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related to a patient-centered culture at the unit level unless par allel sanc- tion 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 prac- tice and a patient-centered culture.

Walk the Talk The cultural metaphor walk the

talk is not ne w, but its use in both popular and professional literature

Marlene Kramer, RN, PhD Claudia Schmalenberg, RN, MSN Patricia Maguire, RN, MN, CNAA, BC Barbara B. Brewer, RN, PhD Rebecca Burke, RN, MS, CNAA, BC Linda Chmielewski, RN, MS, CNAA, BC Karen Cox, RN, PhD Janice Kishner, RN, MSN, MBA Mary Krugman, RN, PhD Diana Meeks-Sjostrom, RN, MSN, PhD, CS, FNP-C, ONC Mary Waldo, RN, PhD, CNS-BC

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

Healthy Work Environments

PRIME POINTS

• Control of nursing practice and a patient- centered culture promote the quality of nurses’ work environments and the quality of patient care.

• Culture is the norma- tive glue that preserves and strengthens the group and provides the healing warmth essential to quality care.

• “Walk the talk” is a best practice through which the values of unit and hospital culture are lived and control of nurs- ing practice by nurses can be achieved.

T o “walk the talk”—put- ting values into action, leading by example, practicing what you preach—is a best prac-

tice related to 2 of the 8 a ttributes or work processes identified by staff nurses as essential to a healthy wor k environment. These 2 attributes, control of nursing practice and a culture in which concern for the patient is par a- mount, are the focus of this ar ticle. Another commonality of these 2 essential attributes is that they are the only 2 of the 8 tha t have as many departmental/hospital-wide impli- cations as they do unit-focused implications. Nurses cannot control practice or engage in activities

Article 6 in a series of 8

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and in everyday colloquial usage is increasing.1,2 In the study that pro- vided the data for this ar ticle, 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 wor k environment: nurse manager sup- port, control of nursing practice, and a patient-centered culture. The follow- ing 2 examples illustrate use of this metaphor with respect to a patient- centered culture and control of nurs- ing practice. The first excerpt from a 2001 staff nurse inter view3 illustrates the metaphor with respect to culture.

We have a responsibility to participate in research, especially being a magnet hospital! It’s part of our

culture, our norms. Nurs- ing in this hospital is “gung ho” on research . . . But it’ s not enough to talk the game, there has to be action. The very least we can do to sho w that we value research is to fill out surveys like this.

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 upcom- ing activities. A week after the invi- tation was declined, the investiga tor was informed that the administrative group had been hasty in their deci- sion and that the request was being sent to the shared governance

research council for disposition. The council contacted the investiga- tors, 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.”4

Source of the Data In the spring and summer of

2006, we conducted a na tionwide study4-7 in 8 strategically selected magnet hospitals. The purpose of the study was to ascer tain the orga- nizational structures and leadership practices that staff nurses identify as necessary for a healthy work environment, specifically, struc- tures 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 environ- ments 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 prac- tice and patient-centered culture as well as the other 6 essentials. It has been administered to staff nurses in hundreds of hospitals, mostly mag- net hospitals, since its develop ment in 2003. The results of these EOM evaluations were used to select the hospital sample for this study.

We selected the 8 magnet hospi- tals, according to the 8 censu s-tract regions of the United States, that

Marlene Kramer is vice president, nursing, at Health Science Research Associates, Apache Junction, Arizona.

Claudia Schmalenberg is president, nursing, at Health Science Research Associates, Tahoe City, California.

Patricia Maguire is a research associate and consultant at H ealth Sciences Research Associates, Townsend, Massachusetts.

Barbara B. Brewer is the director of professional practice at John C. Lincoln Hospital, Phoenix, Arizona.

Rebecca Burke is senior vice pr esident, patient care services, and chief nursing officer at Miriam Hospital, Providence, Rhode Island.

Linda Chmielewski is vice pr esident, hospital operations, and chief nursing officer at St Cloud Hospital, St Cloud, Minnesota.

Karen Cox is executive vice president and cochief operating officer at Children’s Mercy Hospitals and Clinics, Kansas City, Missouri.

Janice Kishner is chief nursing officer and chief oper ating officer at East Jefferson General Hospital, New Orleans, Louisiana.

Mary Krugman is director of professional resources at University of Colorado Hospital, Denver, Colorado.

Diana Meeks-Sjostrom is the director of nursing research at St Joseph’s Hospital of Atlanta, Georgia.

Mary Waldo is a clinical nurse specialist in outcome studies and nursing r esearch at Providence-St Vincent’s Hospital, Portland, Oregon. Corresponding author: Marlene Kramer, RN, PhD, FAAN, 3285 N Prospector Rd, Apache Junction, AZ 85219 (e-mail: [email protected]).

To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 3 62-2049; e-mail, [email protected].

Authors

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had the highest or second -highest EOM scores. To obtain the interview sample, we selected the clinical units with the highest EOM scor es within each hospital. The “experts” that we interviewed on these units consisted of 244 staff nurses nominated by their peers and managers, 105 nurse man- agers, and 97 physicians nomina ted by staff nurses or managers. The number of staff nurses inter viewed varied by the size of the unit but usu- ally consisted of 2 or 3 staff nurses, 1 nurse manager, and 1 physician per unit. We interviewed the chief operat- ing officer, the chief nursing officer, and 4 to 6 representatives from pro- fessional departments such as respi- ratory therapy, physical therapy, dietary, and pharmacy in each hospi- tal to obtain the perspectives of these personnel of the nursing department and the degree of interdepartmental collaboration. We also conducted “participant-observation,” a qualita- tive research technique,11,12 in all central and unit council meetings during the 4-day on-site visit.

Control of Practice The American Nurses Creden-

tialing Center, which governs mag- net designation, refers to control of nursing practice as “shared” or “unit-based” decision making related to an environment in which admin- istrators use a participative man- agement style.13 The Institute of Medicine,14 in the institute’s delin- eation of 5 evidence-based manage- ment practices needed for a healthy work environment, define it as “involving workers in decision mak- ing 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 impor tance that affect nurses, the context of nursing practice at unit, departmen- tal, and hospital levels, and the qual- ity of patient care provided.15 The input includes access to po wer and exchange of information, views, and judgments; the decision making is interdependent and shared; and the issues of importance include prac- tices, standards, policies, and selec- tion of equipment.

Nurses wrote of control of nurs- ing practice as follows:

Control of nursing practice means two things to me. On the unit, it means tha t I determine the order and sequence of my work, inter- ventions, and functions. What works best for most of my patients. It means that I have a “say-so” in how the unit is r un, how we float, and do self-schedul- ing. . . Control of nursing practice also means that nurses as a group, all of us in this hospital, the man- agers and administrators, well they’ve always been responsible for making the decisions, what is new [is] that now staff nurses are involved. We are responsi- ble and accountable for group decisions. Together, with the administrators, we control our practice and the practice environment. We are responsible and accountable for the quality of nursing in this hospital. And those aren’t just empty words. . . . We not only

have “a say,” we make deci- sions about policies and issues and equipment. . . . Sometimes when a prob- lem or issue is pr esented, it is made clear from the “get-go” that we are being asked for input only, that administration will make the decision. And that’s OK as long as we kno w “up front.” When you make the decision, you are account- able for the outcomes.

Staff nurses in both the U nited 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 indi- vidual, patient-centered decision making with the patient as the pri- mary and often sole beneficiar y. In much of the nursing liter ature,18,19

clinical autonomy and control of nursing practice are combined, referred to simply as decision ma k- ing, and are discussed as though they were the same attribute. The American Association of Critical- Care Nurses standards for main- taining 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 char acteristics of a profession, is the self-regulation and self-determination of professional

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issues, practices, and standards by professionals. The following excerpt from an interview with a staff nurse illustrates the application of this def- inition to nursing. (All ex cerpts 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.)

What MDs do in Medical Council, we do in Nursing Council. We solve practice issues like what kind of dressing is best for the hos- pital to buy for PICC lines, we establish standards of practice, review quality indi- cators, and are responsible and accountable for the gen- eral practice of nursing in this hospital. We also have a hand in deciding skill mix and how many positions and what kind of positions go where. We worked out all the procedures for how to get flu shots to the pa tients and staff that needed them. . . . We decide on what should be done with new graduates who don’t pass boards . . . It doesn’t wor k unless there is communica- tion and follow-through between central and unit councils. If it’s an issue affecting nurses or patients on all units, then it’s decided

centrally but you need input from all units. But, then, there are some issues that are unit-specific and these we take care of in Unit Council.

Shared Governance 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 opera- tionalized 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 mak- ing) of nurses at all levels, to admin- istrative areas previously controlled by management.23 Shared governance is a structural configuration of coun- cils and committees that provide formal mechanisms that ensure nurses’ responsibility, right, and power to make decisions and to control nursing practice.

Whether termed shared leader- ship, clinical governance, collabora- tive governance, shared decision making, or simply the nursing council, the structure alone will not “bake the cake.” The str ucture must be accompanied by best manage- ment practices that make shared governance possible through

implementation of principles such as partnership, ownership, account- ability, and equity.4 Investigators and experts have noted or empiri- cally shown that shared governance structures that are not practical and are not accompanied by best man- agement practices will not enable nurses to control practice. Laschinger and Wong24 state that

“most shared governance efforts are seen by staff as chiefly str uctural, with staff nurses on councils and committees but without the author- ity to have significant control over professional practice, thus leading to cynicism and unwillingness to assume accountability for client outcomes.” Cynicism, unwillingness to be accountable, and lack of deci- sion making were also reported in a nationwide survey25 of staff nurses working in hospitals that suppos- edly had shared governance sys- tems in place.

Although shared governance is not identified as a for ce of magnet- ism or listed as a sour ce of evidence,26

it is commonly understood that shared governance or a similar structure is required for designation as a magnet hospital. H owever, staff nurses in some magnet hospital s did not confirm the existence of workable shared governance struc- tures. In 3 of 34 magnet hospitals participating in 2 different studies,8,10

staff nurses reported that shared governance structures were not

What makes shared governance structures viable and what best practices make shared governance structures effective in enabling nurses to control nursing pract ices?

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viable and workable and did not enable the nurses to contr ol nursing practice. So, the question becomes as follows: What makes shared gov- ernance structures viable and what best practices make shared gover- nance structures effective in enabling nurses to control nursing practice? Those are the questions we posed to the 500 experts we interviewed in the study reported here.

What Was Learned Structures That Enable Control of Nursing Practice

The experts interviewed identi- fied 2 structures, shared governance and career ladders, and 5 pr actices that enabled nurses to contr ol nurs- ing practice within the organization.

Shared Governance. Many shared governance formats, varieties, and names were described. Most of the structures were labeled something other than shared governance. The structures followed different models4,23; the councilor model was by far the one most fr equently used. Councils were usually organized according to different functions, such as practice, quality improve- ment, research, evidence-based practice, education, and informat- ics. In some hospitals, the councils were organized according to profes- sional role, such as staff nurse, charge nurse, nurse manager, educator, and advanced practice nurse.

In smaller organizations, func- tions were grouped into fewer types of councils, and not all centr al councils were replicated at the unit level. Com- pared with smaller organizations, larger hospitals had more councils, sometimes with a double focus such as charge nurse practice council or staff nurse evidence-based practice

council, and central councils were more often replicated at the unit level.

Career Ladder Programs. Career ladder programs, specifically the criteria delineating participation and/or leadership in council activi- ties were frequently cited as enabling and promoting nurses’ control of practice. Movement through the steps of the car eer lad- der was usually associated with salary increases or bonuses. Although important and much appreciated, increases in salary and bonuses were not the only or neces- sarily the chief motivating factors for participation in control of nurs- ing practice, but they were a facili- tator. Many nurses stated that they participated in a career ladder pro- gram because they had a pr ofes- sional responsibility to do so.

Best Practices That Promote Control of Nursing Practice

The 5 best practices that pro- moted control of nursing practice were specific behaviors demon- strating the walk aspect of walk the talk—managers’ and leaders’ actions that made shared governance structures workable, thus facilitat- ing nurses’ control of nursing prac- tice. Nurses in one hospital described walk the talk as follo ws:

We believe that the suc- cess of our organization, which we define as the highest quality of patient care possible, high patient satisfaction, professionals who are job satisfied as well as professionals who judge that they are con- tributing, are making a difference in the quality

of care a patient is receiv- ing—the success of such an organization is dependent upon a “professional democracy” form of gov- ernment. Professional departments being run by professionals and decisions made by professionals who are knowledgeable about clinical issues and close to the frontline application of solutions. This is our talk, our beliefs, one of our cu l- tural values. If we, every- body, truly believe that, then we must walk the talk and put our beliefs into action.

Providing Access to Power. In the literature, providing access to power is usually referred to as “empower- ment.” The experts described it as “leaders and managers who made you feel that you had something to contribute and that you had the power to make decisions tha t affect nursing practice, and that you were not only allowed to use that power, but were expected to do so.” Shared governance structures “that worked” were perceived as a source of formal power.

Shared governance structures and control of nursing practice are about authority, power, and influ- ence. Staff nurse inter viewees did not appear to be afr aid of or shy away from the concept of po wer. They had clearly adopted the ne wer meaning of this word. Rather than power meaning “to impose your will upon another,” power is the capacity to cause change, influence events, initiate action, and control out- comes.4,27 Traditionally, power was

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conceptualized as a fixed mass, a finite quality; if one person had power, someone else had lost it. Power was described this way by a speaker at the September 2006 mag- net hospital conference in Denver. A newer concept and one used in all 8 hospitals, is that power is infinite;

power has an exponential quality that can be released, distributed, and shared to the mutual benefit and growth of all involved. 28 A staff nurse remarked as follows:

Just because administration shares some of their p ower with us doesn’t mean that they lose their authority and power. The rule is that decisions are made by the people “in the know,” those who have the most experi- ence and knowledge about the issue or problem, and who are most affected by the outcomes. And for most clinical issues, that’s the staff nurse, or educator, or clinical specialist.

On the basis of r esearch by Laschinger and Wong,24 we antici- pated that “access to power” would be a possible indication of viable shared governance structures. Thus, we tested all staff nurs es (not just those on the units with high EOM scores) in the 8-hospital sample by using the Conditions of Work Effec- tiveness Questionnaire II, a tool us ed to measure the extent to which nurses

perceive that they are empowered. In this tool, empowerment is defined as access to po wer. The tool is used to measure 4 specific lines of power—information, opportu- nity, support, and resources—and access to both formal and informal power. Staff nurses in these 8 mag-

net hospitals scored quite high in empowerment, higher than any other sample of staff nurses r eported in the literature and within a per- centage point of nurses in adv anced practice positions.29

Information, opportunities, and support were the chief sources of power. The chief source of informal power in the majority of the 8 hos- pitals was the oppor tunity and expectation that staff nurses would collaborate with physicians and other professionals in events such as regu- larly scheduled interdisciplinary patient care rounds.30,31 The interde- pendent decision-making character- istic of these kinds of r ounds had the force and power of all par ticipat- ing professional disciplines.4

Another source of informal power was an “integrated” shared gover- nance model rather than the usual “silo” model (ie, shared governance structures housed in and oper ated out of individual depar tments).32

Integrated models in which the shared governance structure was housed in the hospital, not in any single department, were described by interviewees in 3 of the 8 hospi- tals. Compared with nurses in the

other hospitals, nurses in these 3 hospitals had significantly higher empowerment scores, particularly with respect to the informal po wer generated through collaborative interactions with colleagues as noted earlier. The integrated model was also reported as being far mo re effi-

cient than the silo model: “When all disciplines are represented in coun- cil, you can discuss the impact and implications and make decisions without having to go back and check with each separate department.”

Promoting Widespread Participa- tion. “Time and opportunity to par- ticipate” and ‘“individual differences in contributions” were 2 of the major factors cited by inter viewees that will “make or break” the viability and workability of a shared governance structure and the effectiveness of the structure in enabling control of nurs- ing practice. The first factor, time and opportunity to participate, is largely a best management pr actice issue of having enough staff mem- bers so that nurses can get off the unit to attend meetings and paid time off to attend when day-long meetings are held. The second fac- tor, recognizing the contribution of different nurses and making it possi- ble for them to contribute in differ- ent ways, not only increases the workability of the shared governance structure but also results in a wider scope of participation with the bene- fits of participation accruing to a larger group of people.

Pride in and acknowledgment of outcomes, accomplishments, and actions of shared governance councils is both self and professionally reinforcing.

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shuns large group meetings or group decision making. Output from the efforts of these teams provides the moral, ethi- cal, and scientific guidance and authority for the decision making essential to improving quality of patient care.

What Clinical Nurses Can Do

Setting up a shared gover- nance structure and a clinical lad- der program and implementing many of the best pr actices associ- ated with control of nursing practice are leadership functions and respon- sibilities. But there is much that staff nurses can do to put their beliefs about professional behavior and responsibilities into action.

Walk the Talk. If you believe in the “Professional Democracy” form of self-regulation and self-determination for your profession, if you believe that nurses have not only the a bility but the professional right, responsi- bility, and accountability to contr ol the context of nursing pr actice in the organization in which they work, you demonstrate this talk by getting involved. Although high expectations are laudable, a ne w shared governance structure may not work perfectly from the beginning. Self-determination and self-regulation are processes that must be learned. Democracy isn’t easy.

Participate. Participation means identifying and presenting issues, participating in council meetings, providing input on issues, ca nvass- ing peers, communicating results of decisions, and ascertaining the progress and disposition of problems and issues. Only 1 of the 8 hospitals we visited had a formal system f or keeping track of issues and their disposition. Any nurse who identified a problem or had a question or a “why can’t we?” completed a half- page form and submitted it to the nurse’s council representative. In this system, it was manda tory that the nurse receive a written reply as to the disposition or decision r elated to the query within 2 weeks.

Recognize Contributions of All. For workable shared governance struc- tures to positively affect nurs es’ con- trol of nursing practice, enthusiastic and spirited participation by nurses at all levels is a must . But we are all different. Some nurses may recognize

Using Recognition to Reinforce Participation. Using recognition to reinforce participation refers to recog nition of the shared gover- nance structure and of the decision-making outcomes, not the individuals involved. When physi- cians, administrators, and profes- sionals from other departments recognize the worth and value of nurses controlling the context of the practice of nursing in an organiza- tion, these nonnurse professionals will use the str ucture, thus making it more workable and effective. In addition, the act of “wor king together” generates more informal power.

Taking Pride in and Acknowledging Outcomes, Accomplishments, and Actions of the Shared Governance Councils. Pride in and acknowledg- ment of outcomes, accomplishments, and actions of shared governance councils is both self and pr ofession- ally reinforcing. Nothing succeeds like success. Acknowledgment is also a way in which the wor k of “less visible” participants can be recog- nized and appreciated. One nurse remarked as follows:

I know that I had a par t in that decision. And that’s fine. The credit goes to the group, not to any one indi- vidual. And I’ll check with Sue again to see if ther e is something else I can do to help. I’m a whiz on the com- puter and I’m happy to go onto the Web at home after I get the kids to bed.

Having Evidence-Based Practice Teams. Evidence-based practice teams and their activities are often attractive to a frontline nurse who

Best Practices That Promote Control of Nursing Practice 1 Providing Access to Power 2 Promoting Widespread

Participation

3 Using Recognition to Reinforce Participation

4 Taking Pride in and Acknowledging Outcomes, Accomplishments, and

Actions of the Shared Governance

5 Having Evidence-Based Practice Teams

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research council, present it, and have to have our approval before it can go ahead. That’s a biggie! And when you feel that power and responsibility, you make doggone sure that you make the right decision. . . . The doc came up to me after the meeting and said that he figured out a way that he could improve his proposal by a question I had asked. Wow, that makes me feel good and professional.

Take Pride in Achievements. “By your actions they will know you.” Take pride in your accomplish- ments; know what they are even if you were not involved in ever y ini- tiative. Recognize the achievements of peers and the group. Accept responsibility and demonstrate a willingness to be held accountable for decisions made. Nurses in one hospital explained the following:

If, in spite of everyone doing their homework, the council makes a wrong or perhaps not the very best decision about the best antipressure mattresses for the hospital to purchase, we must own our mistake and figure out ways to “live with it” until the mattresses wear out.

Culture in Which Concern for the Patient Is Paramount

Culture is the combination of symbols, language, beliefs, assump- tions, and behaviors that manifest people’s or society’s artifacts, values, and norms, the 3 components or lev- els of culture.33 When applied to an organization, hospital, or clinical

unit, the culture is referred to as a corporate culture, the focus of this article. Artifacts are the visible cre- ations of the culture, the image of the unit, status symbols, rites, rituals, ceremonies, and “sacred cows” (per- sons, things, or beliefs tha t cannot be attacked but are revered and pro- tected). An example of an ar tifact on one of the units in our study was that all professionals who achieved specialty certification were the sub- ject of a “toast and r oast” ritual enthusiastically attended by all physicians and nurses on the unit. Values are the time-honored, deep- seated, pervasive beliefs of what “ought to be.” They ar e the stan- dards by which we make decisions that influence every aspect of our lives. Walking the talk is how we make our vision and values tangible.1 Values are the concerns and goals ascribed to by most peo- ple in a work group that shape the group’s behavior. Norms are the agreed upon ways of doing things. Norms guide performance and include both the implicit and the explicit shared meanings of behav- ior and the rewards and sanctions associated with compliance or non- compliance.

Cultures can be located anywhere along a continuum from rich, dynamic, and powerful to weak or static, depending on how overt and pervasive the norms and values are. In weak cultures, norms are subtle, difficult to discern, or no t ascribed to by all. The dynamism of the c ul- ture depends on the str ength and pervasiveness of values, the longevity of the work group, the attention given to transmitting the culture to new people, and on ho w well taught and reinforced the values and

participation as a professional responsibility, but family obligations inhibit full participation. For others, participation is a matter of differ- ences in interests and abilities:

I prefer giving direct patient care to sitting in a meeting. I’m not interested in the big meeting stuff. You’re talk- ing to a guy on the fr ont line with a rifle; my inter- ests don’t lie in tha t direc- tion. I’m a meat and potatoes kind of guy.

Some nurses will want to serve as unit representatives and/or to lead councils. Others, like this meat and potatoes kind of guy, can participate by offering suggestions and r ecom- mendations in their unit council, by doing investigative work such as determining the best equipment for various patient procedures, by for- mulating standards, or by conduct- ing best practice searches on the Internet and evaluating current prac- tices. What is important is that the contributions of all are recognized, respected, and appreciated; that lines of communication are kept open; and that both the problem or issue and the solution or decision are “owned” by all.

Use Power Wisely. It is difficult for staff nurses to demand access to power, but they can avail themselves of the lines of po wer offered: “If you don’t use the power presented; you’ll lose it.” There is nothing wrong with feeling powerful and being responsi- ble and accountable for decisions that reflect that power. One nurse remarked as follows:

When a physician’s research project is going to involve nursing, they come to

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norms are by group members. The vitality, strength, dynamism, and adaptability of the culture depend on the degree of communication among members and on the degr ee of acceptance of the values among sub- group members. Three processes need attention to ensure a dynamic culture: establishing values and norms, transmitting the values and norms to new team members, and changing and updating values and norms when necessary.

History of a Patient-Centered Culture of Excellence in Magnet Hospitals

A culture of excellence was asso- ciated with the original 1984 Magnet designation and was described as “something almost palpable; you can feel it when you walk into a hos- pital.”34 Designation as a magnet hospital by the American N urses Credentialing Center is based on the structures (called the Forces of Mag- netism) associated with an excellent work environment that were derived from results of the original study and on the criteria for cer tification of nursing service administrators.13

Although the 14 Forces of Mag- netism and the sources of evidence for the forces have no references to culture,26 since our first study in the mid-1980s, staff nurses in magnet hospitals have consistently reported the presence of a patient-centered culture in their work environment. In 1988, a total of 88% of the 1 634 staff nurses in 16 magnet hospitals and 75% of the 2336 staff nurses in 8 nonmagnet hospitals reported that they worked in a culture of excel- lence in which “concern for the patient was paramount.”35,36 In 2003, in a study10 of 4320 nurses in 26

magnet and nonmagnet hospitals, 90% of the nurses in magnet hospi- tals and 67% of those in nonmagnet gave affirmative answers for the same item. In 2006, in a study 8 of 10 483 nurses in 18 magnet and 16 non- magnet hospitals, 88% of nurses in the magnet hospitals and 74% of those in nonmagnet hospitals reported that concern for the patient was paramount.

These consistent findings in large samples in different magnet hospitals would seem to in dicate that the emphasis and valuation of culture from the original magnet hospital criteria as an a ttribute of excellence have survived and with- stood the test of time. And ev en though identified in the original study, culture was not included as a Force of Magnetism, perhaps because culture is an exceedingly difficult construct to measure. In a recent study37 designed to differentiate intensive care unit cultures associ- ated with end-of-life decision mak- ing in 4 adult medical and sur gical intensive care units, a 6-member research team conducted participant observations and collected data for 5 hours a da y, 5 to 7 days a week, for 7 months on each of the 4 units stud- ied before judging that the team had identified the dif- ferent intensive care unit cultures.

Most quantitative tools used to measure culture measure only the value dimension of culture.38,39

Sometimes the dominance of one value over another is measured by presenting competing aspects. In 1985, we used the work of Peters

and Waterman40 on a culture of excellence to measure cultural val- ues in hospitals. B ecause the compe- tition between cost and quality car e was, and continues to be, a nagging reality, we constructed the following item: Cost (money) is impor tant, but quality patient care comes first in this organization. In 1988, a total of 77% of nurses in magnet hospitals and 65% of nurses in nonmagnet hospitals responded affirmatively to this item. In 2003, the percentages were 78% and 57%; in 2006 , they were 76% and 63%. Unquestionably, in both magnet and nonmagnet hos- pitals, the percentage of nurses who report a patient-centered culture decreases when respondents are specifically requested to factor in the competing value of cost. But what is truly remarkable is that for all 3 periods, the decr ease in per- centages remained the same, between 12.5% and 13%. This find- ing reflects remarkable stability in these competing values over an 18-year period, again showing that in hospitals with a cultur e of excel- lence, the value of a patient-centered

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What Clinical Nurses Can Do

Walk the Talk

Participate

Recognize Contributions of All

Use Power Wisely

Take Pride in Achievements

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culture has survived despite the tremendous competing value of “cost” in recent years.

In 2001, after staff nurses in 14 magnet hospitals identified the 8 work processes or attributes (1 of which was a culture in which con- cern for the patient is paramount) essential for a healthy work environ- ment,41 we constructed the EOM tool to measure all 8 attributes. We included the values of a culture of excellence40 as well as the competing cost–patient care item.10 The patient- centered culture subscale of the EOM tool does not measure all 3 aspects or levels of culture; it measures only values and the 3 value processes.

In the study reported here, 446 staff nurses, nurse managers, and physicians from the 101 patient care units on which staff nurses had pr e- viously confirmed a patient-centered culture were asked, “What are the 5 dominant cultural values of the unit on which you work.” (Readers may find it beneficial to r espond to this question before reading the results, thus allowing comparison of the readers’ work situation with that of these interviewees working on excel- lent units in excellent hospitals.) We followed the suggestion of Cam- mann et al37 for eliciting norms, the behavioral aspect of walk the talk, by requesting interviewees to “describe a nurse who ‘fits into’ the work group on this unit.” Some- times the prompt “What does he or she do that tells you that they fit in” was used. Answers to these ques- tions were descriptions of behav- iors. Because norms are agreed- upon ways of doing things, these behaviors should reflect the norms of the unit related to the core cul- tural values.

The total number of r esponses was 1989 because some inter vie- wees cited fewer than 5. Using the- matic and categorical analysis,11,12

we grouped the 1989 value responses into 9 categories on the basis of the explanations and descriptions pro- vided by the inter viewees. A total of 57 responses did not fit the 9 ca te- gories and were dropped, leaving a total of 1932 identified core values in 9 categories. Normative behav- iors described in response to the nurse-who-fits-in question were grouped by value categories and will be used to pr ovide descriptions of behaviors related to the values. In this article, we have used a large number of verbatim excerpts to illustrate both the walk (norms) and the talk (core values) in order to adequately represent the range from this large number of r esponses.

Hospital values were gathered from in-house documents, on-site coinvestigators, chief nursing officers, and the hospitals’ official Web sites. Although obtained at the time of the on-site visit, information was not tabulated until interviews from all units had been tr anscribed and analyzed in order to avoid preset- ting the categorical analysis of the unit core values.

Unit Core Values and Normative Behaviors

Table 1 displays the core values in 8 magnet hospitals as described by staff nurses, nurse managers, and/or physicians on 101 units pre- viously confirmed by staff nurs es to have a patient-centered culture of excellence. The values are presented in order of the frequency that the response was cited. The analysis is based on 1932 responses. Table 1

also presents the hospital core val- ues as cited in hospital doc uments, by on-site coinvestigators and chief nursing officers, and/or on the off i- cial Web sites of the hospitals. T he table allows a comparison of simi- larities and differences between unit and hospital core values.

Patient/Family Centered— Patient First

A total of 60% of the staff nurses and managers and 49% of the physi- cians cited the value patient/family centered—patient first. It was cited by interviewees on all units in all hospitals. Descriptors of this value included doing the “right thing” for the patient; genuine caring and doing one’s best. The patient is the first and priority concern.

A nurse who “fits in” on this unit is one who, at the end of the da y, feels comfortable saying as we are walking out: “I really feel good; I did a good job, I made a differ ence in the lives of my patients. If I hadn’t picked up that groin bleed when I did, Joe would have been in serious trouble.”

Three adjectives were used to describe this value: Safe care is the minimum, but we aim for excellence and quality care. Customer orienta- tion was also used, but not as often as safe, excellent, or quality care. A feel- ing of professional pride in being able to give that level of care on a consis- tent basis was sometimes mentioned as a component of quality car e.

This hospital has received many awards, both formal and informal, for quality patient care. The EMTs and ambulance drivers have told us that they will say to the patient, “It will take a little longer, but I’m going

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to take you to ____ hospital because they give the best care in the city.”

Quality care means consis- tently good outcomes and patients who are satisfied; being attentive to the needs of patient and family; giving family-centered, holistic care; keeping patient and family informed.

Teamwork Teamwork was cited as a cor e

unit value on all units in all hospitals. For the total group, 57% of the nurses and managers and 37% of the physi- cians identified this as a cor e value.

On this unit, you never have to ask for help; we answer others’ call lights; we work together to get the job done. Nobody leaves till all patients are cared for.

The end goal is mor e impor- tant than the prominence of any one person or gr oup.

The “team” owns the qual- ity of care and the process of providing it.

We work together well, no cliques. We cover for each other so that all nurses can go on interdisciplinary rounds for their patients.

We don’t complain or bitch—cheerful, helpful. Smile; don’t let the small things get you down.

With the teamwork they have going, the nurses on this unit can handle very complex patients that no one nurse could handle alone. (MD)

References in this category were to the “unit-based” team that con- sisted primarily of nurses and other nursing personnel, but also secre- taries and housekeeping. However, the team also included the medical director, the residents, pharmacists,

Table 1 Unit and hospital core values in 8 magnet hospitals

Unit core values

Patient/family centered–patient first

Teamwork

Competent performance

Family orientation and camaraderie

Respect, trust, and equality

Integrity and honesty

Autonomy and patient advocacy

Stewardship

Compassion and justice

Hospital core values

Quality care

Collaboration, teamwork

Continual improvement

Respect

Integrity

Stewardship

Compassion Justice

Hospitality Community

No.

1120

1024

754

715

676

483

154

115

Responses (n = 1932)

and unit-based therapists, such as the physical therapist in orthope- dics. Pride in what the team could accomplish was also frequently cited.

Competent Performance Competent performance was

cited as a core value by 39% of all interviewees, slightly more so by physicians (41%) than by nurses (39%) and managers (36%).

High-quality, caring peo- ple who are incredibly competent is the major value of this unit. We have the best nurses, therapists, and doctors in this hospi- tal on this unit. (MD)

Everyone functions at a very high level. It’s per- formance, not just head knowledge, although you can tell that they have the knowledge base by the questions they ask—ver y organized; they give you the relevant information and offer suggestions and recommendations. (MD)

The quality of the nurses equals competence plus personal attributes and characteristics such as kindness, caring, compas- sion. (MD)

There is a big emphasis here on education—keep- ing self constantly up-to- date. Always try and look to improve yourself. There is a big push on establish- ing evidence-based prac- tice and getting certified.

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Sharing information, the results of decisions, and learning from one another is as important as an individ- ual’s own competence. (MD and NM)

Family Orientation and Camaraderie

Family orientation and cama- raderie, defined as “a feeling of close friendship and trust among a group of people; a spirit of friendl y famil- iarity and goodwill that exists between comrades,” was described by 37% of the r espondents, slightly more often by staff nurses (4 1%) than by the others.

Family encompasses a great deal of affection on both sides and includes ever y-

thing that you would expect and receive from your fam- ily. Family always has to take you in even if you do something they don’t like. They must accept you as you are and have uncondi- tional positive regard for you as a person and as a nurse; they are concerned about you as a person not just a fellow employee.

We’re there for each other; they watch my back and provide emotional support. I had a ver y sick child. They came in and took car e of the rest of my children.

We’re close-knit and we see each other socially outside of work. If something hap- pens in your family, call someone and they’ll take care of replacing you— come in on day off and no grumbling.

Physicians tended to describe this value as follows:

We like one another; many of the nurses are my friends. They are positive, upbeat and work is fun. We enjoy it; we laugh and cry together. We like one another; we want to be here. Work is an upper; not a downer. It’s a nurturing work environment where

everyone can express their concerns and feelings.

Respect, Trust, and Equality Respect, trust, and equality

toward each other and with pa tients was a core value cited by 35% of the interviewees on some units in all hospitals. This value was fairly evenly divided among nurses, man- agers, and physicians. B e courteous and treat everyone, patients and coworkers, as equals and in a digni- fied manner.

Everyone has value, is val- ued, and is treated well. We are trusted to do what we are supposed to do. If the patient needs something,

you can be trusted to see that the patient gets it. You never leave until you get it or see that someone else gets it for the patient.

I can trust that when my peers do something for my patient, they will give my patient the same quality of care that I would give.

Integrity and Honesty Integrity and honesty as evi-

denced by effective, efficient, genu ine communication was a core value cited by 25% of the r espondents, more so by nurses (26%) and mana gers (28%) than by physicians (19%).

We tell it as it is; if y ou make a mistake, admit it. We know

that we will not be c hastised, judged, or belittled.

The personal characteristics and attributes of the individual wer e part of this value.

A “quality person” is hard to explain in an inter view. The best I can do is to describe our pattern of communica- tion. We talk openly to one another; you can bring up any issue and discuss it; the goal is to fix the pr oblem, not find blame. If it’s some- thing we are not to know about, fine, then come right out and say that, but don’t fabricate or dress it up.

Be courteous and treat everyone, patients and coworkers, as equals and in a dignified manner.

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Part of honesty is wor king hard, showing up when you are supposed to be her e, and being motivated to do a good job.

Clinical Autonomy and Patient Advocacy

A total of 25% of the inter vie- wees described the values clinical autonomy and patient advocacy, both of which involve decision mak- ing of some type. The 2 v alues are grouped together because that is the way interviewees presented them. Not only in this study, but in other studies16-19 as well, clinical autonomy, defined as making decisions in the best interests of the patient, encom- passes 2 major arenas: (1) the “need to rescue,” ongoing surveillance, “avert disaster or complications” and (2) advocacy for the pa tient, do or get him/her what they need. Both autonomy and advocacy were described by all 3 gr oups of intervie- wees, but physicians cited autonomy appreciably more often (37%) than did nurse managers (13%). Staff nurses (32%) cited patient advocacy more often than did physicians (11%).

Comments on autonomy included the following:

A core value of this unit and one that I value the most is the nurses’ ability and willingness to make decisions for the benefit of the patient . . . . I can’t tell you how often nurses on this unit have averted patient harm—well not always harm, but cer tainly discomfort and misadven- ture for the patient. I trust them. They look ahead and

foresee what might hap- pen; often they make observations and have information I don’t have, so they make better deci- sions than I could. They call these things to my attention so that together, the patient gets much safer and better care. (MD)

You can and are expected to practice autonomously on this unit. You can use all your skills and make decisions independently or by working collaboratively with physicians, thera- pists, and others.

Interviewees spoke of advocacy as follows:

As a nurse, you bring to the situation that which is uniquely nursing—caring, teaching, advocating, and interpreting for the patient/family.

What do I mean by pa tient advocacy? I see the nurses are doing what needs to be done to help the pa tient progress toward independ- ence. (NM, rehabilitation unit)

I see the arrangements the nurse makes so that we know that the patient is going home to a safe envi- ronment. (MD)

Nurses advocate for the patient; they plead their cause. There are times when the nurses judge tha t

what I have ordered is not what is best for the patient. They speak up and say so. And, more often than not, I change the order. Sometimes, it’s a matter of one or t he other of us not having complete information. (MD)

The nurses interpret to me how the patient is feeling, what the patient is trying to say, what they need. The nurse will ask the pa tient a question or, just this morning, the nurse said to the patient, “Ruth, tell Doctor ____ exactly how your stomach and chest feels, the same way you told me this morning.” (MD)

I see nurses educate the patients, go the extra mile for them. (MD)

Part of autonomy and advocacy is respecting patient’s privacy; keeping the patient and family informed of what’s going on, in the loop, anticipat- ing their needs. Advocacy is “feeling with,” getting for the patient and family what they want and need and what they would do for them selves if they were able.

Stewardship and Compassionate Caring

In addition to the 7 v alues just described that were cited by some interviewees in each of the 8 study

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hospitals, stewardship (154 responses; 8%) and compassionate caring (115 responses; 6%) were described by interviewees on some units in 2 or 3 of the hospitals. Ste wardship means that we wisely care for and share human, environmental, and financial resources held in tr ust, to serve needs now and in the futur e, entrusted to us in a spirit of accountability and responsibility for the common good. It means keeping on schedule so tha t you guard and value patients’ time and energy, nurses’ and physicians’ time and energy, and are able to pro- vide service to clients. An example was provided by staff on the car diac rehabilitation unit:

An example of ste wardship? Our program is more expen - sive, but we get better results. We monitor differ- ent things. It’s not a money- maker, but the hospital backs us up because our outcomes are better.

Resources are finite, not lim- itless. We must be cognizant of this and use them wisely. From a practical, personal point of view, what does this mean? I am a r esource for quality patient care. I must use my time, skills, compe- tency wisely, give it to those patients who need it the most, and delegate work that can safely be done by techs to the techs. If a hospi- tal runs out of resources, they go under, and then no one gets the care they need.

The core value described as compassionate caring had several components:

Practicing compassion means to care for all patients whether they can afford to pay or not, and you treat all equally and with respect whether they are paying or not. Compassion means to feel with the patient and family; it means empathy, tender- ness and kindness and then wanting to do something about it.

Feeling for and understand- ing their suffering and then a desire—no, I’m driven to want to alleviate their suf- fering, to make things better.

It is a privilege to be with a person transitioning to everlasting life.

It’s a deep feeling for and understanding of the mis- ery and suffering of another person, and the concomi- tant desire to promote its alleviation. A “passion for nursing”—“a fire in the belly.”

Summary When the 1932 value responses

cited by the 446 inter viewees were grouped into 9 value categories, the dominant core values on all units in the 8 magnet hospitals wer e patient/ family-centeredness and teamwork. Next, in order, were competent per- formance, family orientation and camaraderie, and respect, trust, and equality. In the next tier wer e integrity and honesty and clinical autonomy and patient advocacy. Staff nurses identified patient advocacy as

a dominant core value more fre- quently than did physicians. Physi- cians cited competent per formance and autonomy more often and teamwork less often than did the other 2 groups. The 1932 value responses could have been grouped into 2 other broad categories: values that were patient focused and those that were staff focused. If this grouping had been used, the 2 patient-centered core values (patient first and autonomy and advocacy) would have accounted for 83% (n = 1604) of the total responses, justifying the conclusion that these 8 magnet hospitals had cultures in which the pr edominant value was concern for the pa tient.

Hospital Values Core hospital values and

descriptions as provided in hospital documents are presented in Table 2, listed in order of prevalence within the 8-hospital sample. Some, but not complete, correspondence exists between hospital values and unit core values. Allowance must be made for differences in how values are labeled and defined. Agreement between hospital and units is almost 100% for the top 4 v alues, the top 5 if collaboration and teamwork are considered the same:

1. Quality care, including advo- cacy and patient-centered values

2. Respect and equality 3. Integrity and honesty 4. Continual improvement and

competent performance 5. Collaboration and teamwork. For 2 unit core values, family

orientation and camaraderie and autonomy and advocacy, the unit and hospital had no dir ect parallel. For 2 hospital values, community

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and hospitality, the hospital and unit had no direct parallel. In gen- eral, unit values are focused inward, and hospital core values are more outwardly focused.

Although the 8 hospitals had many commonalities in the core val- ues, they also had unique differ ences, making each hospital individual and “special” to the various communities the hospital serves. Some hospitals were more family oriented than oth- ers were; some were research focused and emphasized the advancement of technology, including robotics; oth- ers placed high value on commit- ment and loyalty to the hospital and to the corporation. Two hospitals were characterized by particularly “giving” environments: giving to the patients, to employees, and to the community. In one of these hospitals, nurses donated some of their accu- mulated leave hours either to provide special duty care for extremely criti- cally ill patients or to hire special duty nurses for such car e.

No attempt was made to identify norms related to hospital values as

was done with the unit v alues. Con- siderable evidence indicated that hospital values were “talked.” The values were prominently posted near the central elevators, in the lobby, and on the way to the cafete- ria; displayed in the hospital logo or stationary; and often inscribed on the reverse side of employee name badges. Being able to quickly list a hospital’s core values does not mean that the values were “normed” or “walked.” A parallel analogy was presented by one of the speakers a t the 2006 National Teaching Institute conference in Anaheim, California. The speaker was describing pr oce- dures used in conjunction with introducing companionship dogs into hospital settings. In addition to requirements for physical check- ups and for name badges with photo identification that were affixed to a dog’s collar, the back of every dog’s name badge listed the hospital core values. The speaker jokingly mentioned that this was done so that, when requested, the dog could bark out the core values

for members of the Joint Commis- sion or other visitors. In summar y, we can say that some of the cor e hospital values extend to the unit level, where considerable evidence indicates that staff, managers, and the team build and nur ture a unit culture, including appropriate val- ues and corresponding norms.

What These Findings Mean to Critical Care Nurses

A mark of excellence in organi- zations is the extent to which a sys- tem of common and shar ed core values is in place, v alues that go beyond the technical requirements of a job and convert neutral organi- zations into viable, dynamic institu- tions.40 Going beyond the technical requirements is what the adminis- trators, the nurse managers, and the staff in excellent hospitals have done. What makes for dynamic organizations or units is the extent to which common core values are normed or walked. Only the staff, the team, can tr anslate values into norms (ie, “commonly agreed-upon

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Table 2 Presence of stated core values in 8 magnet hospitals

Core values and descriptions

Quality care, clinically excellent care, amazing ser vice including patient advocacy, holistic care

Respect for each individual, equality, honor the intrinsic dignity of those we ser ve and who ser ve

Integrity, honesty, fairness, adherence to ethical practice

Continual improvement, research, clinical innovation, constant pursuit of quality , growth

Stewardship, efficient and responsible use of all resour ces, responsibility

Compassion

Community (make a positive difference in health of the community we ser ve)

Collaboration (join others in commitment to the common good), teamwork including fun, enjoy

Justice, care for all, especially poor and vulnerable; health care is a right

Teamwork

Hospitality (courteous and generous reception of all persons)

Hospital

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ways of behaving”33) or, to use the metaphor, walk the values. Through their actions, nurses decide “how we practice nursing here.” “On this unit we do it this way” is a frequently used preface to the expression of a norm. In addition to being involved in the development of v alues and norms, staff must also be involved in their transmission to newcomers, and in changing values and norms when necessary. The following excerpt from an interviewee says it far better than we could:

On this unit, we help one another. Nobody goes home till everyone is done. You watch out for the other guy and their patients. If you see they are getting swamped or a patient is in difficulty, you go and help. You don’t wait to be asked. You just go and do . . . . Mary transferred into our unit from the neuro ICU and that’s not the way they do it there. They practice like cowboys and loners down there. We told her that if she wanted to “fit in” here, this is what she would have to do. At first, we wanted to say, “Look, if you don’t do it this way, we’re never going to come and help you,” but you can’t really do that because that’s taking it out on her

patients. Then, something I learned in school. You norm your values by con- trolling consequences. So that’s what we did. We did- n’t make her feel a par t of the group until she could see the benefits of ever yone working together. There may be some units wher e the “lone cowboy” approach is best, but it’s not here.

We did not pursue identifica tion of the norms through which hospi- tal values are operationalized or walked. However, increasing evi- dence indicates that determination of the norms is necessar y. Just as clinical nurses need to be able to present the evidence for the auto - nomous decisions they make, man- agers need to use evidence- based management results to inform managers’ decisions. Pfeffer and Sutton42 note that in order to make evidence-based decisions the “ne w cultural norm,” leaders must ask subordinates for the evidence to support the need and efficacy for changes the subordinates propose. Many nurses in magnet hospitals have noted that in order to sustain excellence and quality patient care, the values represented by the Forces of Magnetism must become entrenched and part of the culture of the organization. To accomplish this, the values repre- sented by the Forces must be trans- lated into action (norms). 43 Some investi gators44 have attempted to measure the impact of hospital cul- ture (values and norms) on the out- comes of care. If such research is to continue, and it should, we need more information and data on the

norms that support a hospital’s cul- tural values.

The articulateness of the inter- viewees in describing their v alues, putting into words and exemplify- ing abstract concepts was tr uly amazing. Educators and staff devel- opment would do well to ha ve their students and orientees read the excerpts that these interviewees used to describe values such as autonomy and advocacy, which are at the very heart of nursing.

Conclusion Control of nursing practice and

a patient-centered culture promote both the quality of nurses’ work envi- ronments and the quality of pa tient care. Control of nursing practice enables nurses to control/improve the context of nursing pr actice; use of evidence-based practices enables nurses to improve the quality of car e provided to patients. Culture is the normative glue that preserves and strengthens the group and provides the healing warmth essential to qual- ity care. Walk the talk is a best pr ac- tice through which the values of unit and hospital culture are lived and control of nursing practice by nurses can be achieved. The 8 a ttributes of a healthy work environment identi- fied by staff nurses in magnet hospi- tals must become part of the hospital and unit culture if excellence and quality in patient care are to prevail.

Walk the talk is also one of the role behaviors of nurse managers universally identified by staff nurses as supportive. In the next ar ticle in this series, we present the results of studies related to the last 2 essen- tials of a healthy wor k environment: nurse manager support and per- ceived adequacy of staffing. CCN

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d•tmore� To learn more about patient-focused care, read “Changing the Work Environment in Intensive Care Units to Achieve Patient- Focused Care: The Time Has Come,” by Kathleen McCauley and Richard S. Irwin in the American Journal of Critical Care, 2006;15: 541-548. Available at www.ajcconline.org.

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eLetters Now that you’ve read the article, create or contribute to an online discussion about this topic using eLetters. Just visit www.ccnonline.org and click “Respond to This Article” in either the full -text or PDF vie w of the article.

Financial Disclosures This research was funded in par t by a grant from the American Association of Critical-Care Nurses.

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