Principled Leadership...in Mental Health Systems and Programs. William A. Anthony and Kevin Ann Huckshorn. Boston, Illinois: Boston University Center for Psychiatric Evaluation; 2008. hardcover 256 pages, $59.95.
Although the intended audience for this book is leaders and students of leadership in the mental health care field, the principles and approach can be applied to other disciplines and organizations. As more baby boomers move into the health system, their mental health care issues and how they are managed should concern all of us. If we just think of friends or children of friends who have confronted mental needs, or of patients we care for on medical surgical units, with comorbidities of mental illness, we cannot help but be concerned about the resources to care for them.
The authors purposely titled the book Principled Leadership, with 2 ideas in mind. The first focus is "those principles that guide effective leaders' actions." Leadership also is referred to as "principled" because the services provided by the leader's organization are designed to help people recover from serious mental illness. "We were concerned only with learning from leaders whose organization was moving toward increasing the opportunities for people to recover as compared to leaders whose primary concern was financial viability or maintaining the status quo" (p 15). The authors drafted 8 leadership principles to frame their ideas for how mental health care organizations can be successful, drawing from 2 years of teaching this as a course and interviewing several leaders. Although the original course contained 12 principles, the authors did not interview with preconceived notions of leadership theory but rather gathered their learning from the experiences of the leaders. The Leadership Academy uses this powerful approach to understanding leadership during lunch sessions, between 2 modules of leadership curriculum, participants listen to the stories of successful healthcare leaders in their city. When you allow leaders to tell their story and what they have learned, wisdom and insight are gained. The authors of Principled Leadership combined this qualitative approach with current leadership theories. Examining definitions of leadership over the last 40 years, the authors define leadership "as creating a shared vision and mobilizing others toward specific organizational goals consistent with the vision" (p 11). The approach shows the years and energy the authors put into this book and serves in itself as a motivation for leaders wishing to improve mental health care in their organizations and in this country. For this, they are to be applauded.
The 8 principles (and chapter titles) are as follows:
1. Leaders communicate a shared vision.
2. Leaders centralize by mission and decentralize by operations.
3. Leaders create an organizational culture that identifies and tries to live by key values.
4. Leaders create an organizational structure and culture that empowers their employees and themselves.
5. Leaders ensure that staff members are trained in a human technology that can translate vision into reality.
6. Leaders relate constructively to employees.
7. Leaders access and use information to make change a constant ingredient of their organization.
8. Leaders build their organization around exemplary performers.
This is indeed a unique book. The authors are academically grounded in fundamental leadership theories. And maybe because they are mental health care experts as well, they bring these theories to life through the stories of leaders who make a difference. We hear from the CEO who did a U-turn on his organization's use of seclusion and restraints in emergency centers by eliminating them. We also hear from leaders who decided people with mental illness were people and important enough to include on policy committees or involve in training side by side with staff. The authors share the personal vision statement of a dietary staff member: "My mission is to serve three meals a day to help people recover" (p 118). Then, there is the leader who took on the data debate concerning the percentage of people who had a serious mental illness and an addictive disorder. What do you think the percentage is? See page 174 for the answer.
This book challenges mental health care leaders to lead and transform the system to one of recovery. It will not surprise you to discover that one of the authors is a nurse.
Making Room in the Clinic. Nurse Practitioners and the Evolution of Modern Health Care. Julie Fairman. Chapel Hill, NC: Rutgers University Press; 2008. hardcover 270 pages, $49.95.
Making Room in the Clinic is a comprehensive historical, sociological, and political chronology of the development of the role of the nurse practitioner. Healthcare is changing rapidly and nurse practitioners will be playing a key role in its reform. Nursing history is being made and nurses themselves are becoming empowered by both legislative and care delivery improvement efforts to ensure a strong presence for the future. Understanding the evolution of this role, and the social and political impact made on this country, will significantly assist nursing leaders in making critical decisions now and in the future.
The author provides a thorough perspective of the evolution of the nurse practitioner role, but more uniquely delves into the social and political dynamics between medicine and nurse practitioners, a perspective often skimmed over and generalized. In doing so, the struggles of nurse practitioners to grow and redefine themselves are well illustrated. Both resistances and blessings from various sectors of medicine to the nurse practitioner movement are addressed. The evolution of nurse practitioner practice, resulting from necessity and practitioner shortage, is discussed at length. The significance of the nurse practitioner movement crossing professional lines while still maintaining their own professional integrity is quite powerful. As nursing administrators, the interpersonal relationships between doctors and nurse practitioners and nurse practitioners and the body of nursing itself must be clearly understood to coordinate safe and adequate care and continuity for the clients we serve.
Truly the road to advancement of nursing practice was rocky, with a multitude of roadblocks, but there were physicians who ensured the potholes were paved, sometimes to their own detriment. Nurses must be strong, intelligent, autonomous, and courageous to embark on the nurse practitioner role. These attributes, along with the inability of medicine to fill voids in access to primary care, George Ferrar, Jr, president of the Pennsylvania Medical Society in 1969, assured his membership, "this health professional could become the single great opposing force that medical doctors have ever faced."
The author also addresses the complexity in development of nursing education programs in academic health centers was fairly complex in that nursing education was integrated into medical education and practice. In Chapter 3, the author details 2 programs from which many nursing education programs derived their influence: the University of Florida and the University of Rochester. The leadership at the University of Florida, led by Dean Dorothy Smith (late 1950s-1971), worked diligently to develop a clinical-practice, shared governance, and practice unification. Practicing nurses and nurse educators in the early stages of change struggled. Graduate nurse specialists programs were not initially valued or seen appropriate by hospital administrators. Although Smith finally gave in to the resistance at University of Florida, many other universities, including the University of Rochester, developed programs modeled on Smith's work of integrated patient care.
This segues profoundly into Chapter 4, "Stealing the Spellbook," opening with a metaphorical comparison of "The Sorcerer's Apprentice" to healthcare in the late 1960s and 1970s. The author identifies failing nursing and medicine organizations, healthcare institutions, the federal government, or third-party insurers as the "napping sorcerer." This allowed the "apprentice," nurse practitioners, to seize the moment, unleashing experimentation and creativity in practice. The stories however do not end similarly. Where the sorcerer's apprentice required saving by the sorcerer, nurse practitioners used the opportunity to rapidly advance and develop autonomously.
The author next delves into the turmoil and struggle of the individual nurse practitioner in the 1960s. The hesitancy of the American Nurses Association to embrace the nurse practitioner role and competing individual ideologies within medicine and nursing along with turbid dynamics within the American Medical Association were trumped by the formation of professional splinter groups that supported the advancing role of nurse practitioners. In the 1970s, the National Joint Practice Commission and other organizations entered the scene in attempts to mediate the collaborative relationships developing as specialty nurse practitioner organizations evolved, emphasizing practice-based clinical focus. By the end of the 1970s there were more nurse practitioner educational programs, producing more nurse practitioners in the workforce. The 1980s through to the 21st century was a time of "Making Room in the Clinic" during which the "nurse practitioner roles continued to reshape, expand and formalize" (p 184). The issues of competition versus collaboration, negotiation of scope of practice, and growing organizational support continue to frustrate the healthcare professional.
"The care chronically ill patients want and need helps exemplify why nurse practitioners are more than physician extenders or substitutes, and that they provide services that, while overlapping with medicine, are also different" (p 190). Nurse administrators and executives must clearly understand and address these stark differences in perspectives of delivery of care since understanding these perspectives is imperative to strong healthy collaborative relationships and ultimately, as the author eludes, provides the service that is at the heart of the profession: human health and well-being. As nurse leaders take a decisive role in defining future healthcare delivery practice, the nurse practitioner will be a central and key component of the patient-care model. Those nurse leaders who fully understand the historical and social development of the nurse practitioner role and collaborative relationship will be most successful in mediating between physicians, nurse practitioners, and the patients receiving their care.
Rita Meadows, MSN, FNP-BC
Georgetown Medical Associates, Georgetown, Delaware