accountable operation. In nursing, control of nursing practice is operationalized through shared governance or similar structures. Born on the heels of the participative management and decentralization themes of the early 1980s, shared governance is a nursing management innovation that legitimizes nurses’ control of nursing practice while extending the influence (input and decision making) of nurses at all levels, to administrative areas previously controlled by management.23 Shared governance is a structural configuration of councils and committees that provide formal mechanisms that ensure nurses’ responsibility, right, and power to make decisions and to control nursing practice.Whether termed shared leadership, clinical governance, collaborative governance, shared decision making, or simply the nursing council, the structure alone will not “bake the The structure by best management practices that make shared governance through of such as and and have noted or that shared governance structures that are not and are not by best management practices will not nurses to control practice. and that shared governance are by staff as with staff nurses on councils and committees but the to have control professional practice, leading to and to for to and of decision making were also in a nationwide of staff nurses working in hospitals that had shared governance in shared governance is not identified as a of or as a of it is that shared governance or a similar structure is for as a magnet hospital. staff nurses in magnet hospitals not confirm the of shared governance structures. In 3 of magnet hospitals in 2 staff nurses that shared governance structures were not and and not the nurses to control nursing practice. the as shared governance structures and what best practices make shared governance structures effective in nurses to control nursing are the we to the we interviewed in the study interviewed identified 2 shared governance and and 5 practices that nurses to control nursing practice within the shared governance and were of the structures were other shared The structures the was by the were usually according to such as practice, quality evidence-based practice, and In hospitals, the councils were according to professional such as staff nurse manager, and practice were into of and not all central councils were at the unit level. with hospitals had with a focus such as nurse practice council or staff nurse evidence-based practice council, and central councils were often at the unit the leadership in council activities were as and nurses’ control of practice. through the of the was usually with or and much in and were not the only or the chief for in control of nursing practice, but they were a nurses that they in a because they had a professional to do 5 best practices that control of nursing practice were the walk aspect of walk the and that shared governance structures nurses’ control of nursing practice. Nurses in hospital walk the talk as the access to power is usually referred to as The it as and you that you had to and that you had the power to make decisions that affect nursing practice, and that you were not only to use that but were to do Shared governance structures were as a of formal governance structures and control of nursing practice are and Staff nurse not to of or from the of had the of this power will power is the to influence action, and control power was as a a had had was this by a at the magnet hospital in A and used in all 8 hospitals, is that power is power has an quality that can and shared to the and of all A staff nurse as the of research by and we that to a of shared governance structures. we all staff nurses on the units with EOM in the sample by the of a tool used to measure the extent to which nurses that they are In this is as access to The tool is used to measure 4 of support, and access to both formal and Staff nurses in these 8 magnet hospitals in any other sample of staff nurses in the literature and within a of nurses in practice and were the chief of The chief of power in the of the 8 hospitals was the and that staff nurses with physicians and other in such as patient care The interdependent of these of had the and power of all professional of power was an shared governance the shared governance structures in and of in which the shared governance structure was in the not in any single were by in 3 of the 8 hospitals. with nurses in the other hospitals, nurses in these 3 hospitals had particularly with respect to the power through collaborative with as noted The was also as being the all are in council, you can the and implications and make decisions to and with each and to and in were 2 of the by that will or the and of a shared governance structure and the of the structure in control of nursing practice. The first and to is a best management practice of staff so that nurses can the unit to meetings and to meetings are The second the of nurses and making it for to in not only the of the shared governance structure but also results in a of with the of to a group of to refers to of the shared governance structure and of the not the physicians, and from other departments the and of nurses the context of the practice of nursing in an these will use the making it and In the of in and of and of shared governance councils is both and is also a in which the work of can and One nurse as practice and their activities are often to a nurse group meetings or group decision from the of these the and and for the decision making essential to quality of patient a shared governance structure and a clinical and many of the best practices with control of nursing practice are leadership and is much that staff nurses can do to their beliefs professional and into you in the form of self-regulation and self-determination for profession, you that nurses have not only the but the professional right, responsibility, and to control the context of nursing practice in the organization in which they you this talk by are a new shared governance structure not work from the and self-regulation are processes that and issues, in council input on issues, results of and the and of and 1 of the 8 hospitals we had a formal for of issues and their disposition. nurse identified a or had a or a a form and it to the council In this it was that the nurse a as to the or decision related to the within 2 shared governance structures to affect nurses’ control of nursing practice, and by nurses at all levels is a we are all nurses as a professional responsibility, but is a of in and patient care to in a nurses will to as unit representatives to this and of can participate by and in their unit council, by work such as the best for patient by standards, or by best practice on the and is is that the of all are and that of are and that both the or and the or decision are by is for staff nurses to access to but they can of the of power you use the power is with and being and accountable for decisions that that One nurse as they will in what they are you were not in the of peers and the and a to accountable for decisions Nurses in hospital explained the is the of and that or and the 3 or levels of to an or clinical unit, the culture is referred to as a the focus of this article. are the of the the of the unit, and or beliefs that cannot but are and example of an on of the units in study was that all were the of a and by all physicians and nurses on the unit. are the beliefs of what to are the standards by which we make decisions that influence aspect of the talk is how we make and values are the and to by in a work group that the are the ways of and include both the and the shared of and the and with or can a from and to or on how and the and values In are to or not to by The of the culture on the and of the of the work the to the culture to new and on how well and the values and are by group The and of the culture on the degree of and on the degree of of the values processes to ensure a values and the values and to new and and values and culture of was with the and was as almost you can it you walk into a as a magnet hospital by the American Nurses Credentialing is on the structures the of with an work environment that were from results of the study and on the for of nursing the of Magnetism and the of for the have to since first study in the staff nurses in magnet hospitals have the of a patient-centered culture in their work environment. 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were patient and that were staff this had been the 2 patient-centered values first and autonomy and have for of the the that these 8 magnet hospitals had in which the was concern for the hospital values and as provided in hospital are in in of within the but not between hospital values and unit for in how values are and between hospital and units is almost for the 4 the 5 and are the 2 unit and and autonomy and the unit and hospital had 2 hospital and the hospital and unit had In unit values are and hospital values are the 8 hospitals had many in the they also had unique making each hospital and to the the hospital hospitals were were research and the of on and to the hospital and to the hospitals were by particularly to the to and to the In of these hospitals, nurses of their to provide care for or to nurses for such was to identify related to hospital values as was with the unit that hospital values were The values were the central in the and on the to the in the hospital or and often on the of to a values not that the values were or A parallel was by of the at the Institute in The was used in conjunction with into hospital In to for physical and for with that were to a the of the hospital The that this was so the the values for of the or other In we can that of the hospital values to the unit indicates that managers, and the and a unit appropriate values and of in is the extent to which a of and shared values is in values that the of a and into the is what the the nurse managers, and the staff in hospitals have for or units is the extent to which values are or the the can values into ways of to use the walk the their nurses we practice nursing this unit we do it this is a used to the of a In to being in the development of values and staff also in their to and in values and The following excerpt from an it we not of the through which hospital values are operationalized or indicates that of the is as clinical nurses to to present the for the decisions they to use evidence-based management results to and note that in to make evidence-based decisions the cultural for the to the and for the nurses in magnet hospitals have noted that in to and quality patient the values by the of Magnetism and of the culture of the To the values by the into have to measure the of hospital culture and on the of such research is to and it we and data on the that a cultural of the in their into and was and staff development do well to have their and the excerpts that these used to values such as autonomy and which are at the of of nursing practice and a patient-centered culture promote both the quality of nurses’ work environments and the quality of patient Control of nursing practice nurses to the context of nursing use of evidence-based practices nurses to the quality of care provided to is the that and the group and the essential to quality the talk is a best practice through which the values of unit and hospital culture are and control of nursing practice by nurses can The 8 attributes of a healthy work environment identified by staff nurses in magnet hospitals of the hospital and unit culture and quality in patient care are to the talk is also of the of nurse identified by staff nurses as In the article in this we present the results of studies related to the 2 essentials of a healthy work environment: nurse manager and of

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