Stewardship in health care, in the nursing profession, and of self

The theory of stewardship incorporates concepts of environ-
mental1 and theological2 notions of practical reasoning. Within the nursing literature,3 , 4 stewardship has emerged as a topic of nurse leadership; however, there is a need to clarify the origins and meaning of the term.

Traditional definitions of stewardship

In the Book of Genesis, God appoints humanity as the steward of all creation. The Old Testament tells the story of Joseph, who is sold by his brothers into slavery and becomes Putiphar’s steward and ultimately the Pharaoh’s. From this parable, a steward is a selfless servant who manages assets and possessions without owning them, foresees future trends and creates plans and interventions.5

The parable of ‘talents’ in the New Testament describes another aspect of stewardship in which a master divides his worldly goods between his three servants. The moral portrayed in this parable is that when one is entrusted with something of value, there is an obligation to improve on it.

The Islamic institution of Hisba is responsible for organising public administrative functions within the dimensions of morality, normality and technology. The head of the Al Hisba is called the Muhtasib, who was first appointed in Medina in the 9th century. The Muhtasib in the pre-colonial Arab civilisation was responsible for the regulation of medical practice and pharmaceuticals, which incorporated equitable provision of services to the public.6

State-orientated definitions of stewardship

The broad definition of state-orientated stewardship is that the function of government is responsible for the welfare and interests of the population, especially the trust and legitimacy with which its activities are viewed by the general public.5

In 2001, the Institute of Medicine proposed six aims to improve the health care system for the 21st century.7 The recommendations were that health care should be safe, effective, patient-centred, timely, efficient and equitable. These recommendations have been assumed by both the health care community and the communities served and form the context around discussions about health care. This may lead to leadership opportunities for nursing that afford ways and a knowledge base to initiate dialogue with colleagues, including consumers and health insurers. Such opportunities allow for transformational structures, programmes and systems that meet the six recommendations of the Institute of Medicine (2001).4 It can therefore be assumed that nursing managers in all disciplines of nursing will be the chief patient and safety officers and stewards for their organisations and institutions.4

To achieve the six aims, nurse leaders will have to engage in developing, assessing and refining innovative and fresh modes of care delivery. To do this, a solid foundation in health care economics, financing and statistics will be order of the day for this aspect of stewardship.

The potential of stewardship

The potential for improving and enhancing policy outcomes is the predominant positive potential of stewardship. Another prospect of stewardship is to revive a sense of social purpose among public sectors of management, together with assisting to restore a sense of trust and legitimacy to the role of the state.5 This ‘attractiveness’ of a stewardship approach may be a realistic (and achievable) possibility to channel fresh and emerging systems of integrated care in more socially responsible ways.

Stewardship of nursing

The leadership potential of stewardship in nursing requires new models of delivery of care, and we need to address the ever-changing nature of the work of a nurse.4 With evolving new roles in the nursing profession, collaboration with nursing research colleagues will be required to develop mechanisms of evaluation and assessment which further refine evidence that supports the essential and exclusive contributions of the professional nurse in outcomes of care and prevention.4 Development and enhancement of the evidence in research call for nursing stewards who will embark on such issues to design new financial models in order to constantly build the business side of nursing care delivery models. Such leadership will become synergistic with the work in the area of stewardship of the health care system.

Future nurse leaders or stewards will be directly centred on working with nurse practitioners and nurse educators to transform the practice environments in which they work. The intended outcome is to make practice environments more positive, healthy and engaging. Areas for dialogue may be within:4

• patient-population centredness

• safety for patients and health care personnel

• the needs of an ageing workforce

• increased autonomy for advanced nurse practitioners

• increased respect for the contributions made by professional nurses

• clarification of the caring work of the nurse, and

• enhancement of the collaborative practice of the multidisciplinary health care team.

Lastly, but perhaps most importantly, an opportunity for nursing stewardship lies in the regulatory and accreditation aspects of the profession. Nurse leaders or stewards are finding themselves collaborating with regulatory boards to improve on standards of practice, certification and accreditation, thus ensuring that standards and regulations support the nurse of the future and new models of care delivery, and remain true to a patient/population-centred health care system.

Another aspect is for nurse leaders or stewards to influence decision-making at the point of service. An ‘invigorating’ nurse leader or steward is urgently needed.8 Storch9 insists on nurses creating health care environments that uphold value-based nursing practice by acknowledging that who one is – one’s moral character – is essential for leadership. Nurse leaders or stewards need to engage with how this is to be done, utilising character, dialogue and shared meanings and values.

Stewardship of self

To meet the domains of stewardship in health care and the nursing profession, it is crucial that nurse leaders engage with the development of self. Succession planning to develop and nurture a new generation of transformational nurse leaders may be the only way to achieve this. To meet the concept of lifelong learning, nurse leaders or stewards will need to use of mentors and personal coaches to assist them in refining skills and improving competencies.4 Healthy nurse leader stewards will thus become visible and sound role models within their institutions to maintain the balance between self and professional fulfilment.4

The future of nursing is rapidly changing. Things are somewhat chaotic at times, but the opportunities for stewardship are many and varied. We are ideally suited to serve as nurse leaders or stewards in all aspects of health care. By embracing the six aims of health care improvement, the leadership of nursing can be both invigorating and transformational.

Nicki Fouché

Nursing Science Editor

Nicki.Fouche@uct.ac.za

1. Welchman, J. The virtues of stewardship. Environmental Ethics 1999;21:411-423.

2. Magill G. Organizational ethics in Catholic health care: honouring stewardship and the work environment. Christian Bioethics 2001;7(1):67-93.

3. Dingel-Stewart S, LaCoste, J. Light at the end of the tunnel: a vision for an empowered nursing profession across the continuum of care. Nurs Adm Q 2004; 28:212-216.

4. Haase-Herrick K. The opportunities of stewardship. Nurs Adm Q 2005; 29:115-118.

5. Saltman R, Ferroussier-Davis O. The concept of stewardship in health policy. Bull World Health Organ 2000;78(6):732-739.

6. Taymiya I. Public Duties in Islam: The Institution of the Hisba. Markfield, UK: Islamic Foundation, 1985.

7. Institute of Medicine. Crossing the quality chasm: a new health care system for the 21st century. Washington: National Academy Press, 2001.

8. Murphy N, Roberts D. Nurse leaders as stewards at the point of service. Nursing Ethics 2008;15(2):243-253.

9. Storch J. Ethical dimensions of leadership. In: Hibberd J, Smith D, eds. Nursing Leadership and Management in Canada. Toronto: Mosby, 2006:395-414.