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Celebrating books: ‘Should’ – taking back your power over words [to post whenever too busy for notes!] June 23, 2017

Posted by mariemanthey in Creative Health Care Management, Inspiration, Leadership, Professional Practice.
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In the midst of all the Symposium goings-on, we wanted to take a minute and celebrate the work of one of our CHCM staff member, Rebecca Smith. At CHCM she is involved in all the writing activities of the company, and also consults in the area of human communication/relationships.

Creative Health Care Management last year re-issued Rebecca’s book: ‘Should: How Habits of Language Shape Our Lives‘, due to its very useful applicability to the health care environment.

In ‘Should’, Rebecca explores the power of language at a psychological level – the power it has to hold us back or to move us forward. It is another non-silo work, applicable to everyone in every part of their life. Including, of course, nurses.

I had the privilege of providing the foreward for the 2016 edition and here’s an excerpt from that:

‘The culture of nursing is replete with all forms of oppression, but I have always thought that the most insidious among them is self-oppression, often referred to as victim mentality. There is no question that our work is hard or that there is, and will always be, more work to do than time or resources to do it. In fact, it is no mystery why people in all disciplines within health care might slip into feeling victimized or oppressed.

But that doesn’t mean self-oppression and victim mentality are the only choices available to us.

Self-empowerment — the opposite of self-oppression — is possible for all people in all circumstances (remember how self-empowered Nelson Mandela became during his time in prison!), and just as the name implies, it happens from the inside out. It happens because of the decisions we make to empower ourselves, and one of the most direct routes to doing so comes through noticing and changing the language we use to describe our lives. If our language is full of references to our own powerlessness, what kinds of stories do we end up telling ourselves about who we are, what we do, and how much we matter?

Part conceptual, part workbook, this work is full of concrete, applicable ideas. If you’ve already read Rebecca’s book, we’d love to hear about your experiences with her ideas. Otherwise we strongly encourage you to pick up a copy for your self-empowerment library!

 

Authentic Nursing: Past, Present and Future June 18, 2017

Posted by mariemanthey in Creative Health Care Management, Inspiration, Leadership, Manthey Life Mosaic, Professional Practice.
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Nursing is a dynamic profession, constantly moving forward for the well-being of patients and their families.

Let’s look back at one of the early mainstream articles about the onset of Primary Nursing; let’s celebrate recent exciting book releases; and let’s prepare for an incredible week of growth and discovery at the CHCM International Relationship-Based Care Symposium!!

Looking back at the Past:

Primary Nursing: Hospitals bring back Florence Nightingale

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ChgoTrib_2.78_PageTwo

This article provides clear details about the way things were before Primary Nursing. This excerpt (from the 2nd page) is talking about Carol Davis, Primary Nurse, who had been ‘foreman’ in a task-based nursing delivery system at Rush-Presbyterian-St. Luke’s in Chicago before the implementation of Primary Nursing there.

“I was the kingpin who cracked a whip over a crew of people who were unskilled, making sure they got their tasks done,” Davis recalls. “That kept me running around like a chicken without a head.”

She managed about a dozen or so aides, assigning them to various tasks for 25 to 40 patients. Davis made sure the chores were completed on schedule and recorded on patients’ charts, and that her workers went to lunch and returned on time.

Having her own ‘team’ was unheard of. Her aides, like chessmen, were constantly shifted around to other registered nurses, new patients, new units and new tasks. She didn’t have time to get to know her helpers and their abilities.

Furthermore, she had no time for interacting with patients except at pill time. “We were caught in a system that put procedures ahead of patients’ needs,” Davis says. “Nursing didn’t have much of a human face, yet none of us knew how to correct that.”

Results included a turnover rate of RN’s of 48.7% each year!

Celebrating the Present:

Advancing Relationship-Based Cultures is Creative Health Care Management’s newest publication, just in time for the Symposium! Edited by Mary Koloroutis, and David Abelson, the book explores the  culture of health care organizations, looks at what is  necessary for optimal outcomes, and suggests strategies to achieve those outcomes. Advancing Relationship-Based Cultures explains and expands a fundamental and often overlooked truth in health care: It is the confluence of relational and clinical competence that advances healing cultures.

Not as recent, but very relevant: Transforming Interprofessional Partnerships – A New Framework for Nursing and Partnership-Based Health Care by Riane Eisler and Teddie Potter. The only interprofessional partnership text written from the nursing perspective, it provids a model for partnership with patients and other health care professionals.

Prepare for the Future: The Symposium is Here!!!

And moving forward, the Symposium is here! Next week will be an incredible journey, which we’ll share here on the blog as much as possible.

In addition, there will be content on Twitter, Facebook, and even other channels possibly. Find me at @colormenurse on Twitter and join the conversations!

This will be an amazing event, coming only once every 4 years, and each Symposium has many dynamic, passionate health care leaders from around the world. Attendees this year are coming in from Germany, Switzerland, Brazil, Italy and with the US a large number of states are represented.

I am looking forward to seeing many of you next week and together with you working  to advance healthy workplace cultures for those receiving care, and for those who work there.

Personally… Being Mortal by Atul Gawande June 11, 2017

Posted by mariemanthey in Inspiration, Manthey Life Mosaic, Professional Practice.
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I lost a close friend recently, after a long struggle with some chronic medical conditions.

It’s a sad period, but one comfort is that his last days went as well as they possibly could. I’m reminded of this book: Being Mortal, written by practicing surgeon Atul Gawande.

In the book Atul explores what it means to ensure that the positive meanings of one’s life extend through the final phases of that life, clinically and in all other ways. Atul has completely defeated the normative medical profession’s reluctance to address that period after medicine stops being applicable. He explores what continues to be important for the person themself and their family.

I found it extremely moving and useful – not just for that period but for everyday. Highly recommend!

Additional Resources:

NY Times Book Review

Frontline: PBS Special

Pennsylvania Library Book Discussion Notes

The Guardian Book Review

Announcement: CHCM Book Release! May 22, 2017

Posted by mariemanthey in Announcements, Creative Health Care Management, Inspiration, Leadership, Professional Practice.
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I am  excited to let you all know about Creative Health Care Management‘s newest book publication!

It is called Advancing Relationship-Based Cultures, and I love both the content and the book’s authenticity regarding health care today.

Edited by Mary Koloroutis, and David Abelson, the book explores the  culture of health care organizations, what is  necessary for optimal outcomes, and strategies to achieve those outcomes.

Advancing Relationship-Based Cultures explains and expands a fundamental and often overlooked truth in health care: It is the confluence of relational and clinical competence that advances healing cultures.

A relationship-based culture is one in which a critical mass of people provides care and service with relational competence. In these cultures, the skills that foster relational competence are actively developed, nurtured, practiced, reinforced, and evaluated. While countless thought leaders have championed the importance of improving relationships, this book provides vision and strategies for system-wide culture transformation….and it does so with a depth and authenticity that is breathtaking.

Readers of this book will understand that a strategy that includes improving all relationships will improve all other measures as well. When you empower people, giving them the tools to take excellent care of themselves, one another, and the patients and families in their care; organizations thrive and patient-care is optimal.

Chapter Overview

  • Foreword: The Giver and the Receiver Are One
  • Overview: Advancing Relationship-Based Cultures
  • Chapter 1: A Relationship-Based Way of Being
  • Chapter 2: Attuning, Wondering, Following, and Holding as Self-Care
  • Chapter 3: Attunement as the Doorway to Human Connection
  • Chapter 4: The Voice of the Family
  • Chapter 5: Loving Leaders Advance Healing Cultures
  • Chapter 6: One Physician’s Perspective on the Value of Relationships
  • Chapter 7: Embedding Relational Competence
  • Chapter 8: The Role Human Resources in Advancing Culture
  • Chapter 9: Relationship-Based Teaming
  • Chapter 10: Care Delivery Design that Holds Patients and Families
  • Chapter 11: Evidence that Relationship-Based Cultures Improve Outcomes
  • Chapter 12: Relationship-Based Care and Magnet® Recognition
  • Epilogue: Continuing the Conversation
  • Appendix

Softcover, 344 pages. (2017)

ISBN: 978-1-886624-97-9

Salons – Looking Back, Looking Forward May 19, 2017

Posted by mariemanthey in History, Inspiration, Leadership, Nursing Salons, Professional Practice.
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Alternate title: Salons – Then and Now

A Talk for All Times | Nursing Forum, October 2010

Salon conversations | Nursing NewsNurse.com | 2012

 

Nursing Salons were created to provide a safe opportunity for people from throughout the diverse practice of nursing to share their stories, hear from others, come to grips with the realities of their workplace, offer support, and regain the feeling of unity.

They caught on like wildfire, not only in the U.S. but around the world as well.

At the top of this post you’ll see some links to the birth of these Salons: my article in Nursing Forum Magazine from 2010, and a note from an early adopter in 2012.

It’s interesting to relive those initial ground-breaking moments, and review the origins of all that has come to be.

Looking forward, I hope Salons continue to spread into every community and are attended by members of  all health professions.  These conversations create ripple effects throughout the system.

Imagine if doctors and nurses and professionals from other health disciplines all over the country met together and had conversations like this. Margaret Wheatley tells us that conversations change people and people change the world.

We see this happening in ways large and small at Salons. The salon in my home yesterday evening was no exception.

My dream is that doctors and nurses and all clinicians begin meeting in homes all over the US and talk to each other about the work we do.   I KNOW the health care system would be impacted in a major way.   We would migrate health care forward, in big changes and small changes, in ways that can not be specifically predicted but can be expected with absolute certainty.

I hope that everyone is able to take part in this wonderful vehicle for self-care and enhanced professional practice. And I hope that together we continue to build the best future possible for the health of society.

Have any of you has been to a salon recently? How did it go? Are any of you still looking for one near you? Are any of you planning events and considering adding a salon before/after/during? It’s always great to hear from you!

Reading List:

Turning to One Another: Simple Conversations to Restore Hope to the Future (2002) Margaret Wheatley

Richard Olding Beard: An Extraordinary Feminist. May 7, 2017

Posted by mariemanthey in Academia, History, Inspiration, Professional Practice.
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This note is about a work-in-progress, a scratch pad entry from the Desk of Marie Manthey.. it includes a resource list at the end and an invitation to comment and join in the process!

Nursing and the Women’s Movement have had an interesting, challenging and contradictory relationship since modern nursing was born around the 1870’s.

Never a feminist herself, Florence Nightingale created a profession for nurses – for women – where none had existed before. This profession is based on values that have been associated with women.

Fast forward 40 years to the life of Richard Olding Beard, a professor of physiology in the University of Minnesota Medical School. His strong vision of the contribution nursing could make to the benefit of society gave the school of nursing a trajectory that continues to compel the future.

He founded the School of Nursing at the University of Minnesota, which was the first nursing education program within an academic institution. He clearly supported higher education for women and recognized the foundation of science in nursing. He presciently imbued the School of Nursing with multiple societal values that continue to be expressed in the work of its graduates today. Richard Olding Beard saw Nursing’s potential capacity for increasing social justice in the world; for example because of how nursing values the act of caring for the sick – all of them – without regard for position, wealth or status.

There is much more to come, in the full article. To end this preview, here is one of my favorite quotes of his:

“The history of a university or school – and particularly of a professional school – may be guided or misguided by its governing body, may be inspired or uninspired by its faculty, but it is actually written in the work and in the play, in the life and character, in the future achievements and influence of its students.” R. O. Beard, Graduation of the School of Nursing, September 1923.

Beard’s writings (articles mainly) have been a treasure trove for me, and I encourage you to check them out. There is a collection of his writings at the Anderson Archives at the University of Minnesota Library.

Additional information: Honoring the Past, Creating the Future – School of Nursing Celebrates a Century of Leadership. Minnesota Nursing, Spring/Summer 2009. P 2-3.

Please comment below with any questions, thoughts, anecdotes etc..!

RAA Content Series – Part I May 2, 2017

Posted by mariemanthey in History, Leadership, Manthey Life Mosaic, Professional Practice.
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Part I

 

A useful framework for improving the workplace and other areas of life is RAA. RAA stands for Responsibility, Authority and Accountability. Those words convey multitudes of meanings.   Their use in this paper is based on definitions found in dictionaries, and applied in this article to:

Organizing complex functions,

Clarifying interpersonal relationship issues and

Achieving the full experience of will power.

To introduce this concept, I’ll share the story of its origins, and how this concept came to become the framework I hold up to every aspect of life.

It started when a group of nurses on a single hospital unit began to change the way they were taking care of their patients.   It was the late sixties and unrest was a societal norm.   I connect the underlying causes motivating the protesters and the changes initiated by these nurses.     These days, with different kinds of disruptions underway, the relevance of these concepts is higher than ever.

Paul Goodman wrote about decentralization, the Equal Rights Amendment was nearly passed, ‘power to the people’ was a popular slogan.   As I was trying to understand the principles behind the changes the nurses were making, I was led to literature about Responsibility, Authority and Accountability.   Interestingly enough, some of that literature was about the use of these concepts in military organization, and in the law.   Ultimately, I opted for a simple definition based on dictionary terminology.   My definition is as follows:

Responsibility – The clear allocation and acceptance of response-ability so everyone knows who is doing what (who is managing the process of each specific functionality being accomplished).

Authority – The right to act – to make decisions and direct behavior of others – in the area for which one has been allocated and accepted responsibility.   There are two levels of authority: Authority to recommend and authority to act.   Clarification of which level applies in each specific situations is functionally useful.

Accountability – The retrospective review of the decisions made or actions taken to determine if they were appropriate.   In the case of the decision-making having been non-optimal, corrective action can be taken for the purpose of improving functionality. That corrective action must never be punitive.

 

ORGANIZING COMPLEX FUNCTIONS

I spent the next 10 years pragmatically applying these concepts to both a delivery system for nursing care and to the complex bureaucratic institution known as a hospital.   These were not theoretical applications of concepts or armchair speculations, but rather actual reorganizations involving changing roles, relationships and responsibilities of real people working in real hospitals.   During that period of pragmatic and intense organizational application, I learned many things.   Among them:

  1. How changing work organization impacts on personal development, as well roles, relationships, work quality and energy levels of workers.
  2. How disparity in the balance between responsibility, authority and accountability at the personal, departmental and administrative levels of operations creates dysfunctional organizations and troubled human relationships.
  3. How personal maturity and responsibility acceptance are totally intertwined
  4. The defined difference between a profession, an occupation and a vocation.

IMPLICATIONS FOR ORGANIZATIONS

Lack of clarity and disparity of balance regarding among these concepts results in dysfunctional organizations and negative interpersonal relations.   These conditions in turn, produce low morale, inefficiency and low quality work.

First of all, the issue of clarity.   The scope of responsibility involved in each and every role, needs to be clear to both the person in the role and to those who interact with that role.   Role confusion regarding scope of responsibility creates incredible job stress and interpersonal tensions.   Whenever responsibility has not been clearly allocated, there is a power vacuum resulting in power struggles.   These power struggles can fall anywhere on the spectrum from having individuals assume authority way beyond their legitimate scope and …conversely,  things not being done because everyone assumes the other person will do it.   Role clarity with specific attention to scope of responsibility is essential to effective functioning.

Clarity of authority levels is also crucial.     The delegation of authority should ideally be exactly commensurate to the scope of responsibility.   An effective decentralized organizational structure will reflect careful attention to matching responsibility to authority.   In some situations, individuals may be unwilling to accept responsibility and will therefore be reluctant to use the authority they have been delegated.   These individuals will manifest continued dependencies and often fall into victim thinking. On the other hand, some individuals refuse (or are unable) to see the limits of their responsibility scope, and insist on exercising authority over functions that fall outside their scope of responsibility.   These situations result in an abuse of power.

When these elements are not in alignment, individuals affected by that have an opportunity to provide correction.   For example:

Imagine a situation where your boss asks you to take over a new function.   Maybe run a new clinic in a nearby town, in addition to your current clinic responsibilities. He/she says “You are responsible for getting this up and running and ‘in the black’ within a year.   Do a good job!”     You may say, will I be choosing the site we will rent?   And the answer is “NO …the site is already decided.”   You may then ask, will I be hiring the staff for this clinic?   And the answer is NO…. the type of staff (and consequent costs) will be controlled by Budget Control Office.   You may ask, will I have a marketing budget to announce this new service. And the answer is NO…that is under the control of the marketing department. And you say, will I have anything to say about location, equipment to be purchased, staff to be hired, services to be given and amount clients will be charged, to which every answer is “NO – someone else has that responsibility.” You are only responsible for bringing it into profitability within one calendar year. In this scenario, a wise employee would say, ‘Boss…. I am willing to coordinate the opening of this clinic and to do everything in my power to assure financial success, but I cannot take responsibility for that since I have no decision-making authority.’

.. to be continued

The Mosaic of Marie Manthey’s Life April 30, 2017

Posted by mariemanthey in Creative Health Care Management, History, Inspiration, Manthey Life Mosaic, Nursing Peer Support Network, Nursing Salons, Professional Practice, Values.
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ColoringBookCover

by Marie Manthey

I became ill at the age of 5 and was hospitalized for a month at St. Joseph’s Hospital in Chicago. It was a traumatic experience in a couple of ways. First of all, my parent’s didn’t know how to prepare me, since they had never been hospitalized themselves.. so they just said I was going to a large building. They left me there for a month, visiting twice a week, and sometimes when one or the other of them came, a very painful procedure was done involving an IM injection of their blood. As a result, I felt not only abandoned but also frightened and confused about the pain associated with their visits.

Florence Marie Fisher is the name of a nurse who cared for me. One day she sat at my bedside and colored in my coloring book. For me, that translated to ‘cared for me’ … and I decided then that I wanted my life to be about that kind of caring.

From that time on I knew I would be a nurse. I entered a hospital diploma program right after high school, and worked for the next four years as staff nurse, assistant Head Nurse, and Head Nurse. During the last of those years I started going to night classes in the community colleges .. not necessarily at first to get my degree.

I was invited to enroll in the degree program at the University of Minnesota, which was one-of-a-kind at that point. After 15 months of full-time study, I received my Bachelors degree in Nursing Administration. Soon after I was recruited into the U of M’s Masters program in Nursing Administration, in what was the last of the 3-quarter Master’s degrees.

Before finishing that degree, I was recruited by Miss Julian to be an Assistant Administrator of Special Projects. This was a new position that gave me an unbelievably valuable opportunity to learn first-hand about leadership and administration. I was able to experience directly not only organizational dynamics, but was also privileged to work with a group of administrators who used Senge’s principles of a learning organization even before he’d written ‘The Fifth Discipline.’

It was during this time that I became one of two Project Directors for Project 32 (at the University of Minnesota), a pilot program to improve hospital services from an interdisciplinary/interdepartmental perspective. This project eventually morphed in to Primary Nursing, and my career became about understanding and implementing organizational changes that result in the empowerment of employees and the accompanying development of healthy workplace cultures.

Throughout the next ten years of my life in nursing administration – first at another community hospital within the Twin Cities, and then at Yale New-Haven Hospital in Connecticut – I freely helped others with Primary Nursing.. Always accepting visitors and often speaking both locally and nationally as well as publishing as time allowed.

During this period of my career, what had been a manageable, socially acceptable level of alcohol consumption escalated in to full-blown alcoholism. There was an intervention and I entered a 6-week residential treatment program on the East Coast, and have been sober ever since.

In my first year of sobriety as I was feeling my way forward, there were no positions in Nursing Administration available to me. Instead I wrote my initial book on Primary Nursing .. and returned calls to all who had ever asked me to speak, putting out the word that I was available for speaking and consulting. The result was that Creative Nursing Management, Inc. was born, now the longest-running nurse-managed health care consulting firm in the U.S.

When I finished writing Primary Nursing, the publisher asked me who I wanted to dedicate it to.. and that had to be Florence Marie Fisher, the nurse who had colored in my coloring book when I was five. We weren’t able to contact her then, and so I gave up on that idea of actually connecting with her.

My career as a successful entrepreneur has continued ever since. Running a business was not ever something I thought I would do. I didn’t see myself as a businesswoman, but rather as a professional woman. Nevertheless, through many trials and many errors, the company grew. I often say we were successful not because of my business acumen, but rather because my work was authentic and based on real-world realities and values.

In time we grew into a multi-faceted, multi-national firm called Creative Health Care Management. I sold the firm when I turned 65 (in 2000) to the employees themselves. Now in semi-retirement (still, in 2017!) I remain involved in the important work of developing nursing practice and improving patient care.. just without the stresses and challenges inherent in leading an entrepreneurial entity.

An additional aspect of my work today involves tackling the challenge of Substance-Use Disorder. A group of us concerned with the problem of shame and stigma associated with SUD formed a Peer Support Network here in Minnesota, and we are partnering with entities involved in all aspects of the situation.

Another vitally important component of my professional life today has to do with my involvement with my alma mater. After transitioning away from day-to-day involvement in the running of CHCM, I became active in the Alumni organization at the U of M School of Nursing, and also became an adjunct faculty member there. In 1999 the University of Minnesota awarded me with an honorary doctorate, which was thrilling beyond compare. Today I am also active with the Heritage Committee at the School of Nursing, and am engaged in other ways as well with the University.

I also continue to be a part of my own and others’ Nursing Salons – a safe space for nurses in all walks of the profession to share conversations and support one another.

My ongoing interest in changing the way we think about workload and resources is part of the same picture. As healthcare incorporates more and more technology, the temptation strengthens to discard the human caring aspects.

As nursing matures as a profession, I am more convinced than ever, that the choice to care – and to express care and compassion by one’s behavior – is the absolutely correct choice nurses must make in order to continue to serve society justly.

Clinical competence must be on one side of the nursing coin, and care on the other. This is the ‘Coin of the Realm’ nurses must choose if, in fact, the covenant between nursing and society is to continue to exist.

Timeless Treasures: ‘Utopia’ April 28, 2017

Posted by mariemanthey in Creative Health Care Management, Inspiration, Leadership, Professional Practice.
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By Marie Manthey

Utopia is a nursing unit where the staff members are treated with respect by both the hospital that hires them and they physicians with whom they work. It is a place where the respect people have for themselves and each other means that relationships are healthy and supportive. It is a place where people understand the value of maintaining their own peace of mind.

In this Utopia, nurses are self-confident and have a sense of self-worth. They know they aren’t perfect, and accept the reality that they will make mistakes. They understand that no one wants to make mistakes, but that mistakes are inevitable because they are human, and only God is infallible.

Nurses in Utopia have a sense of purpose in life and believe they have both the right and responsibility to shape their own futures.

Nurses in Utopia feel good about themselves and can therefore love their patients. They recognize and respect the interests of other nurses, patients and physicians and respond to them appropriately. These nurses have an ability to get the job done, even within their own limitations. They are free to use the very best level of skill, knowledge, intuition, and personality strengths they possess in administering care to their patients. They understand the fundamental value and worth of their profession and are ennobled by the dignity of the human interactions they engage in during the normal course of their professional activities.

Nurses began working in this Utopia early in the Nineties, when they finally learned that the essence of human growth lies in the self and that in order to grow, one must change and that each of us can only change ourselves — not anyone else.

References:

Relationship-Based Care Field Guide

Visions, Strategies, Tools and Exemplars for Transforming Practice

Editors: Mary Koloroutis, Jayne A. Felgen, Colleen Person, Susan Wessel

Part 1: Vision ||Chapter One: Begin at the BeginningPage 41

Originally published in Primarily Nursing Journal, 7[5].

The Choice of Every Nurse Every Day…an excerpt of my introduction to this new book….. June 24, 2013

Posted by mariemanthey in Creative Health Care Management, History, Inspiration, Professional Practice, Values.
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Advancing-Professional-Nursing-Practice-Book

A painting is not created by a free floating hand making marks with oils on canvas. The hand belongs to an artist connecting with his or her mind, body, and spirit, not only to the process of creating a painting, but to those who will one day see the painting. The hands of the artist are not where the skill lies. Without the whole person showing up in the creation of the painting, there is no art; there is just painting.

The art of nursing can be thought of in much the same way. The nurse can show up as little more than a pair of hands doing tasks, but this is not nursing; this is just doing tasks.

The art of nursing (as is perhaps true of any art) is about connection. In the art of nursing, the nurse connects to the patient, and the nurse also connects to the profession of nursing. Advancing Professional Nursing Practice is about the art of both of those connections. It is a book in which the ANA standards are named and explained, connecting nurses to the practice and performance standards of their profession. It is also a book about Relationship-Based Care, which is a care delivery model that connects nurses to patients and families by removing barriers to the nurse-patient/family relationship and improving relationships throughout the organization.

I’m always happy for nurses who get to work in cultures that support healthy relationships throughout the organization, and I share the distress of those who work in environments that seem to be fueled by chaos and competition. It is the choice of the nurse, however, whether to show up in either environment as a whole person, fully invested in the care of patients and families; or simply as a technically competent task doer.

In 1966, the way I viewed nursing was changed forever by an article I read in the American Journal of Nursing. It was written by Sister Madeleine Clemence, and it was called “Existentialism: A Philosophy of Commitment.” The way I saw it, this learned nun, a woman far ahead of her time, was challenging me, a young nurse leader, to show up as a whole person in my work. Her article challenged me to change my own practice and to mentor others to do the same:

“Commitment can mean many things: a promise to keep, a sense of dedication that transcends all other considerations, an unswerving allegiance to a given point of view. In existentialism, commitment means even more: a willingness to live fully one’s own life, to make that life meaningful through acceptance of, rather than detachment from, all that it may hold of both joy and sorrow.”[1]

It was no accident that Sister Madeleine was talking about “acceptance of, rather than detachment from, all that life may hold” in the context of the nurse’s work. As a nurse herself, she could see that the work of the nurse is secular for all, but sacred for only those who commit themselves to making it so. As we go about the work of nursing, are we solving problems or are we entering into the mystery of what it means to be with a person who is suffering, vulnerable, and afraid? She quotes philosopher Gabriel Marcel, writing, “A mystery is a reality in which I find myself involved…whereas a problem is [merely] in front of me.”

It raises a provocative question for nurses: Am I involved with my patients, or are they merely in front of me?

Over a century-and-a-half ago, Florence Nightingale helped to make nursing an art through bringing compassion into her own practice and then writing about it so that others might see that when the basic relational needs of the patient are tended to, there is a healing that takes place whether cure is possible or not. She famously encouraged the soldiers of the Crimean War to write to their loved ones. She understood the simple human truth that connection is healing—connection with loved ones (be they near or far), connection with one’s own thoughts and feelings, connection with the realities of one’s current situation.

The compassionate focus on connection that Florence Nightingale brought to nursing is still there, but it has gotten lost in the shuffle over and over; throughout history every time there was a major change in the world of health care. Here is some historical background:

Prior to the Great Depression, private duty nursing was the main avenue of employment for the nation’s RNs. As the Depression eliminated this avenue for many, RNs returned to their home hospitals as temporary workers, often on a volunteer basis, sometimes working for their room and board. As such, they found themselves working in a highly regimented, task-based, time-focused system of care that was designed to control practice and teach student nurses. This eventually became the main avenue for employment of RNs and remained so until fairly recently.  This move from more autonomy for RNs to less autonomy is a pattern that has repeated itself throughout modern history.

After WWII, the proliferation of new hospital beds coupled with the baby boom (which greatly reduced the nursing workforce), resulted in team nursing, a delivery system designed to maximally utilize technical expertise and assistive support staff under the direction and supervision of an RN. Again, the focus was on assigning and supervising the performance of tasks, since the only person educated to provide a therapeutic relationship was nearly always consumed with supervision and the performance of tasks requiring a higher skill level than that of her staff.

The system upheaval that characterized the last 30 years of the twentieth century, which was driven by finance, technology, and regulation, resulted in most health care organizations dealing with higher patient acuity coupled with severe cost cutting, which again resulted in a focus on managing the tasks of care rather than managing therapeutic relationships. The resulting dehumanization within the care system drove a spiral of regulations and system constraints that further complicated (and continue to complicate) an already intensely complex adaptive system.

The age we live in is no different. As we deal with the myriad changes of health care reform, we’re seeing, once again, a return to task-based practice. This time, however, it feels different to me in various ways. I’m heartened by the numbers of organizations that are embracing Relationship-Based Care. The publication of See Me as a Person is another example – it addresses the need for nurses and other caregivers to be “in it” with their patients rather than merely ministering to their bodies. As the next major societal shift in health care advances, whatever it is, the profession of nursing must continue to define itself. Society trusts us to do so, and our covenant requires it.

Nurses must ask themselves some important questions: What exactly is it that must always be present in order for nursing to really be nursing? What is the actual core of nursing? What strengthens that core? And what must be present in order for that core to even exist? In short, what is the nursing imperative?

I would ask you to mount your own inquiry, and come up with your own answers. Here are mine:

The nursing imperative is a two sided coin. On one side there is the imperative to be clinically competent in both technical skills and clinical judgment. The other side is the willingness to step into being with the human being for whom the nurse is caring. In health care, people experience vulnerability at every level of their being: mental, emotional, physical, and spiritual. The privilege of nursing is having the knowledge and skill, the position and relationship, to interact with a vulnerable human being in a way that alleviates pain and increases mental, emotional, physical, and spiritual comfort. This is the privilege of nursing—the being with a vulnerable human being. If this privilege is ignored or overlooked, nursing isn’t happening. No matter what is happening in a care environment, authentic human connection with the vulnerable human beings in our care can and must happen. That, to my mind, is the nursing imperative.

It’s clear that half of the nursing imperative is that we have a mastery of the technical aspects of nursing, but the other half of the nursing imperative—and it truly is no less than half—is staying present to the vulnerability of others. This book seeks to address the dual nature of the nurse’s work, both the instrumental and relational. If you are a nurse (or about to become one), I’d ask you to keep this dual nature in mind as you read this book.

Marie Manthey, MNA, FRCN, FAAN, PhD (hon.)

March 8, 2013


[1] Clemence, M. (1966). Existentialism: A philosophy of commitment. American Journal of Nursing, 66(3), 500-5.