For at least two decades, the role of the nurse practitioner has been viewed primarily within the confines of providing primary care. However, graduation, passing the State Boards, and obtaining a position in primary care certainly does not signal the end of the professional development for today's nurse practitioner. Instead, this is, in all likelihood, the first step toward a professional future that is, as yet, just beginning to unfold. If the nurse practitioner chooses to align himself or herself with a major health care corporation, then movement into organizational administration is the inevitable direction in which the career of the nurse practitioner will progress. Forward thinking theorists, such as Marilyn Anne Ray (2001) are already developing the theoretical framework necessary to assist the nurse practitioner in a virtually seamless movement toward professional growth beyond the primary care setting.
In recent years, the development that has created an entirely new arena for nursing, as well as a new practice arena for nurse practitioners, is managed care. According to Ray (2001), "In recent years, economics has been a potent contestant in macro- and microcultures. Now there is an ever greater concentration of economic and political power in a handful of corporations, which separate their interests - which are usually profit-driven - from the interests of human beings, which are life-centered. The conflict between health care as a business and health care as a human need has resulted in a crisis for health-care organizations. Rather than professional [nursing care being] valued as an expression of one's soul or an expression of one's creative self, working in health-care organizations is increasingly business and machinelike" (Ray, 2001, p.423). However, does this mean that nurse practitioners who move into administration and show talent in health care management are leaving the concept of patient care behind? Certainly this is not the case when a closer look is taken at Ray's Bureaucratic Caring Theory.
In order to understand Bureaucratic Caring Theory better, it is necessary to expand on the concepts of caring that have so long been a part of nursing theory and practice. The following list of caring components will better illustrate this point: Physiological and Technological, Ethical, Educational and Social, Spiritual and Religious, Legal, Political, and Economic (Ray, 2001). As shown, it is easy to see the evolution of the role of the modern professional nurse practitioner. No one would argue that caring practice has the nurse practitioner meeting the physiological and technological needs of the patient. No one would argue that a caring nurse practitioner is not going to pay particular attention to the ethical component of patient care and needs. The role of the nurse practitioner as patient and community educator and advocate necessarily includes educational, social, spiritual, religious, and legal components.
Yet, the nurse practitioner of the 21st Century must look toward professional growth and understand that their contribution to a fuller development of the role of the nurse practitioner may, indeed, lie in the power and authority that comes with being a part of administration. Although many individuals view the organization as "the enemy," especially in this era of managed care, it must be understood that without the organization, there can be no patient care at all. Therefore, it is vital that the political, legal, and financial health of the institution be protected. Once a nurse practitioner moves into administration, he or she becomes both a part of the organization, as well as continuing to remain a part of the health care environment that is responsible for direct patient care.
As part of the organization, the nurse practitioner/organizational administrator is obviously no longer responsible for direct patient care. Instead, he or she is in a decision-making position in which the best interest of the organization will take precedence over anything else. The question then becomes one of whether the needs of the organization or the needs of the patients should be more important to the nurse practitioner/organizational administrator. This is a position from which the nurse practitioner can have strong input into the areas that are so important to their practice, such as patient and community education and advocacy (Sherwood, Brown, Fay, and Wardell, 1997). However, can one professional serve two masters and still be effective in caring for the best interests of both?
Logically, the organization cannot exist without patients. Therefore, quality patient care is in the best interest of the organization. This concept also works in reverse. Patient care cannot exist without an organization to provide services. Therefore, it is in the best interest of the hospital staff to support the needs of the organization. The role of the nurse practitioner/administrator, who lives a professional life that overlaps both the organization and the traditional role of the nurse practitioner, is to ensure that each of these entities understands their symbiosis and that neither acts in such a manner as to cause injury to the other.
The question now becomes one of what does the nurse practitioner/administrator do when there is a conflict between the needs of the organization and the ability of staff to provide quality care for patients? Does the nurse practitioner/administrator automatically side with the organization, or are there criteria for making a decision as to which side he or she should take?
The answer to this question is at the same time simple and complex. First, while loyalty is to be prized in business, blind loyalty (to either side of a dispute) is always bad business. Second, the nurse practitioner/administrator should develop the role of liaison between the organization and staff so that both will trust him or her to advise them in an honest and professional manner.
Finally, how does caring fit into the equation of the role of the nurse practitioner/administrator? If he or she is immersed in the organizational environment, and obviously not providing direct patient care, are managerial decisions connected to caring? The answer is yes because of the symbiotic relationship between the organization and patients. A financial, legal, political, or ethical decision made by the organization has a direct bearing on the ability of staff to provide quality patient care that includes all of the components of caring practice. Therefore, the role of the nurse practitioner/organizational administrator, who is part of both the organizational bureaucracy and the staff, is instrumental, as liaison between the two, in the ability of the organization to meet its mission of providing quality patient care. Becoming part of the administration is an inevitable career growth path for the majority of today's nurse practitioners and must be understood by the profession and by the organizations they will lead.