1. Fulmer, Terry PhD, RN, FAAN
  2. Gibbons, M. Patricia DNSc, RN


Dr Joyce H. Clifford was world renowned for her excellence in nursing administration and leadership. The purpose of this article is to examine her complete body of published scholarship and analyze her papers as a method of understanding her intellectual progression as a leader in the discipline, as well as to document how her conceptualization of professional practice and the practice environment advanced nursing practice and patient and family care. Using the qualitative method of narrative inquiry, a systematic analysis of her papers was conducted to describe the evolution of her scholarship and her impact on the discipline and patient care. We reviewed all known existing papers, categorized them into 3 stages, and discuss them here. Using quotes from her work, we have added her voice to the compelling professional practice issues she addressed in her lifetime.


Article Content

JOYCE CLIFFORD was a formative and transformative nurse executive who had a profound impact not only on her contemporaries, but also on her proteges who have gone on to an impressive array of nurse leadership roles where they continue to translate her ideas. Countless numbers of primary nurses, physicians, and clinicians can tell stories of her impact on their practice and even today we continue to learn from her through the richness of her presentations, publications, and consultations that have been published and recorded. She spoke to the profession at a time when nursing was emerging as a strong and autonomous profession. For those of us who had the privilege to know Dr Clifford personally, we remember her as a steadfast friend, a passionate advocate, a humorist, an eternal optimist, and a committed teacher and coach. Dr Clifford was both a visionary and an extraordinary teacher. Her ability to engage staff in moral imagination filled the Beth Israel Hospital (BIH) with energy that only comes from the belief that all things are possible. She was unrelenting in her passion for excellence in nursing practice and uncompromising in her capacity to inspire and engage all of us in transforming care and the environment in which care is provided.


Joyce Catherine Hoyt was born in New Haven on September 12, 1935. She was 1 of 4 daughters of Raymond Hoyt, an ironworker, and his wife, Helen. She grew up in New Haven and received a nursing diploma from St Raphael Hospital in New Haven and a bachelor of science degree in 1959 from St Anselm College in New Hampshire. In the early 1960s, she joined the Air Force and in 1968, received a master's degree in nursing administration from the University of Alabama in Birmingham, where she was stationed. She met her husband Lawrence Clifford at the University of Alabama and they had 44 years of a happy and fulfilling marriage. They never had children. The Cliffords next moved to Indiana, where she was an associate professor of nursing (nursing administration) from 1971 to 1973. From there, she was recruited to Boston's BIH by its president and chief executive, Dr Mitchell T. Rabkin, a member of the Harvard Medical School faculty. Dr Clifford received her doctorate in the field of Health Planning and Policy Analysis at the Heller School of Brandeis University in 1997. She served as Senior Vice President and Nurse-in-Chief at the BIH, and later, the Beth Israel Deaconess Medical Center (BIDMC) in Boston for more than 25 years before establishing The Institute for Nursing Healthcare Leadership, Inc, where she served as the president and chief executive officer until her death in 2011. In 1980 Dr Clifford became a fellow of the American Academy of Nursing, and was the President of the American Organization of Nurse Executives in 1982. Further, she was a member of the Board of Trustees of the American Hospital Association from 1991 to 1994. She was a member of multiple professional organizations, as well as a trustee for her alma mater, Saint Anselm College in New Hampshire.


Dr Clifford was truly world renowned and celebrated as an exceptional nursing leader who advanced the professional practice model of primary nursing, a model where an individual nurse cares for a particular patient over the entire course of a hospital stay. She advocated for professionalism in nursing throughout her career. The purpose of this article is to examine her complete body of published scholarship and analyze her papers as a method of understanding her intellectual progression as a leader in the discipline, as well as to document how her conceptualization of professional practice and the practice environment advanced nursing practice and patient and family care.



To ensure we fully captured her scholarship, we reviewed Dr Clifford's curriculum vitae and used PubMed, CINAHL, and Google Scholar to identify all of her published work. Each article was read and the qualitative methodology approach of narrative inquiry was employed. This "uses verbal or written representations of events or experiences, expressed in a way can be understood by others."1 A narrative has a finite time sequence with a beginning, middle, and end. Using the purposive and single sampling unit approach, (Clifford) we have focused on the details and context of her work. Analyses identified 3 distinctive themes of her work: (1) early: the primary nurse and professionalism, (2) middle: the nurse manager as leader and collaborator, and (3) final: the role of policy in shaping professional nursing practice. Quotes have been selected to provide evidence and confirm patterns in her work.2


Early phase: The primary nurse and professionalism

Dr Clifford's earliest articles articulated the mandate for nursing autonomy, accountability, and authority as central to achieving quality patient and family care.3-83-83-83-83-83-8 She came of age during an era when the majority of nurses, trained in hospital-based diploma programs, provided much of the workforce for hospitals with little support and a near absence of leadership development. Nursing practice was experienced as a series of tasks carried out in response to the physician's plan of care and medical orders. As such, nurses often reported to physicians and their work was viewed as subordinate to doctors' work. She wrote,


Nurses in our setting, like nurses in many others, described conflict between their professional self-image and the behaviors they seemed force to accept in order to survive within the then current team-functional delivery system. That system failed to provide or support those aspects of professionalism that would lead to the development of either meaningful practice or consumer satisfaction. Nurses were seldom recognized as possessing authority within their own area of expertise.9(p65)


Dr Clifford held another vision. She saw nursing as a discipline with an independent practice and knew strategically and tactically how to make public the autonomy and accountability of nurses for their practice while responding to societal needs. The context for her work is extremely important, as it was crucial to her success. The early 1970s were a time of rapid change, partly in response to the advances of the 1960s including the birth of intensive care units, new pharmaceuticals, and advanced technology. Medicare and Medicaid had become a reality in 1965 and the funds that flowed from these new programs had positive impact on hospital budgets. These changes took place within a society that was focused on individual rights as evidenced by the women's movement and the civil rights movement. As such, there was a public outcry to humanize health care and Dr Clifford addressed this need by arguing that patients had a right to nursing care planned and evaluated by a registered nurse, that nurses had a right to practice based on their educational preparation, and that hospitals had a right to quality, cost-effective care. She championed "primary nursing," a model first conceptualized by Manthey at the University of Minnesota Hospital. Dr Clifford's message resonated globally and she soon began important engagements with the international nursing and health care communities. In 1980, she was invited to lecture on primary nursing at the Diakonhjemmet Hospital in Oslo, Norway and spent a week consulting with that institution. This led to a long and sustained relationship between the 2 organizations. Over the next decade, teams would travel between the 2 hospitals and this was a model she then used with other global nursing colleagues throughout her career in Japan, Puerto Rico, Canada, Finland, New Zealand, Israel, and Australia. Her capacity and energy was remarkable. She wrote about this in compelling ways: "primary nursing became a system of nursing care that could respond to societal requirements and become an excellent model for improving care to patients and increasing the professional stature of the registered nurse."10(p116) Establishing professional requirements for practice and integrating them with organizational requirements was a hallmark of her early work at the BIH and established nursing's dual responsibility to the discipline and the organization. "The need for nursing service and nursing education to plan together for the improvement of both has been cited so often it runs the risk of becoming one more nursing cliche."11(p56) She expected that nurses would build effective relationships with clinical and administrative colleagues, value teamwork, and create professional practice environments to support care, all the while demonstrating how to do this in her own executive practice. When reflecting upon her 40 years in management Clifford talked about the wisdom gained early in her career. "The one constant for health care is the need people have for compassionate, competent nursing care. No matter the changes, past, present, future-this societal need continues to be the management challenge in health care."10(p118) It is extremely important to document the leadership and support of Dr Mitchell T. Rabkin, the then president of the BIH. He sought out a leader of strong conviction and intellect and found those qualities in Dr Clifford, the visionary professional who would partner with him to transform the care environment and position the BIH as a leader nationally and internationally in personalized patient and family clinical care. "To say that we were fortunate enough to have a strong hospital administrative group, which supported the energies of the nursing department as we struggled for answers to questions we had not yet raised, is a gross understatement."7(p143) Without Dr Rabkin's vision and leadership, Dr Clifford may well have never come to the BIH-a thought almost unimaginable to many of us.


Clifford understood how to successfully manage change. She often said that the environment in which care is provided is as important as the practice itself. Dr Clifford spoke of the responsibility of the chief nurse and all nurse leaders to create environments that fostered independent clinical decision making by the clinical nurse, accountability for practice, and continuity in patient care. "...the fact is that the traditional role of establishing and maintaining an environment for care that is personalized and encourages patient and family participation has been, in the recent past, at best fragmented and in large part nonexistent."4(p1089) The delivery system known as primary nursing was selected as the best system to allow these values to be implemented. For this change in practice to occur and for the nurse to be supported in her practice, Dr Clifford knew that effective unit-based leadership was necessary. The first role to be redesigned and strengthened at the BIH was the role of head nurse. Under Dr Clifford's leadership, the position of head nurse (nurse manager/director) transitioned from day-to-day supervisor of the patient unit to leader of the practice and manager within the hospital organization. The head nurse was now accountable for creating a practice environment in which nurses would know their patients and patients would feel known and cared for by their nurse while managing the organization's resources and ensuring that the hospital's patient care mission was met. Dr Clifford was a fierce advocate for accountability and expected every nurse who worked with her to live out that accountability by being a responsible professional and taking full responsibility for the outcomes of care provided. "The concept of accountability is a complex, critical notion with many implications for nurse administrators. It is strongly related to the concepts of responsibility, authority, and autonomy."5(p19) Finally, Dr Clifford believed that the advancement of the discipline would come only when nurses had the full authority to practice to the full extent of their education and ability. Here, she worked untiringly to distinguish what was nursing practice versus the nurse's participation in medical practice, thereby creating the proper authority for the role. She wrote about the role of nursing administration in facilitating professional nursing practice in international textbooks12 and her work was translated for those communities.8


The Robert Wood Johnson Foundation/Institute of Medicine report The Future of Nursing has 4 significant messages: (1) nurses should practice to the full extent of their education and training, (2) nurses should achieve higher levels of education and have seamless progression, (3) nurses should be full partners with physicians and other health professionals in redesigning health care in the United States, and (4) effective workforce planning and policy making require better data collection and improved information infrastructure. Dr Clifford was prescient.13 We would argue that it was Joyce Clifford's scholarly work that led us to this moment that we think of as "the future of nursing era." It's to our great good fortune that Dr Clifford was both an exceptional thought leader and an author.


Throughout her professional journey, Dr Clifford left us a roadmap by publishing in prestigious journals of the day, including the Journal of Nursing Administration, Nursing Administration Quarterly, Nursing Economics and Publications of the National League for Nursing, and the American Organization of Nurse Executives. In the early phase of her writing, her attention was on the care of patients and families and the critical role that nurses played in assuring excellence. During the 1960s, Dr Clifford pointed out that the emphasis for nursing care was on completing the tasks of direct care with little notion of leadership. Nursing was concerned with providing treatments and completing orders often directed by physicians. "There is no doubt that such a system results in depersonalization and ritualization of patient care. The nursing goal becomes performance of tasks rather than comprehensive professional care directed toward the wellbeing of the patient."9(p63) In that era, Dr Clifford documented that there was very little interaction with the staff nurse and the head nurse. The head nurse was to liaison with the physicians and the staff nurses were to be seen and not heard. Dr Clifford knew that leadership in all roles was crucial to establishing the full authority and accountability within the nurse's scope of practice. Her early career in military service and in academe sharpened her thoughts on leadership: the United States Air Force Nurse Corps in Alabama (Major), and Director of Medical Nursing at the University of Alabama Hospitals and Clinics. Dr Clifford also brought her considerable expertise as scholar and administrator to later roles as Chief Nursing Officer at the BIH, BIDMC, and finally as founder and Executive Director of the Institute for Nursing Healthcare Leadership in Boston, Massachusetts. In her book, Perspectives in Primary Nursing,6 she discussed how all nurses should conduct research, publish articles, and keep professional practice momentum squarely moving forward.


In her article3 titled, "A Reaction to Donna McCarty and Marita MacKinnon Schifalacqua: Primary Nursing: Its Implementation and Six Month Outcome," Dr Clifford argued that the limitation of the head nurse role was a serious problem for advancing the accountability of the profession. She noted that it was imperative to have decentralized decision making so that progress could be made more rapidly and that caregiver-to-caregiver communication was an essential element to successful patient care outcomes. She stated that "the head nurse could no longer simply coordinate, but needed to lead with authority and decision making capacity."3 This article was one of the many ways she advocated for primary nursing as the preferred practice model for the discipline.


On December 26, 1982, the New York Times published an article, titled "Primary Nurses Bring Back One-on-One Care," where the BIH was recognized for excellence in nursing and for progressive thinking related to the provision of nursing care.14 In this article, Dr Clifford provided her key strategy in carrying out her vision by sharing a question she always asked when reviewing care or the environment in which it is provided: "How can we improve this?"14 This was her mantra and it guided her through many continuous improvement efforts over the years, well before quality improvement measures were commonplace in the clinical setting.


Another way that Dr Clifford advanced the concept of nursing professionalism was by providing presentations through a series of distinguished lectureships and forums in Japan, Netherlands, Canada, Puerto Rico, Finland, and Norway. The majority of her articles focused on leadership and mobilizing the profession for the advancement of quality care. Her lectures provided astute insight into the health care system and called out the difficulties and opportunities for nursing. In all of her articles the ultimate goal was to focus on how nurses could improve the patient care experience and make it a more holistic and humane encounter.


Middle phase: The nurse manager as leader and collaborator

In the next phase of her work, Dr Clifford took on even more challenging issues and in partnership with Dr Mitchell T. Rabkin, she gave voice to what so many of us wanted to discuss. In her 1983 article at the University of Pennsylvania, she noted that "...the more willing we are to begin ongoing conversations with our physician counterparts, the closer we will come to the goal of cooperative and collegial relationships."15(p6) To that end, Dr Clifford devoted her career to addressing organizational barriers that disempowered nurses and impacted patient care because of bureaucratic structures that reduced the autonomy, authority, and responsibility of the nursing discipline. In the mid to late 1980s, Dr Clifford shifted her exploration to that of the nurse executive role and collaboration. She had previously focused on the nurse at the bedside as an autonomous professional and kept that as a constant, but now developed and expanded her ideas on the role of the head nurse as executive.


In "Managerial Control versus Professional Autonomy: A Paradox," she noted that the 2 hats-the nursing administrator's hat and the nurse's cap-were at odds with each other and that the dilemma of managerial accountability and professional accountability was no longer reconcilable tension. Instead, each had to be incorporated into the other.


The concept of managerial accountability (implying managerial controls) and that of professional accountability (implying autonomous decision-making at the practitioner level) must be integrated to create an environment within which professional nursing practice can take place ... nurse administrators must also maintain their identities as professionals, with all that is implicit in that term. And nurse administrators must also maintain their identities as nurses if they are to develop appropriate mechanisms for assuring control of nursing practice, public accountability and protection of accountability of the individual practitioner.5(p19)


Dr Clifford wrote about "Improving Hospital Management and Information Systems: The Nurse Executive in the Institution's Leadership Team"12 and also on "Determination of the Nurse Shortage"16 and "Nursing Research and Policy Formulation: The Case of Prospective Payment."17 In these articles, she was emerging not only as a thought leader on the nurse executive role, but also as a health policy leader, shaping practice from both a national and a global perspective. In the mid-1980s, (the era of the diagnostic related groupings (DRGs), cost containment, and the advent of product lines) Dr Clifford wrote about "The Nurse Executive: Will the Professional Practice Model Survive?"18 In this article, Dr Clifford defended primary nursing as an appropriate professional practice model and pointed out,


Nurses will no longer accept the mere performance of tasks as their practice goals or outcomes. Nor will they remain in systems that promote fragmented, uncoordinated care leading to dissatisfaction for everyone-the patient, nurse, and hospital. Instead, nurses seek opportunities to provide comprehensive, professional care through a system that allows for continuity of patient care as well as the opportunity for them to maximize their knowledge and skill.18(p141)


One wonders what Dr Clifford would think about the Affordable Care Act, the movement toward patient-centered medical homes and accountable care organizations? She would certainly ask about the role of nurse leadership and our vision for optimal patient care outcomes. We might infer how she would view this sea change from what she wrote in "What DRGs Mean to the Patient and the Provider."19 She was deeply aware that the shift in payment strategies would have a profound impact on the discipline of nursing because if budgets were to be cut, she felt relatively certain that nursing would take those cuts much more quickly than the discipline of medicine.


Dr Clifford always kept her arguments evidence based. In one interview, she wrote "Our data do not suggest that we are more costly, when I compare Beth Israel's nursing hours per patient day with my colleagues in this community we have stayed at the mean."20(p12) She knew the power of data and that any of us who argued emotionally would be left behind in the restructuring of health care.


Final phase: The role of policy in shaping professional nursing practice

By advancing her education, completing her PhD in Health Policy at Brandeis University in 1997, and publishing her dissertation in 1998 Restructuring: The Impact of Hospital Organization on Nursing Leadership21 she was moving into her final phase-that of health care policy leader. She left us yet another link in the roadmap of her thinking related to how she examined the impact and influence of societal and policy changes on our discipline. One question that many of us ask is "How did she have time to do it all? When did she have time?" How could she possibly have had the time to complete her dissertation while leading a complex nursing service? For her dissertation, she engaged an expert panel and collected original data in 3 hospitals in 3 different states. Her data were collected from multiple sources (interviews, observations, and organizational documents) and her unit of analysis was the chief nursing officer.21 Many of us who think we are busy can look at Dr Clifford as inspirational.


Always responsive to contemporary issues, her articles were increasingly focused on what restructuring meant to professional practice. She was on editorial advisory boards for Health Management Quarterly, Nursing Administration Quarterly, Nursing Management, Journal of Nursing Administration, and Nursing Spectrum. As she progressed in her own thinking related to health care policy changes that would advance the profession on behalf of the patient, Dr Clifford wrote in Diana Mason's Policy and Politics for Nurses: Action and Change in the Workplace.22 She further wrote about the future of nursing practice23 in Dr Chaska's book The Nursing Profession: Turning Points.


Dr Clifford is regularly described as the architect of nursing's professional practice model-a model that has been recognized nationally and internationally in hospital and in outpatient/community services. Her model has been studied and emulated by nurses and health administrators around the world (Australia, New Zealand, Israel, England, Scotland, Germany, the Netherlands, Kenya, Thailand, China, Saudi Arabia, Japan, and all of the Scandinavian countries). Her leadership has been recognized with Sigma Theta Tau's Founder's Award for Promoting High Professional Standards (1982), Clairol's Distinguished Mentor Award (1990), the Award of Honor of the American Hospital Association (1990), the National Nurse Executive Leadership Award of the American Organization of Nurse Executives (1996), 3 honorary degrees, the Lifetime Achievement Award of the American Organization of Nurse Executives (2003), the AACN-Marguerite Rodgers Kinney Award for a Distinguished Career of the American Association of Critical-Care Nurses (2004), a Living Legend Award from the American Academy of Nursing (2005), and recipient of the Living Legend in Massachusetts Nursing Award presented by the Massachusetts Association of Registered Nurses (2007).


Dr Clifford held additional leadership positions on boards including the American Journal of Nursing Publishing Company (board chair), the American Hospital Association, the Institute of Medicine's Committee on the Adequacy of Nurse Staffing, The Council on the Economic Impact of Health Care Reform, Strengthening Hospital Nursing Program (RWJ/Pew), and The RWJ Executive Nurse Fellowship Program. Her book Restructuring: The Impact of Hospital Organization on Nursing Leadership was frequently cited in the 2004 Institute of Medicine report on patient safety.21


There is an important postscript to Dr Clifford transformative work at the BIH. She was the Vice President for Nursing and Nurse-in Chief from 1973 to 1996, at which time the BIH merger with the New England Deaconess Hospital took place. She then served in the new BIDMC as Senior Vice President, Nursing and Nurse-in-Chief and Chair of Nursing programs from 1996 to 1999. The primary nursing model was negatively impacted by the hospital restructuring and cost cutting and in the book, Code Green, the story of how mergers, reimbursement changes, and insurance rates "dismantled" primary nursing was told.24 Dr Clifford did not publish any articles that responded to this book. She was a source for the author who published this from her doctoral dissertation. Dr Clifford, as noted earlier, was a consummate optimist, and always believed the cycle would correct itself and consumers would demand excellent nursing care. It should be noted that the professional practice model in place at the BIDMC today is based on shared governance, collaborative practice, and the professional values of respect, accountability, and collaboration, all inherent in the model Dr Clifford espoused.


We are all extremely fortunate to have had Joyce Clifford in our lives and we are even more fortunate to have the continued benefit of her leadership through her written work. Dr Clifford, a true scholar, an expert, a champion, and a consummate leader influenced a generation of nurse leaders and created a vital and important roadmap for the future of nursing practice and leadership.




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3. Clifford JC. Reaction to Donna McCarty and Martia MacKinnon Schifalacqua: primary nursing: its implementation and six-month outcome. J Nurs Adm. 1978;8(5):29-32. [Context Link]


4. Clifford JC. Primary nursing: a contemporary model for delivery of care. Am J Health Syst Pharm. 1980;37:1089-1109. [Context Link]


5. Clifford JC. Managerial control versus professional autonomy: a paradox. J Nurs Adm. 1981;11(9):19-21. [Context Link]


6. Clifford JC. Perspectives in Primary Nursing. London, England: Aspen Publication; 1982. [Context Link]


7. Clifford JC. Professional nursing practice in a hospital setting. In: Aiken LH, ed. Nursing in the 1980s: Crises, Opportunities, Challenges. Philadelphia, PA: Lippincott; 1982:101-109. [Context Link]


8. Clifford JC. Nurse executive skills: what does the health care system need? (published in Japanese). Int Nurs Rev. 2000;24(1):10-13. [Context Link]


9. Clifford CJ. The potential of primary nursing. In: Healthcare in the 1980s: Who Provides? Who Plans? Who Pays? New York, NY: National League for Nursing; 1979. [Context Link]


10. Clifford J. Managing through four decades: a personal reflection. Nurs Adm Q. 2000;25(1):115-118. [Context Link]


11. Clifford CJ. The role of the nurse administrator: clinical or administrative. Nurs Adm Q. 1979;3(4):56-58. [Context Link]


12. Clifford JC. Improving Hospital Management and Information Systems: The nurse executive in the institution's leadership team. World Hospitals XXI; 1985:(4)28-30. [Context Link]


13. IOM Ra. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2010. [Context Link]


14. Springarn ND. Primary nurses bring back one-on-one care. New York Times. December 26, 1982:26. [Context Link]


15. Clifford CJ. Nurse-physician communication: competition or cooperation? Presented at: Fourth Annual Dean's Distinguished Lecture; 1983; School of Nursing, University of Pennsylvania. [Context Link]


16. Clifford J. Determinants of change in health care: determination of the nurse shortage (United States). Paper presented at: Fourth Northeast Canadian/American Health Conference; 1984; Burlington, VT. [Context Link]


17. Clifford J. Nursing research and policy formation: the case of prospective payment. Am Nurs Assoc. 1984;(G-164):i-iv; 1-73. [Context Link]


18. Clifford JC. The nurse executive: will the professional practice model survive? J Prof Nurs. 1988;4(2):77-141. [Context Link]


19. Clifford JC. What DRGs mean to the patient and the provider. J Geriatr Psychiatry. 1988;22(2):201-210. [Context Link]


20. Clifford JC. An interview with Joyce C. Clifford. Interview by Carmella A. Bocchino. Nurs Econ. 1991;9(1):7-17. [Context Link]


21. Clifford JC. Restructuring the Impact of Hospital Organization on Nursing Leadership. Chicago, IL: American Hospital Publishing; 1998. [Context Link]


22. Mason DJ, Talbott SW, Leavitt JK eds. Policy and Politics for Nurses: Action and Change in the Workplace, Government, Organizations, and Community. Philadelphia, PA: WB Saunders Company; 1993. [Context Link]


23. Clifford JC. The future of nursing practice. In: Chaska NL, ed. The Nursing Profession: Turning Points. St Louis, MO: Mosby; 1990:617-623. [Context Link]


24. Weinberg DB. Code Green: Money-Driven Hospitals and the Dismantling of Nursing. New York, NY: Cornell University Press; 2003. [Context Link]


advanced practice nursing; clinical nursing; nursing leadership; primary nursing