STEWARDSHIP IN HEALTHCARE, IN THE NURSING PROFESSION, AND OF SELF

The theory of stewardship incorporates concepts of environmental1 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.
 THE PRINCIPLES OF TOTALITY AND INTEGRITY

Principle of Totality of a Human Person

1. To promote human dignity in community, every person must develop, use, care for, and preserve all of his or
her natural physical and psychic functions in such a way that…
a) Lower functions are never sacrificed except for the better functioning of the whole person
and even then with an effort to compensate for this sacrifice.
b) The basic capacities that define human personhood are never sacrificed unless this is
necessary to preserve life.
2. To be a complete human being is not merely having the higher level of functions but to have all the basic
human functions in harmonious order.
3. Human body functions contribute to higher functions not merely by supplying what is needed for physiological
functioning, they also supply part of the human experience that is essential to human intelligence and freedom.
4. The good of the part is essentially subordinate to the good of the whole.
5. In case of danger to itself, the whole can dispose of the part for its own benefit.
6. In a living physical organism such as the human organism, the parts by their very nature exist for the sake of
the whole.

Conditions for Principle of Totality

1. That the organ by its deterioration in function may cause damage to the whole organism or at least pose a
serious threat to it.
2. That there is no other way than taking the indicated action against it or obtaining the desired good result.
3. That the damage being avoided to the whole is proportional to that which is caused by the mutilation or
incapacitation of the part.

 This principle of totality does not apply to moral organization (family, society, and humanity), a person is still
independent. He is not a subordinate to any group. He is the subject, principle, and end of all social institutions.
 Authority cannot directly dispose the physical and personal being of a person, removal of the undesirable or
weak parts of the society.

Ethical Issues
Mutilation - The destruction of member, organ/ part of the body (organic) or the suppression of a physical
function (functional) in such a way that the organism becomes no longer basically whole.
It is an action by which an organic function/ the use of a member of the body is intentionally destroyed either
partially or wholly.
Types:
a. Direct – Willed in itself, as end or as means, intended and caused intrinsically wrong. Offends human
dignity. Individual does not have the right to mutilate himself, much less does society.
b. Indirect (Therapeutic) – Licit is an act of good stewardship of the body; necessary for the survival of the
patient or to free him of proportional sufferings/ infirmities.

Sterilization - A medical or surgical intervention, which causes a patient incapacity of generation.

a. Indirect (Therapeutic) – Inevitably required for the survival and health of a person, sexual organs,
integrating parts which must yield to the good of the whole. Licit if:
 Sickness is grave, certainly diagnosed and definitive that it offsets the evils of sterilization.
 It is necessary because it is the only possibly effective remedy.
 Exclusively curative. Intention is important.
b. Direct – Immediate effect is to render procreation impossible.
Types:
1. Eugenics – Seeking to avoid the transmission of hereditary defects.
2. Hedonistic – Evade the complications and responsibilities of procreation without giving up the sexual
pleasure.
3. Demographic – To control the birth rate.
4. Preventive – Render pregnancy impossible which might aggravate the sickness that already exist.

Organ Donation - A person may will to dispose of his body and to destine it to ends that are useful, morally
irreproachable, and even noble among them, the desire to aid the sick and suffering.
- Criteria:
1. There’s a serious need on the part of the recipient that cannot be fulfilled in any other way.
2. The functional integrity of the donor with a human person will not be impaired even though anatomical
integrity may suffer.
3. The risk taken by the donor as an act of charity is proportionate to the good resulting to the recipient.
4. The donor’s consent is free and informed.
5. The recipients for the scarce organs are selected justly.

Cadaver Donation- It is forbidden to cause the death of the donor of the organ transplant.
3 Conditions:
1. Donor must be verbally and legitimately dead.
2. Informed consent
3. Remains must be treated with respect.