ORN Journal ~ July, 1998 Power perceived is power achieved. (Power struggles in perioperative nursing)
 Author: William Duffy (see Copyright information at the end)
 
As dollars shift to the surgical arena, so do the groups that are vying for power in the institution. In some cases, leaders without perioperative backgrounds, or even nursing backgrounds, are assuming power positions within the surgical suite. What has led hospital administrators to rely less on their clinical experts and seek others to fill perioperative positions of influence? A key reason for this looming crisis is the use (or lack of use) of power. 

POWER TO INFLUENCE CHANGE Many nurses are unprepared for the political maneuvering and power politics that occur in every institution. This is particularly true in the OR where, for years, the unit remained behind its double doors while the rest of the hospital adapted to economic realities. Perioperative nurses need to show administrators that the knowledge we have benefits the setting to meet the needs of all disciplines within the OR. Perioperative nurses advocate to and for patients, physicians, and administrators and represent all customer groups. Our clinical expertise and unique understanding of customer needs make nurses key players in the mix. Now, nurses need to spread this perception to others. Unfortunately, nurses seem to be winning the battles but losing the war. We need to stop giving our power away and start using it more effectively to influence and care for all customers' needs. At the recent American College of Surgeons' meeting, physicians who took over leadership of ORs at their institutions talked about their lack of knowledge regarding the scope and depth of running the day-to-day operations. They relied on nurses to get things done. Although surgeons praised nurses, they remain the ones in charge. 

MANAGING POWER STRUGGLES Nurses need to look at themselves, rather than searching and blaming "change" or some outside group for the power struggles they are experiencing. Change is constant. It always was there and always will be. Change was present when nurses gained influence, and it is there now when we may lose it. Change cannot be good when it helps nurses and bad when it does not. Nurses should be happy there is the opportunity for change so we can turn situations like this around. Power is defined as "possession of control, authority, or influence over others."(

1) This is an ominous definition. It has the good characteristics of providing people with the ability to control and influence their own lives; yet it also hints at something darker. The dark side of power is its ability to control and influence the lives of others. This dark side may be why nurses tend to shy away from power and actually give it away. This shying away has left nurses in a quandary. On one hand, nurses are frustrated and angry at the events surrounding their profession and the health care environment. On the other hand, nurses send messages through statements and actions that say they are not in control and cannot improve the situation. Both of these messages weaken the perception that administrators, surgeons, and industry have of perioperative nurses. 

LOOKING INSIDE Take an outsider's look at the image that some of our colleagues present. An example is the conversations heard on the exhibit floor at AORN Congress. Do you hear nurses tell vendors to contact purchasing department personnel because they have responsibility for purchasing decisions? Do other nurses say their institutions "only buy through group purchasing agreements, so do not bother showing us products"? Do nurses say, "all we want is a free gift," and imply they are not interested in hearing about how vendors can improve patient care? Are our colleagues wearing business suits or jeans at their own business meetings? If you were a vendor, would you start to wonder if it was worth the tens of thousands of dollars you spend to come to AORN Congress, or would you start thinking you should focus on the materials management convention? Try the same thing at work. Keep the "outsider" mindset. Listen to the comments our peers make about issues facing the department. Is the message they are sending that of a person in control or that of a laborer whose mission is to get direction, perform a task, and go home? Do you hear, "All I want to do is take care of patients"? The plain truth is that, in many instances, when the OR doors were thrown open, many of our colleagues were not prepared for the business realities that awaited them. If nurses are going to really care for their patients, they must provide both fiscal and clinical patient care. As the patients' ombudspeople, nurses have to be involved to prevent hospitals from making poor fiscal decisions that could affect patient care. In a sense, nurses not only have to nurse their patients, they also have to nurse their jobs to keep them healthy. 

CHANGING PERCEPTIONS Perception is more powerful than facts, and it is the area on which nurses should focus their attention. Changing perceptions is difficult when you think no one is listening or that you are just being tolerated, but it can be done. An example of perception versus fact is the US Navy. The United States sends its ships to ports all over the world to project its naval power. The fact that it would take months for the United States to respond to a crisis is lost in the perception of the power gained from the display of US ships. The key is to have people perceive that you have power. When nurses achieve that perception, they actually will achieve the power they want. Power perceived is power achieved. To start changing this perception, you have to start with yourself. As professional nurses, we have plenty of power. Here are some tactics and strategies that nurses can use to retain control of their power and gain influence. Remember that this is a political process and it will take time, but if you stay focused, you can achieve your goals. 

Thinking like owners. First, nurses have to start thinking and acting like owners. Owners have a certain attitude about their business that separates them from workers. Owners believe that they can improve their business and that their own actions matter. Owners also know that their customers can make a choice. Your patients, physicians, coworkers, and administrators can decide to use your talents or those of someone else. If you are feeling left out or unappreciated, then start selling the invisible product--yourself. Harry Beckwith's book, Selling the Invisible, is an easy-to-read guide to selling service.

(2) Nurses provide a service as owners of their professional practice. This book will help you identify the best strategies to influence your customers and change their perception. Do not leave it to chance if you want to be more appreciated for the work you do. Take action to begin retaining control by marketing your service and becoming an owner. Selling your product. The responsibility for marketing your service sounds like we are asking you to also become a salesperson. Well, you already are. We are all salespeople. In looking out for ourselves, we have to sell our skills, value, and abilities.

(3) That is how we get hired, receive raises, and even engineer support from others to get through the day.

(4) Our actions sell the perceptions we want people to have of us. One of the problems nurses have is not their not trying to become better salespeople. When nurses become aware of the selling situations surrounding them daily, they will be on their way to becoming more effective and valued employees.

(5) Knowing the competition. Whether you become an owner or not, you have to stay aware of your competition. In the work setting, commitment is conditional on performance, and performance is always competitive.

(6) Competitive performance is a significant change for a group of professionals who come from a culture of entitlement. We have all heard the statement, "There will always be jobs for nurses." Today, the question is, "In what capacity will these jobs be?" The new realities of health care require that we communicate our value to employers before, and better than, some other person or group. As "president" of your own business contracting your services to your present employer, you should be able to * describe what you do by asking and answering the question "What is the service you provide and how good is it compared to others who are vying to provide the same service?" (ie, does your employer see the value from the additional salary it pays an RN versus a surgical technologist?); * identify what is expected of you, including the goals of your employer; * specify what you can do to improve your worth and how you would measure results; * account for your role in the growth of the company, what you can do to improve the bottom line, and what new skills you can develop to accomplish this responsibility; and * communicate what you do in terms that can be understood by non-health care professionals.

(7) Basically, you need to ask yourself "Can I sell my story?" As a customer, would you buy your services based on these answers? If you have trouble answering these questions or have only superficial answers, you may have work to do before you can sell yourself over your competition. If the surgical services environment is to become the power base of hospitals, perioperative nurses have to be able to compete and get their message out. A key point to remember is to not let the competition become personal. Coworkers, in general, do not know how to deal with emotional reactions in the workplace. They tend to shy away from people who demonstrate this behavior. Nurses need to understand what is happening and avoid taking the bait designed by your competition to get you to react emotionally. Instead, plan a course of action to get around the obstacle. This will send a message that you can handle this type of challenge. Understanding competition and the fact that it will happen allows us to make a choice. 

Nurses can shy away from the challenge and let someone else set the direction or they can choose to participate. Competition can be a scary thing, but it is part of life and it does not have to be unpleasant. Athletes know this; they compete against each other every day and still are friends off the playing field. Competition is about people trying to control their environment. Sometimes friction will develop, but do not let it distract you and do not let it affect your working relationship with your competitor. You may need that person as an ally in other situations. Stay focused on your goal and do not bum bridges. Communicating effectively. The next step is to learn to communicate more effectively with customers. A large portion of a nurse's work day involves sending and receiving verbal and nonverbal messages. Unfortunately, male and female communication patterns do not necessarily mesh in the workplace. Our different styles of communication often lead to misunderstood messages and inaccurate perceptions. Research has shown that males favor a hierarchical communication pattern while females tend to expect the person they are communicating with to maintain an equal standing in the conversation.

(8) Nurses can increase their ability to influence others if they understand their own communication style and those of their customers. Deborah Tannen's book, Talking from 9 to 5, Women and Men in the Workplace: Language, Sex and Power, examines these differences and offers insights to overcome barriers to communication.

(9) Nurses need to speak their customers' language in addition to understanding their styles of communication. Administrators often do not understand the message nurses try to deliver because they deliver it in "nurse speak" when they should be speaking administrators' language. Administrators speak in terms of dollars and cents, budgets, and cost ratios. Nurses are taking a chance their messages will not be heard if they talk to administrators only in terms of improving patient care. Administrators hear that argument many times each day. The facility would have no money if administrators purchased items each time a clinician advanced the improved patient care argument. Explain the need in their language if you want to get an edge on your competition. Sell your idea to administrators in a way they can understand. Tell them what it will cost, how it will be paid for, and the tangible benefits the department will receive. If you need to talk about improvements in patient care, do so in a manner they can comprehend. Listening. Administrators are looking for nurses they can trust to give them the straight story. They do not always understand the clinical issues that physicians and others relate to them. Nurses can gain an inside track if they establish the perception that they can bridge the clinical and fiscal issues. While nurses learn to speak their customers' language, they should focus on listening to what their customers are saying. Communication today is like a race. It seems that our goal is to guess what people are going to say and fire back a response. Practice waiting for people to finish their thoughts and listening more intently. As your communication pattern slows down, other people will realize they are not in competition with you for air time.

(10) When you are hearing what your customer truly wants, try to choose some problems that can be fixed easily and resolve them. Nurses can gain a lot of respect from their customers if their customers know someone is listening. When that respect is established, it will be easier for nurses to receive positive feedback on their requests. Someone has to make the first move in all relationships. In this situation, nurses want to change the status quo, so the first move belongs to us. Listening to your customers is only half the job. You also have to listen to yourself. Watch how you say no. Unfortunately, nursing has gained a reputation for saying we cannot implement a change, and then doing it when we are told that the change has to be implemented This damages our credibility and limits our ability to influence change. No one likes for their ideas to be turned down flat. Quick rejections bring out defense mechanisms. A better approach is to say yes, and then point out what the costs and risks will be. This method allows supervisors to hear different perspectives without having their ideas dismissed outright. The word "no" never left your lips, and yet you provided your supervisor with an option or reason to back out of the plan. If the decision is to proceed, then you already have established a position to cover the increased costs. The key is that you are at the table working with your supervisor and influencing the solution. These techniques can be used at all levels. If you are a staff nurse and you want to influence your supervisor, you need to speak and listen in his or her language. You will improve your chances greatly and make a good impression. 

BUILDING ALLIANCES Next, nurses need to start building alliances. The best way to start is to ask potential allies questions about their jobs. Become interested in their work. Ask for their advice and listen to what they say. Nurses can expand their knowledge base and gain some insights to what their allies value. Invite the facility's materials manager or a staff member from the finance department to tour the OR. Explain to them what nurses do. Do not try to sell them an idea at that time. Let the work nurses do in the OR impress them. You always can try to influence them another time. Ask questions, learn, and develop that relationship. People will teach if they think someone is interested. Another excellent resource for expanding skills is through vendors. Vendors know business, marketing, and cost analysis. Talk with them and ask them if they would conduct an inservice session. Use their expertise. For example, one vendor partner taught our hospital's OR case managers about inventory management and discussed the risks and benefits associated with inventory and alternative ways to manage the risks. Several weeks later, the case managers voluntarily reduced the inventory by $180,000. This achievement did not go unnoticed. 

POWER ACHIEVED Changing perceptions is hard work. Obtaining something of value usually is; however, you are not alone. Our physician colleagues are facing the same crisis, which may be why so many are leaving the profession or going back to business school. Clinical skills alone will not be sufficient. There are resources to help you, but the decision is yours. You have to act to create change. You will be successful if you follow this plan and take small steps. Take control of your destiny and show the world the power of perioperative nurses. 

NOTES (1.) Merriam-Webster's Collegiate Dictionary, 10th ed, F C Mish, ed (Springfield, Mass: Merriam-Webster, Inc, 1993) 913. (2.) H Beckwith, Selling the Invisible (New York: Warner Books, 1997). (3.) G S Goodman, Selling Skills for the Nonsalesperson (Englewood Cliffs, NJ: Prentice-Hall, 1984) 2. (4.) Ibid. (5.) Ibid. (6.) J E Lapp, Plant Your Feet Firmly in Mid-Air: Guidance Through Turbulent Change (Del Mar, Calif: Demeter Business Books, 1996) 121. (7.) Ibid, 120. (8.) D Tannen, Talking from 9 to 5, Women and Men in the Workplace: Language, Sex and Power (New York: Avon Books, 1994) 23. (9.) Ibid. (10.) R Carlson, Don't Sweat the Small Stuff... and It's All Small Stuff: Simple Ways to Keep the Little Things From Taking Over Your Life, first ed (New York: Hyperion, 1997) 76. WILLIAM DUFFY, RN, BSN, MJ, CNOR, is director of perioperative services at Evanston Northwestern Healthcare Corp, Evanston, Ill. MARIA CARMENCITA DUFFY, RN, BSN, is a staff nurse in the OR at Evanston Northwestern Healthcare Corp, Evanston, Ill. ------------------------------------------------------------------------------- COPYRIGHT 1998 Association of Operating Room Nurses, Inc. in association with The Gale Group and LookSmart. COPYRIGHT 2001 Gale Group ------------------------------------------------------------------------------- Nurses Unionizing-------NLRA and Taft-Hartley ActNursing ResponsibilityMyths and FAQRespect and RecognitionThe Other Healthcare CrisisNursing Shortage, Why . . .?Patient Deaths Tied to RN Shortage Nurse Abuse-------Do Not Be a Victim!Unfair Pulls to Other UnitsCharting Errant DocsProfits Over PeopleVerbal Abuse from DocsNurse vs. Doctor Home~*~Credits~*~Site Map~*~Guestbook ~*~Webrings~*~Awards Nurse Abuse~*~Inspiration~*~Nursing Power Webring~*~Unionization