SlideShare a Scribd company logo
1 of 43
Enhancing Nurse Moral Agency: The
Leadership Promise of Doctor of
Nursing Practice Preparation
^ m d
Abstract
...it is more critical
than ever that we
remain mindful
about the demands
of ‘good’ patient
care.
The development
of knowledgeable
and skillful nurse
leaders is
necessary to
enhance
interdisciplinary
Pamela Grace, PhD, RN, FAAN
An expansive and growing body of literature documents the
problem of nurses’ moral distress when
they are unable to carry out actions that they perceive to be in
the best interests of patients.
Further, nurse leaders and educators are not always well
prepared to help nurses to develop moral
agency. Moral agency is the ability to provide good care and
overcome obstacles to good practice.
One reason for the lack of preparation is that ethics education in
academia, and in ongoing nurse
education, has been inconsistent or has focused more on
dilemmas than the ubiquitous everyday
practice issues. The purpose of this article is to discuss goals of
the nursing profession,
contemporary challenges to good nursing practice, and
leadership from those educated as Doctors
of Nursing Practice (DNP). The author argues that the
proliferation of (DNP) programs, focused as
they are on leadership in practice settings, presents a unique
opportunity to prepare nurse leaders
who are, first and foremost, skilled and knowledgeable about
the ethical content of everyday
nursing practice. An ‘ethics matrix’ is described and proposed
as an essential base for DNP
education upon which all other knowledge is built, with specific
discussion of types of leadership and
the relationship of transformational learning to transformational
leadership.
Citation: Grace, P., (January 31, 2018) "Enhancing Nurse Moral
Agency: The Leadership Promise of Doctor of
Nursing Practice Preparation" OJIN: The Online Journal of
Issues in Nursing Vol. 23, No. 1, Manuscript 4.
DOI: 10.3912/OJIN.Vol23No01Man04
May I stress the need for courageous, intelligent, and dedicated
leadership … leaders of sound integrity. Leaders
not in love with publicity, but in love with justice. Leaders not
in love with money, but in love with humanity.
Leaders who can subject their particular egos to the greatness of
the cause. (Dr. Martin Luther King, Jr. Challenge
of the new age (speech on the Prayer Pilgrimage for Freedom in
Washington, DC, May 17, 1956).
Dr. King’s plea was for leadership during a troubling era. He
hoped to change
prevailing societal attitudes toward African American citizens
of the United States
(U.S.). His words remain cogent today for other settings where
social justice and
human dignity are at risk. For healthcare professionals, it is
more critical than
ever that we remain mindful about the demands of ‘good’
patient care. So many
pressures exist (e.g., financial, political), and it can be
expedient to neglect or
even abandon professional goals and responsibilities (Bultas,
Ruebling, Breitbach,
& Carlson, 2016).
Additionally, nursing leaders both in academic and clinical
settings must often walk
a tightrope between the economic or reputational/visibility
demands of the
institution or school, and upholding professional goals (Gaylord
& Grace, 2018;
Jacob, 2009; Lown, 2007). All of these factors add to the
urgency of developing
nurse leaders who have the knowledge and skills to educate and
support point-of-
care nurses in their work and their ability to advocate for good
patient care at
whichever level is required: immediate, institutional, or even
policy. Skills of
communication and collaboration are also important. The
development of
collaborations for
quality, safe patient
care.
Goals of the Nursing Profession
Nursing goals serve
as the main
anchors for
understanding our
ethical
responsibilities...
These three
domains form an
ethical matrix upon
which to build
other essential
knowledge and
skills for advanced
nursing practice
and leadership.
...it is important to
confirm the DNP
role as one of
ethical
knowledgeable and skillful nurse leaders is necessary to
enhance interdisciplinary
collaborations for quality, safe patient care.
The purpose of this article is to present an argument that doctor
of nursing practice (DNP) graduates focused, as
they ostensibly are, on developing the expertise for good
practice, should first and foremost be prepared for
ethical leadership. As noted in the American Association of
Colleges of Nursing’s (AACN) document, The Essentials
of Doctoral Education for Advanced Nursing Practice (2006),
promulgating the DNP degree was important for
several reasons. Among the reasons was that “expansion of
scientific knowledge [is] required for safe nursing
practice [amid] growing concerns regarding the quality of
patient care delivery and outcomes. Practice demands
associated with an increasingly complex health care system
created a mandate for reassessing the education for
clinical practice for all health professionals, including nurses”
(p.4). Logically then, DNP curricula must be firmly
rooted in disciplinary knowledge; an understanding of
responsibilities of the nursing profession to individuals and
society; and a grasp of the role of interdisciplinary
collaboration in achieving quality healthcare.
The education of DNPs is an ethical undertaking because
advanced nursing practice is no less about facilitating
human health and well-being than are other nursing degrees. All
subsequent specialty knowledge and skills
needed for advanced practice should be built upon professional
goals and from the unifying perspective of nursing
as developed over time. The historically developed, central
unifying focus of nursing has been articulated as
“facilitating humanization, meaning, choice, quality of life, and
healing in living and dying” (Willis, Grace, & Roy,
2008, p. E28). Further, I propose that DNPs can, and ought to,
be developed as transformational leaders.
Transformational leadership is the ability to empower and
motivate others toward a common vision or common
goals, as explained shortly (Gaylord & Grace, 2018).
Ethical aims of nurses to provide humane, quality nursing care
anchored in the goals and mandates of our
profession should be front and center for all our initiatives
including, and most importantly, the development of
nurse educators and leaders (American Nurses Association
[ANA], 2010; ANA 2015; Willis et al., 2008). As a
reminder, these goals are “the protection, promotion and
restoration of health and well-being; the prevention of
illness and injury; and the alleviation of suffering” (ANA, 2015,
p. vii). The types of influences that can distract us
from maintaining a focus on ethical care are well documented in
the literature and seem to be increasing despite
the Institute of Medicine report (2010) outlining the nursing
role in assuring quality care goals (Jurchak et al.,
2017; Liaschenko & Peter, 2016; Miller, 2006; Starr, 2011).
Nursing goals (ANA 2010; ANA 2015; International Council of
Nursing, 2012)
serve as the main anchors for understanding our ethical
responsibilities and
constitute the connecting fibers of what could be called an
‘ethics matrix.’
However, understanding ethical responsibilities, while
necessary, is insufficient for
good practice. Knowledge of ethics ‘language’ and skills is also
critical. A grasp of
the nuances of ethical principles and their relationship to ethical
decision-making
and moral agency (i.e., acting for the good) are also important
as they provide a
common language for team decisions. A third essential facet is
the development of
personal characteristics that motivate one to take action and
persevere to
complete needed actions.
These three domains form an ethical matrix upon which to build
other essential
knowledge and skills for advanced nursing practice and
leadership. An additional
slate of knowledge and skills deemed essential for advanced
practice nursing
across settings is outlined in the AACN (2006) DNP
‘Essentials’ document. These
more specialized knowledge and skills, such as “Scientific
Underpinnings for
Practice” (Essential I) and “Organizational and Systems
Leadership…” (Essential
II), along with the other essentials, should be firmly rooted in
and emanate from
the three-domain ethical matrix to provide cohesion among
them. To state this
another way, the Doctor of Nursing Practice degree is first and
foremost a nursing
degree predicated on furthering nursing goals.
Those responsible for informing, revising, and/or developing
national program and
accreditation standards should consider building curricula
essentials upon this
ethical matrix as an integrating force. It is critical that emergent
DNP leaders in
the discipline are equipped with the knowledge, skills, and
motivation to transform
nursing practice and be instrumental in the development of
ethically aware,
motivated nurses. As DNP programs continue to proliferate, it is
important to
Being mindful of
limited resources
and justice in the
allocation of them
is also an ethical
issue.
transformative
leadership...
Contemporary Challenges to Good Nursing Practice
...[business]
principles can
sometimes collide
with human-
centered goals of
quality patient
healthcare.
The Promise of DNP Leadership
confirm the DNP role as one of ethical transformative
leadership regardless of
specialty practice area.
Challenges posed by contemporary nursing practice
environments require pro-
active, transformative leaders who can facilitate nurses’
confidence in their ability
to act for patients at the bedside, in the community, and in
influencing policy
making (Gaylord & Grace, 2018). There are knotty tensions
between the need for
cost-containment and profits in the U.S. healthcare system, and
the reasons that
healthcare professions and institutions exist. Stated another
way, healthcare
institutions, both inpatient and outpatient, exist because people
have a critical
need for them to assist in addressing a broad array of possible
healthcare needs,
not solely physical illness. The central unifying focus and
nursing goals provide the
broad perspective of nursing related to a focus on health and
well-being that
extends beyond illness.
When the provision of healthcare becomes primarily a business,
corporate goals of profits can overpower human
service goals, straining clinicians’ ability to primarily focus on
patients and their needs (Mechanic, 2006;
Rosenthal, 2017; Starr, 2011). Therefore, persons with unmet
healthcare needs depend on professionals and
institutions that expressly exist to fulfil these needs to actually
so do.
The current situation in the U.S. is that a substantial portion of
healthcare is
susceptible to business principles and these principles can
sometimes collide with
human-centered goals of quality patient healthcare. This is not
the same as saying
that cost-effectiveness in healthcare is unimportant; it is of
course a very
important consideration. Being mindful of limited resources and
justice in the
allocation of them is also an ethical issue. Even countries
without a profit incentive
in the provision of healthcare have to ensure cost-effectiveness
as a social justice
issue, as discussed in detail elsewhere (Grace, 2018; Johnson &
Stoskopf, 2010).
However, the United States, it has been argued, does not have
an integrated
healthcare ‘system;’ we do not have an overarching organizing
structure for
healthcare delivery from cradle-to-grave or from promoting and
maintaining
health to acute and chronic illness care. This situation in the
United States complicates the task of healthcare
professionals to further goals of good healthcare for individuals
and society (Chaufan, 2015; Elhauge, 2010;
Powers & Faden, 2006). What nursing can do as a profession is
to highlight and try to remedy injustices that
interfere with people living a ‘minimally decent life’ by
informing and influencing policy at the individual level, and
advocating for good patient care (Grace & Willis, 2008; Powers
& Faden, 2006).
Recent moves to make a DNP degree the entry level education
for advanced practice nursing, despite ongoing
critiques, seem unstoppable at this point (Dracup, Crononwett,
Melies, & Benner, 2005; Martsolf, Auerbach, Spetz,
Pearson, & Muchow, 2015; McLeod-Sordjan, 2014; Miller,
2008). A positive aspect of this change in advanced
practice preparation, with its emphasis on leadership, is the
promise the movement holds for good (i.e., ethical)
patient care and remediation of injustices for disadvantaged
populations (as related to receiving quality
healthcare, including primary care). Specifically,
transformational leadership skills and characteristics are needed
(Gaylord & Grace, 2018; Marshall & Broome; 2016).
Coherent and comprehensive preparation for doctoral (i.e.,
DNP) level practice requires both a rigorous curriculum
that prepares leaders who understand the nature of their role as
embedded within the profession and its goals,
and essential ingredients (i.e., knowledge and skills) for leading
others. Fundamental to this preparation is, as
noted earlier, an education rooted in an ethics matrix.
Another way to view this idea of building ethical competence is
to consider Rest’s (1982) four cognitive processes
that give rise to moral agency. From an extensive review of
interdisciplinary literature including that of the
cognitive sciences, Rest, a cognitive psychologist, theorized
four non-hierarchical, iterative, and interrelated
processes that take place in the mind of a person engaged in
moral decision-making with an intent to act
(implying both cognitive and affective components). These
processes are developmental in nature and can be
cultivated. Described in numerical order below for discussion
purposes, they are interactive processes and not
linear in nature.
First, Rest purports that there is an ‘interpretation of the
situation’ that includes ethical aspects (moral sensitivity).
Second, the person draws on prior knowledge to make sense of
the situation and decide what should be done
(moral reasoning). Third, a decision is made among competing
actions to determine which is the likely best action
given knowledge of the situation (motivation). Finally, one
envisions the steps to take and obstacles to overcome
A ‘Wake Up’ Call for the Profession of Nursing
Building these skills
should be an
imperative of the
ethics of the
profession.
A unifying core
understanding of
responsibilities of
the profession
coupled with
fluency in ethics
language and
techniques can
provide context,
stability, and
coherency...
Rooting All Curricula in an Ethics Matrix: An Ethical
Imperative
Expedient actions
are those based on
convenience,
efficiency, personal
ease, or fear of
(moral character) (Grace, 2018; Rest & Narvaez, 1993; Rest,
1982; 1983). Given the preparation that advances or
refines a DNP’s capacity to engage in moral agency,
development of a large cohort of ethically aware and skilled
leaders is possible. This cohort can in turn serve to develop the
ethical confidence of students, point-of-care
nurses, colleagues, and allied professionals.
If the doctor of nursing practice role is significantly one of
leadership, then DNPs must understand the unique
nature of their discipline and how nursing goals and
perspectives are both separate from, but overlapping with, the
goals of allied health professions. All healthcare professionals
(self-evidently) share ultimate goals to improve the
health of individuals and society, but they do so through the
different lenses of their professions, and profession-
specific aims. At times, these goals coalesce and require the
pertinent professions to seek collaborative input to
move an objective forward.
The essential set of characteristics, knowledge, and skills
needed for DNP ethical
leadership is captured both by Rest’s (1982) processes and the
previously
discussed ethics matrix, which is informed by Rest’s work. It is
critical to base the
development of leadership skills in nursing goals and
perspectives and attendant
obligations, the demands of ethical practice, and the motivation
to act to improve
practice. This set of knowledge and skills should serve as the
basis from which
other essential knowledge, as outlined in the AACN (2006)
‘Essentials’ document,
is built. Building these skills should be an imperative of the
ethics of the
profession.
There are two senses of nursing ethics discernable in the
literature. In the first sense, nursing ethics is the field of
inquiry that seeks to define such things as good nursing care;
the characteristics of good nurses; and how nurses
should act, to name a few. This process of inquiry draws on
moral philosophy and its’ derivative, professional
ethics, and includes tools of analysis and synthesis. From
nursing ethics, in this sense, we have developed codes
of ethics. In the second sense, nursing ethics is about evaluation
of nurses’ actions related to whether or not they
are intentionally focused on meeting the historically developed
goals of the nursing profession, as articulated
earlier.
As a simple example, we can ask whether a nurse is
intentionally focused on trying to provide a good for or limit
harms to a delirious patient in restraining him, or is he or she
restraining the patient because it is the most
expedient action (Grace, 2009). Ethics in this sense is the
capacity and intent to further the goals of the profession
and relies on both an understanding of the nature of the services
nursing provides and responsibilities to provide
these services in spite of obstacles. Thus, development of DNPs
as ethics leaders necessarily includes both the
nurturing and fortification of personal characteristics and
predispositions (sometimes referred to as virtues) and a
certain level of fluency in ethics language and associated skills
(e.g., situation analysis, mediation, collaboration).
A unifying core understanding of responsibilities of the
profession coupled with
fluency in ethics language and techniques can provide context,
stability, and
coherency for curricula, educational programs, and the support
of point-of-care
nurses. An underlying ethics matrix in which all other essential
domains of content
knowledge are rooted is critical (AACN, 2006). Together, the
proposed unifying
ethics matrix, insights from Rest’s (1982) processes of moral
action, and the
essential content domains and competencies of DNP programs
(AACN, 2006)
provide a strong basis for the development of transformational
leaders and
educators; those who can serve as ethics resources and build
ethical decision-
making and moral agency skills of students, peers, and allied
professionals.
All nurses’ actions are subject to appraisal based on the extent
to which they align with nursing goals and
perspectives, or not. We are responsible for furthering the best
interests of patients and for working toward a
healthy society (ANA, 2010; ANA, 2015; Grace, 2001; 2009;
Grace and Milliken, 2016). Thus, actions based on
expediency or other adverse influences that divert us from the
goal of patient interests are problematic.
Expedient actions are those based on convenience, efficiency,
personal ease, or
fear of censure rather than reactions to patient needs and
concerns. For example,
a terminally ill patient tells the nurse that she does not want any
more aggressive
treatment but is pressured by her family and the medical team to
‘continue to
fight.’ The patient’s perspective and wishes are being
disregarded but she is
reluctant to cause a ‘fuss’ about it for her family’s sake.
However, the nurse does
censure rather than
reactions to patient
needs and
concerns.
Nurse Confidence in Ethical Decision Making: DNP as
Transformational Leader
...even when
nurses have had
formal education in
ethics in
undergraduate
curricula,
confidence in
ethical decision-
making wanes over
time.
Nurses need
preparation to
exercise moral
agency and to
develop the skills
to collaborate with
others to articulate
the goals and
expected outcomes
of actions.
not help the patient to convey to the team her wishes because
she does not want
to alienate the family or physician with whom she must continue
to work.
Alternatively, this nurse may not have been adequately prepared
to advocate for patients or has lacked support in
advocating for patient good in the past, and perhaps has even
received sanctions. Other examples of expedient
actions include succumbing to pressures to complete tasks in a
timely manner, but in the process neglecting the
psychosocial or informational needs of a patient. Milliken
(2018) expands on these ideas in her recent article on
ethical awareness. In upcoming discussion, I will expand upon
the argument for the central role of nurse leaders
and educators, who will increasingly be prepared at the level of
practice doctorates, to support and empower nurse
moral agency using transformative leadership skills.
Literature increasingly describes the problem of moral distress
among all healthcare providers. Arguably, point of
care nurses in critical or acute care settings are at highest risk
for moral distress, because of their place in the
healthcare hierarchy, and because they are often the ones most
intimately aware of patient and family expressed
preferences and worries (Robinson et al., 2014). They also do
not always see themselves as having moral agency
(Jurchak et al., 2017).
There is an expanding body of knowledge about nurse
preparation for ethical
practice, and mounting evidence that, even when nurses have
had formal
education in ethics in undergraduate curricula, confidence in
ethical decision-
making wanes over time. This is especially true as the
complexity of the
environment increases (Jurchak et al., 2017).
The following all point to the need for cohesive, sustained,
multi-modal, ethics education and supports. First, there
is increasing literature about nurse moral distress, where nurses
experience a sense of powerlessness and disquiet
when unable to do what they perceive as ‘the right thing.’
Second, over ten years of unpublished data from
evaluations of a mandatory graduate ethics course (n = 447)
point to the efficacy of this type of educational
offering in building confidence in their moral agency (Grace,
2018). Third, a recent analysis of reasons that staff
nurses and advanced practice nurses (total n = 67) wanted to
join a year-long clinical ethics residency for nurses
(Jurchak et al., 2017) highlighted the desperate need for more
ethics education.
Nurses may feel that they are silenced (Malloy et al., 2009) or
perceive that their
concerns are not heard and considered (Peter, Lunardi, &
McFarlane, 2009; Taran,
2011). Thus, to sustain confidence in one’s moral agency and
capacity for ethical
decision-making in contemporary practice settings, more than
formal ethics
content knowledge is required. Traditional content, such as
history of biomedical
ethics; moral theory and principles; and analytic decision-
making techniques are
all valuable tools. Possession of these tools, while foundational
for moral agency,
is insufficient for consistent action to address problems (Grace
& Milliken, 2016;
Robinson et al., 2014). Nurses need preparation to exercise
moral agency
(Liaschenko & Peter, 2016) and to develop the skills to
collaborate with others to
articulate the goals and expected outcomes of actions.
Knowledgeable and ethically competent educators and
institutional leaders are important. Such leaders understand
the goals and perspectives of the profession as well as those of
allied professionals. They anchor their actions as
educators, mentors, resources and supporters in the goals and
perspectives of the profession. They employ the set
of tools described above to gather more information; gain
clarity about the issues; and to explore nuances of a
situation. Further, they have leadership skills that empower
others to develop their moral agency.
Transformational
leaders in nursing
understand
professional goals
and the ethical
warrants of nursing
practice...
Ethically Skilled Educators and Leaders: A Role for Doctors of
Nursing Practice
...it is incumbent
on the profession
to ensure that the
ongoing
development of the
DNP role reflects
the ethical
foundations of the
profession...
Transformational leadership skills are those most apt to develop
the confidence
and skills of others to achieve mutual goals (Marshall &
Broome, 2016; Gaylord &
Grace, 2018). Transformational leaders in nursing understand
professional goals
and the ethical warrants of nursing practice and are essential to
development of
nurses who are confident in their ethical skills and exercise
them on behalf of
good patient and healthcare. That is, transformational leaders
are those who can
develop and support the moral agency of nurses at all levels and
areas of practice.
Well-designed DNP programs will develop graduates who have
gained such transformational leadership skills and
the know how to continue to develop these abilities. Such
graduates will be both visionary about what is good
practice and have the ability to support it. From essential
domains of knowledge, they will understand the big
picture complexities of institutions; how to influence policy;
design supportive work environments; and the
necessities of good patient care. Using a sound understanding of
nursing ethics,they will move seamlessly among
these areas to educate and support others to develop moral
agency. I believe that good practice is equivalent to
ethical practice, as noted above, because good practice aims to
meet the goals of patient and societal health,
wellbeing, and the relief of suffering.
As highlighted in the AACN Essentials of Doctoral Education
for Advanced Nursing Practice (2006), doctoral
education in nursing has typically been of two main types,
research focused and practice focused. Prior to 2004, a
few universities offered practice doctorates in nursing as
distinct from research-intensive doctorates but not under
a uniform title, leading to confusion (AACN, 2004; Reid Ponte
& Nichols, 2013). The AACN Position Statement on
the Practice Doctorate in Nursing (2004), among other sources,
presented several reasons for rapidly developing
more DNP programs.
There is a growing perception of the need for more highly
skilled nurse leaders.
“Increased knowledge and skills [are becoming crucial] for
clinical and
administrative leadership across services and sites of healthcare
delivery” (AACN,
2004, p.2). This requires advanced preparation in areas not
typically covered in-
depth in current nursing master’s programs. There is an ongoing
faculty shortage
and DNPs could fill a gap (Brown & Crabtree, 2013). Moreover,
strong leadership
is needed in institutional and other clinical settings.
Master’s programs in nursing are already credit-intensive so
moving to the DNP as entry level for advanced
practice would better match program requirements, credits, and
time with the credential earned. These credentials
would also better match professional clinical doctorates in other
disciplines (e.g., pharmacy, dentistry,
physical/occupational therapy). Additionally, the DNP degree
provides an avenue of scholarship and leadership that
is not as acutely focused on empirical research as is
contemporary PhD study (Grace, Willis, Roy & Jones, 2016),
leaving room for development of sorely needed quality,
educational, and safety improvement projects.
“Preparation at the practice doctorate level includes advanced
preparation in nursing, based on nursing science,
and is at the highest level of nursing practice” (AACN, 2004, p.
3). The AACN statement also proposes that DNP
preparation will improve the image of nursing. Additionally,
PhD prepared nurse scholars are increasingly focused
on developing research trajectories and pursuing necessary
funding and resources. Such worthy aims can be all
consuming and lessen available time for teaching (Grace,
Willis, Roy & Jones, 2016) adding to the existing faculty
shortage; this represents an area for DNP prepared nurses to
make an important contribution.
Since 2004 DNP programs have proliferated and now far
outnumber programs offering a research focused PhD in
nursing. There are “303 DNP programs are currently enrolling
students at schools of nursing nationwide, and an
additional 124 new DNP programs are in the planning stages (58
post-baccalaureate and 66 post-master’s
programs)” (AACN, 2017, p. 3). Regardless of one’s
perspective about whether the move to the DNP as entry-level
advanced practice is a good thing for the profession, evidence
suggests that in the coming years there will be a
rapid increase in the number of those prepared at this level.
Thus, it is incumbent on the profession to ensure that
the ongoing development of the DNP role reflects the ethical
foundations of the profession, and historical as well
as contemporary reasons for its existence (Grace, 2001; 2018).
Transactional
leadership is,
arguably, the most
commonly seen in
healthcare settings
and is managerial
in nature.
Underlying,
implicitly or
explicitly, the
achievement of
each [DNP]
essential is ethical
expertise and
leadership
qualities.
Types of Leadership
Transformational
leadership is
aimed at change.
Relationship of Transformational Learning to Transformational
Leadership
There are eight aspects of knowledge and expertise considered
‘essential’ for DNP
graduates to possess in the current (first iteration) AACN
(2006) document.
Underlying, implicitly or explicitly, the achievement of each
essential is ethical
expertise and leadership qualities. However, how to achieve the
essentials is still
at least partially left to each school or college. In the following
section, I outline
what is known about leadership and leadership qualities and
propose that the
nursing profession should focus on developing ethically savvy,
transformative
leaders and that DNP programs are an appropriate medium for
this initiative.
Definitions of leadership vary according to author, style, and
purpose. A synthesized definition, useful for nursing,
is that leaders are effective in moving a group of people toward
a shared goal (Curtis, de Vries, & Sheerin, 2011;
Sullivan & Garland, 2010; Weihrich & Koontz, 2005). In a
review of studies on the psychology of leadership, it is
defined as “a process of social influence in which one person is
able to enlist the aid and support of others in the
accomplishment of a task or objective” (Chemers, 2001, p.
8580). Regarding the DNP role, I define leadership as
both the capacity to anticipate and envision good practice using
nursing goals, knowledge, and perspectives to
shape ultimate aims, and the use of knowledge, skills, and
expertise to motivate and empower moral agency in
others. Inherent in this definition is the possession of an ability
for critical questioning of personal motivations and
a willingness to critique care environments for the ability to
provide good care.
While leadership types and characteristics necessarily overlap,
two main types of
leadership are evident in contemporary literature. These are
‘transactional’ and
‘transformative.’ Transactional leadership is, arguably, the most
commonly
seen in healthcare settings and is managerial in nature. In
transactional
leadership there is a power differential, the leader can direct
actions based on a
sort of ‘bartering’ system (Gaylord & Grace, 2018). For
example, if you accomplish
the task I have given you in a timely fashion, I will give you a
bonus. Within
transactional leadership there are three sub-types (Howell &
Avolio, 1993). One
focuses on reward, one focuses on negative feedback, and the
third allows things
to proceed without much direction but, when things go wrong,
steps in to
remediate. Transactional leadership, then, tends to be task-
oriented rather than
innovative, prescient, and creative (Howell & Avolio, 1993;
Murphy, 2005).
Transformational leadership is aimed at change (Gaylord &
Grace, 2018). The
change may involve all actors including the leader and the
environment.
Transformational leaders “energize and motivate their followers
to achieve their
goals, share their visions, and embrace empowerment” (Grimm,
2010, p.76).
Transformational leadership is relationship based, and
empowers others to actions
of which they had not thought themselves capable (Bass &
Avolio, 1994).
Characteristics that are common in transformational leaders
include: magnetism; possessing internal locus of
control (i.e., see themselves as accountable for actions); offers
inspiration; cognitively curious, questioning
assumptions that are made and willing to be personally
challenged by others; and the capacity to focus
simultaneously both on the big picture and the needs of
followers. In so doing, these leaders act as mentors and
educators (Chemers, 2010; Cummings et al, 2010; Grimm,
2010). Among the goals of transformative leadership,
related to the nursing profession, is the development of moral
agency (i.e., motivation and ability to engage in
ethical actions on behalf of self and others) in nurses
(Blacksher, 2002; Liascheno & Peter, 2015).
The concept of transformative learning is also important to
develop transformational leaders. Those who aim to
empower others need to know how it is possible to help others
transform themselves into moral agents. Theories
of transformational leadership have developed within the
education discipline. Mezirow (2009) recognized this
transformational side effect of good education after his wife
returned to school to advance her education. Further
research led to the development of the concept of
transformational education; education that permits a person to
develop, as such:
Transformational learning is defined as the process by which we
transform problematic frames of
reference (mindsets, habits of mind, meaning perspectives) –
sets of assumption and expectation –
to make them more inclusive, discriminating, open reflective
and emotionally able to change
(Mezirow, 2009, p. 95).
Nursing ethics is at
the base of
everything we do
as nurses.
Conclusion
Author
References
One can deduce from this that the process of transformational
learning is complex, takes time, and may involve
some disorientation. Transformational education aims to
broaden perspectives and develop increasing comfort with
nuances and ‘grey areas.’ My colleagues and I discovered that
our carefully designed, multi-modal, eight hour per
month, 10-month long program, the Clinical Ethics Residency
for Nurses (CERN), had a transformational effect
upon our graduates, as evidenced in their discussions and
evaluation of the program (Grace, Robinson, Jurchak,
Zollfrank, & Lee, 2014; Robinson et al., 2014). They also
evidenced decreased moral distress (Robinson et al.,
2014) and increased their moral agency. Participants included
both point of care and advanced practice nurses.
End of program essays (analysis in process) also demonstrated
that the majority of participants experienced
personal and professional transformation.
Questions remain about what is needed to ensure that DNP
education prepares graduates to be transformational
leaders; how can transformational leadership be maintained; and
how can transformational leadership translate to
practice and education settings? A starting place to find answers
is to reinstitute the importance of an
understanding of the profession of nursing's origins, evolution,
and reasons for continued existence as a separate
entity from other healthcare professions. We have a unique and
central unifying focus on humanizing the
healthcare environment and facilitating “meaning, choice,
quality of life, and healing in living and dying” (Willis et
al., 2008, p. E28). Perhaps even more important is that we
continue to grow all of our education; curriculum
development; research; and practice initiatives or directives
from a nursing ethics matrix.
The rapid proliferation of DNP programs means that, in the
future, there could be a substantial cohort of persons
prepared to provide ethics leadership in whatever clinical,
institutional, or educational setting they are located. As
transformational leaders they will be sensitive to the ethical
nature of all nursing and healthcare practice and able
to communicate this to colleagues, students, and important
others as an essential starting point. They will
facilitate the development and moral agency of students, peers,
and interdisciplinary colleagues.
Anecdotally, many nursing faculty still view ‘ethics’ as an
esoteric topic that can be
taught only by those with philosophy or applied ethics
backgrounds. I believe this
is a fallacy. Nursing ethics is at the base of everything we do as
nurses. It is
helpful to have knowledge of ethics language and skills in
ethical decision-making,
but acquiring this knowledge is not as difficult as sometimes
supposed. It is
critically important that DNP curricula, along with the expected
knowledge and
skills of graduates, are developed with the professional moral
imperative for
individual and social good in mind. We need to situate
graduates so that they can
envision, refine, facilitate, and meet nursing goals from a
nursing perspective.
Pamela Grace, PhD, RN, FAAN
Email: [email protected]
Pamela Grace is an Associate Professor of Nursing and Ethics at
the William F. Connell School of Nursing Boston
College. She is an experienced critical care and advanced
practice nurse and educator. She holds a PhD is in
Philosophy (1998) with a concentration in medical ethics. She
has written and presented extensively on nursing
and healthcare ethics. Her book, Nursing Ethics and
Professional Responsibility in Advanced Practice, (2018) is
now in its 3rd edition and is used internationally as a guide to
ethics in advanced practice settings.
American Association of Colleges of Nursing. (2004). AACN
Position Statement on the practice doctorate in
nursing. Retrieved from
http://www.aacnnursing.org/DNP/Position-Statement
American Association of Colleges of Nursing. (2006). The
essentials of doctoral education for advanced nursing
practice. Retrieved from
http://www.aacnnursing.org/Portals/42/Publications/DNPEssenti
als.pdf
American Association of Colleges of Nursing. (2017). DNP fact
sheet. Retrieved from
http://www.aacnnursing.org/News-Information/Fact-
Sheets/DNP-Fact-Sheet
American Nurses Association. (2015). Code of ethics for nurses
with interpretive statements. Silver Springs, MD:
Author.
American Nurses Association (2010). Nursing’s Social Policy
Statement (3rd Ed.). Silver Springs, MD: Author.
Bass, B.M., & Avolio, B.J. (1994). Improving organizational
effectiveness through Transformational Leadership.
London, UK; SAGE Publications.
Blacksher, E. (2002). On being poor and feeling poor: Low
socioeconomic status and the moral self. Theoretical
Medicine and Bioethics, 23(6), 455-470.
Brown, M. A., & Crabtree, K. (2013). The development of
practice scholarship in DNP programs: A paradigm shift.
Journal of Professional Nursing, 29(6), 330–337.
doi:10.1016/j.profnurs.2013.08.003
Bultas, M.W., Ruebling, I., Breitbach, A. & Carlson, J. (2016).
Views of the United States healthcare system:
Findings from documentary analysis of an interprofessional
education course, Journal of Interprofessional Care,
30(6), 762-768, doi:10.1080/13561820.2016.1206860
Chaufan, C. (2015). Why do Americans still need single-payer
health care after major health reform? International
Journal of Health Services, 45(1), 149-160.
Chemers, M. M. (2001). The psychology of leadership. In N. J.
Smelser & P. B. Baltes (Eds), International
encyclopedia of the social and behavioral sciences (pp. 8580-
8583). Burlington, MA: Elsevier.
Cummings, G. G., MacGregor, T., Davey, M., Lee, H., Wong,
C. A., Lo, E., Muise, M., & Stafford, E. (2010).
Leadership styles and outcome patterns for the nursing
workforce and work environment: A systematic review.
International Journal of Nursing Studies, 47(3), 363-385.
doi:10.1016/j.ijnurstu.2009.08.006
Curtis, E. A., de Vries, J., & Sheerin, F. K. (2011). Developing
leadership in nursing: Exploring core factors.British
Journal of Nursing, 20(5), 306–309.
Dracup, K., Cronenwett, L., Meleis, A. I., & Benner, P. E.
(2005). Reflections on the doctorate of nursing practice.
Nursing Outlook, 53(4), 177-182
doi:10.1016/j.outlook.2005.06.003
Elhauge, E. (2010). Why we should care about health care
fragmentation and how to fix it.In E. Elhuage (Ed.) The
Fragmentation of U.S. Health Care: Causes and
Solution
s (pp. 1-20). New York, NY: Oxford University Press.
Gaylord, N., & Grace, P. J. (2018). Ethical leadership by
advanced practice nurses. In P.J. Grace (Ed.). Nursing
ethics and professional responsibility in advanced practice (3rd
Ed.) (pp. 153-170). Burlington, MA: Jones &
Bartlett Learning.
Grace, P.J. (2009). Nursing ethics and professional
responsibility in advanced practice (1st Ed). Burlington, MA:
Jones & Bartlett Learning.
Grace, P.J. (2018). Nursing ethics and professional
responsibility in advanced practice (3rd Ed.).Burlington, MA:
Jones & Bartlett Learning.
Grace, P. (2018). A review of answers to one of the tailored
questions on a series of anonymous end-of-course
evaluations (2007-2017) for a course titled: Ethical issues in
advanced practice nursing. Unpublished data, Boston
College Connell School of Nursing, Boston, MA.
Grace, P., & Milliken, A. (2016). Educating nurses for ethical
practice in contemporary health care environments.
Hastings Center Report, 46, S13–S17. doi:10.1002/hast.625
Grace, P. J., Robinson, E. M., Jurchak, M., Zollfrank, A. A., &
Lee, S. M. (2014). Clinical ethics residency for nurses:
An education model to decrease moral distress and strengthen
nurse retention in acute care. Journal of Nursing
Administration, 44(12), 640–646.
doi:10.1097/NNA.0000000000000141
Grace, P.J., Willis, D.G., Roy, C., & Jones, D.A. (2016).
Profession at the crossroads: A time of reckoning for
nursing. Nursing Outlook, 64(1):61-70.
doi:10.1016/j.outlook.2015.10.002
Grace, P. J., & Willis, D. G. (2012). Nursing responsibilities
and social justice: An analysis in support of disciplinary
goals. Nursing Outlook, 60(4), 198–207.
doi:10.1016/j.outlook.2011.11.004
Grace, P. J. (2001). Professional advocacy: Widening the scope
of accountability. Nursing Philosophy, 2(2), 151-
162.
Grimm, J. W. (2010). Effective leadership: Making the
difference. Journal of Emergency Nursing, 36(1), 74–77.
doi:10.1016/j.jen.2008.07.012
Howell, J. M. & Avolio, B. J. (1993). Transformational
leadership, transactional leadership, locus of control and
support for innovation: Key predictors of consolidated business-
unit performance. Journal of Applied Psychology,
78, 891-902.
Institute of Medicine. (2010). The future of nursing leading
change, advancing health. http://nacns.org/wp-
content/uploads/2016/11/5-IOM-Report.pdf
International Council of Nursing. (2012). The ICN code of
ethics for nurses. Geneva, Switzerland Author.
Jacob, M. (2009). On commodification and the governance of
academic research. Minerva, 47(4), 391–405.
doi:10.1007/s11024-009-9134-2.
Johnson, J. A. & Stoskopf, C. H. (2010). Comparative health
systems: Global perspectives. Burlington, MA:Jones &
Bartlett.
Jurchak, M., Grace, P. J., Lee, S., Willis, D. G., Zollfrank, A. &
Robinson, E. (2017). Developing abilities to navigate
through the grey zones in complex environments: Nurses
reasons for applying to a clinical ethics residency for
nurses. Journal of Nursing Scholarship, 49(4), 445-455.
doi:10.1111/jnu.12297.
Liaschenko, J., & Peter, E. (2016). Fostering nurses’ moral
agency and moral identity: The importance of moral
community. Hastings Center Report, 46, S18–S21.
doi:10.1002/hast.626
Lown, B. (2007). The commodification of health care.
Newsletter: Physicians for a National Health Program.
Retrieved from
http://www.pnhp.org/publications/the_commodification_of_heal
th_care.php?page=all
Malloy, D. C., Hadjistavropoulos, T., McCarthy, E. F., Evans,
R. J., Zakus, D. H., Park, I., … Williams, J. (2009).
Culture and organizational climate: Nurses’ insights into their
relationship with physicians. Nursing Ethics, 16(6),
719–733. doi:10.1177/0969733009342636
Marshall, E. S., & Broome, M. E. (2016). Transformational
leadership in nursing: From expert clinician to influential
leader. NY, New York: Springer Publishing Company.
Martsolf, G. R., Auerbach, D. I., Spetz, J., Pearson, M. L., &
Muchow, A. N. (2015). Doctor of nursing practice by
2015: An examination of nursing schools’ decisions to offer a
doctor of nursing practice degree. Nursing Outlook,
63(2), 219–226. doi:.1016/j.outlook.2015.01.002
McLeod-Sordjan, R. (2014). Transition to the DNP: Cultural
conflict of the clinical doctorate in America. Online
Journal of Cultural Competence in Nursing and Healthcare,
4(1), 17-28. doi:10.9730/ojccnh.org/v4n1a2
Mechanic, D. (2006). The truth about healthcare: Why reform is
not working in America. New Brunswick, NJ:
Rutgers,
Mezirow, J. (2009). An overview of transformative learning. In
K. Illeris (Ed.), Contemporary theories of learning:
Learning theorists…in their own words (pp. 90-105). New York,
NY: Routledge.
Milliken, A. (2018). Ethical awareness: What it is and why it
matters. OJIN: The Online Journal of Issues in
Nursing, 23(1), Manuscript 1.
doi:10.3912/OJIN.Vol23No01Man01
Miller, J. F. (2006). Opportunities and obstacles for good work
in nursing. Nursing Ethics, 13(5), 471–487.
doi:10.1191/0969733006nej894oa
Miller, J. E. (2008). The doctor of nursing practice: recognizing
a need or graying the line between doctor and
nurse? Medscape Journal of Medicine, 10(11), 253. Retrieved
from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2605113/?tool=
pmcentrez
Murphy, L. (2005). Transformational leadership: A cascading
chain reaction. Journal of Nursing Management,
13(2), 128–136.
Peter, E., Lunardi, V. L., & Macfarlane, A. (2004). Nursing
resistance as ethical action: Literature review. Journal of
Advanced Nursing, 46(4), 403-416.
Powers, M., & Faden, R. R. (2006). Social justice: The moral
foundations of public health and health policy.Oxford:
Oxford University Press.
Reid Ponte, P., & Nicholas, P. K. (2015). Addressing the
confusion related to DNS, DNSc, and DSN degrees, with
lessons for the nursing profession. Journal of Nursing
Scholarship, 47(4), 347–353. doi:10.1111/jnu.12148
Rest, J (1982). A psychologist looks at the teaching of ethics.
Hastings Center Report, 12(1), 29-36.
Rest, J. (1983). The major components of morality. In P.
Mussen (Ed.), Manual of child psychology (Vol – Cognitive
Psychology, pp. 556-629). New York, NY: Wiley.
Rest, J R. & Narváez, D. (eds.) (1994). Moral development in
the professions: Psychology and applied
ethics.Hillsdale, NJ: Lawrence Erlbaum Associates
Robinson, E. M., Lee, S. M., Zollfrank, A., Jurchak, M., Frost,
D., & Grace, P. (2014). Enhancing moral agency:
Clinical ethics residency for nurses. Hastings Center Report,
44(5), 12–20. doi:10.1002/hast.353
Rosenthal, E. (2017). An American sickness: How healthcare
became big business and how you can take it back.
New York, NY: Penguin.
Sullivan, E. J., & Garland, G. (2010). Practical leadership and
management in nursing. Harlow, UK: Pearson
Education.
Related Articles
Identifying and Addressing Ethical Issues with Use of
Electronic Health Records
Susan McBride, Mari Tietze, Catherine Robichaux, Liz Stokes
& Eileen Weber (January 31, 2018)
Ethical Nursing Care Versus Cost Containment: Considerations
to Enhance RN Practice
Paula Kelly, MScN, BScN, RN & Caroline Porr, PhD, MN, RN
(January 31, 2018)
Ethics Education in Nursing: Instruction for Future Generations
of Nurses
Katelin Hoskins, MSN, MBE, CRNP; Christine Grady, PhD,
RN; & Connie M. Ulrich, PhD, MSN, RN, FAAN (January
31, 2018)
In Search of a Moral Community
Lucia D. Wocial, PhD, RN, FAAN (January 31, 2018)
Ethical Awareness: What It Is and Why It Matters
Aimee Milliken, PhD, RN (January 31, 2018)
Starr, P. (2011). Remedy and reaction: The peculiar American
struggle over healthcare reform. New Haven, CT:
Yale University Press.
Taran, S. (2011). An examination of the factors contributing to
poor communication outside the physician-patient
sphere. McGill Journal of Medicine, 13(1), 86–91.
Weihrich, H., & Koontz, H. (2005). Management: A global
perspective (11th ed.). Singapore: McGraw-Hill.
Willis. D. G., Grace, P.J., & Roy, C. (2008). A central unifying
focus for the discipline: Facilitating humanization,
meaning, choice, quality of life, and healing in living and
dying. Advances in Nursing Science, 31(1), E28-E40.
© 2018 OJIN: The Online Journal of Issues in Nursing
Article published January 31, 2018
Follow Us on:
© 2017 The American Nurses Association, Inc. All Rights
Reserved
American Nurses Association - 8515 Georgia Avenue - Suite
400 - Silver Spring, MD 20910
ISSN: 1091-3734 | 1-800-274-4ANA | Copyright Policy |
Privacy Statement
© 2018. This work is published under NOCC (the “License”).
Notwithstanding
the ProQuest Terms and Conditions, you may use this content in
accordance
with the terms of the License.
1
2
Title That Fits on One Line
Your Name
Miami Regional University
DNP Entrance Essay
Date of Submission
DNP Entrance Essay
Intro here…
Need for DNP-Prepared Nurses in the Current Healthcare
System
Paragraph here…
Impact of the DNP Degree on your Career
Paragraph here…
Few Examples on Translation of Knowledge Acquired from
DNP in the Current Workplace
Paragraph here…
References
Grace, Pamela, PhD, R.N., F.A.A.N. (2018). Enhancing Nurse
Moral Agency: The Leadership Promise of Doctor of Nursing
Practice Preparation.
Online Journal of Issues in Nursing, 23(1), 1-11.
Moore, K. S., & Hart, A. M. (2021). Critical juncture: The
doctor of nursing practice and COVID-19.
Journal of the American Association of Nurse
Practitioners,
33(2), 97-99.

More Related Content

Similar to DNP Role as Ethical, Transformative Nurse Leaders

Reply 1Yanira Sanchez 4 postsRe Topic 5 DQ 1Leadershi.docx
Reply 1Yanira Sanchez 4 postsRe Topic 5 DQ 1Leadershi.docxReply 1Yanira Sanchez 4 postsRe Topic 5 DQ 1Leadershi.docx
Reply 1Yanira Sanchez 4 postsRe Topic 5 DQ 1Leadershi.docxcarlt4
 
Professional Paradigm
Professional ParadigmProfessional Paradigm
Professional ParadigmStarwindow
 
Aone nurse executive competencies
Aone nurse executive competenciesAone nurse executive competencies
Aone nurse executive competenciesKathyKoch10
 
Philadelphia College of Osteopathic MedicineINDP 100G 100M.docx
Philadelphia College of Osteopathic MedicineINDP 100G 100M.docxPhiladelphia College of Osteopathic MedicineINDP 100G 100M.docx
Philadelphia College of Osteopathic MedicineINDP 100G 100M.docxkarlhennesey
 
Collaborative healthcareleadership
Collaborative healthcareleadershipCollaborative healthcareleadership
Collaborative healthcareleadershipCarlo Favaretti
 
Approaches in the Practice Discussion.docx
Approaches in the Practice Discussion.docxApproaches in the Practice Discussion.docx
Approaches in the Practice Discussion.docx4934bk
 
Discharge Education Plan in a Heart Failure Clinic.docx
Discharge Education Plan in a Heart Failure Clinic.docxDischarge Education Plan in a Heart Failure Clinic.docx
Discharge Education Plan in a Heart Failure Clinic.docxwrite5
 
NUR 318 Leadership for Quality Care Patient Safety Nursing Leadership.pdf
NUR 318 Leadership for Quality Care Patient Safety Nursing Leadership.pdfNUR 318 Leadership for Quality Care Patient Safety Nursing Leadership.pdf
NUR 318 Leadership for Quality Care Patient Safety Nursing Leadership.pdfbkbk37
 
Developing Organizational Policies and Practices HW.pdf
Developing Organizational Policies and Practices HW.pdfDeveloping Organizational Policies and Practices HW.pdf
Developing Organizational Policies and Practices HW.pdfsdfghj21
 
Change in Healthcare Organizations.docx
Change in Healthcare Organizations.docxChange in Healthcare Organizations.docx
Change in Healthcare Organizations.docxstudywriters
 
Running head LEADERSHIP IN HEALTHCARE1LEADERSHIP IN HEALTH .docx
Running head LEADERSHIP IN HEALTHCARE1LEADERSHIP IN HEALTH .docxRunning head LEADERSHIP IN HEALTHCARE1LEADERSHIP IN HEALTH .docx
Running head LEADERSHIP IN HEALTHCARE1LEADERSHIP IN HEALTH .docxcowinhelen
 
Challenges in Everyday Leadership Capabilities Conversations with Senior Clin...
Challenges in Everyday Leadership Capabilities Conversations with Senior Clin...Challenges in Everyday Leadership Capabilities Conversations with Senior Clin...
Challenges in Everyday Leadership Capabilities Conversations with Senior Clin...ijtsrd
 
Importance of Nursing Theory Discussion HW.pdf
Importance of Nursing Theory Discussion HW.pdfImportance of Nursing Theory Discussion HW.pdf
Importance of Nursing Theory Discussion HW.pdfstudywriters
 
Applying Evidence-Based Practice Evidence for Effective Leader.docx
Applying Evidence-Based Practice Evidence for Effective Leader.docxApplying Evidence-Based Practice Evidence for Effective Leader.docx
Applying Evidence-Based Practice Evidence for Effective Leader.docxjustine1simpson78276
 
Emotionally intelligent healthcare
Emotionally intelligent healthcareEmotionally intelligent healthcare
Emotionally intelligent healthcareEndeavor Management
 

Similar to DNP Role as Ethical, Transformative Nurse Leaders (20)

Reply 1Yanira Sanchez 4 postsRe Topic 5 DQ 1Leadershi.docx
Reply 1Yanira Sanchez 4 postsRe Topic 5 DQ 1Leadershi.docxReply 1Yanira Sanchez 4 postsRe Topic 5 DQ 1Leadershi.docx
Reply 1Yanira Sanchez 4 postsRe Topic 5 DQ 1Leadershi.docx
 
Professional Paradigm
Professional ParadigmProfessional Paradigm
Professional Paradigm
 
Aone nurse executive competencies
Aone nurse executive competenciesAone nurse executive competencies
Aone nurse executive competencies
 
Philadelphia College of Osteopathic MedicineINDP 100G 100M.docx
Philadelphia College of Osteopathic MedicineINDP 100G 100M.docxPhiladelphia College of Osteopathic MedicineINDP 100G 100M.docx
Philadelphia College of Osteopathic MedicineINDP 100G 100M.docx
 
Leadership skills-for-nurses
Leadership skills-for-nursesLeadership skills-for-nurses
Leadership skills-for-nurses
 
Collaborative healthcareleadership
Collaborative healthcareleadershipCollaborative healthcareleadership
Collaborative healthcareleadership
 
Approaches in the Practice Discussion.docx
Approaches in the Practice Discussion.docxApproaches in the Practice Discussion.docx
Approaches in the Practice Discussion.docx
 
Discharge Education Plan in a Heart Failure Clinic.docx
Discharge Education Plan in a Heart Failure Clinic.docxDischarge Education Plan in a Heart Failure Clinic.docx
Discharge Education Plan in a Heart Failure Clinic.docx
 
NUR 318 Leadership for Quality Care Patient Safety Nursing Leadership.pdf
NUR 318 Leadership for Quality Care Patient Safety Nursing Leadership.pdfNUR 318 Leadership for Quality Care Patient Safety Nursing Leadership.pdf
NUR 318 Leadership for Quality Care Patient Safety Nursing Leadership.pdf
 
lamb2018.pdf
lamb2018.pdflamb2018.pdf
lamb2018.pdf
 
Developing Organizational Policies and Practices HW.pdf
Developing Organizational Policies and Practices HW.pdfDeveloping Organizational Policies and Practices HW.pdf
Developing Organizational Policies and Practices HW.pdf
 
Change in Healthcare Organizations.docx
Change in Healthcare Organizations.docxChange in Healthcare Organizations.docx
Change in Healthcare Organizations.docx
 
Sample Nursing School Essays
Sample Nursing School EssaysSample Nursing School Essays
Sample Nursing School Essays
 
Primary Health Care Essay Examples
Primary Health Care Essay ExamplesPrimary Health Care Essay Examples
Primary Health Care Essay Examples
 
Leadership development in medicine, nejm 2018
Leadership development in medicine, nejm 2018Leadership development in medicine, nejm 2018
Leadership development in medicine, nejm 2018
 
Running head LEADERSHIP IN HEALTHCARE1LEADERSHIP IN HEALTH .docx
Running head LEADERSHIP IN HEALTHCARE1LEADERSHIP IN HEALTH .docxRunning head LEADERSHIP IN HEALTHCARE1LEADERSHIP IN HEALTH .docx
Running head LEADERSHIP IN HEALTHCARE1LEADERSHIP IN HEALTH .docx
 
Challenges in Everyday Leadership Capabilities Conversations with Senior Clin...
Challenges in Everyday Leadership Capabilities Conversations with Senior Clin...Challenges in Everyday Leadership Capabilities Conversations with Senior Clin...
Challenges in Everyday Leadership Capabilities Conversations with Senior Clin...
 
Importance of Nursing Theory Discussion HW.pdf
Importance of Nursing Theory Discussion HW.pdfImportance of Nursing Theory Discussion HW.pdf
Importance of Nursing Theory Discussion HW.pdf
 
Applying Evidence-Based Practice Evidence for Effective Leader.docx
Applying Evidence-Based Practice Evidence for Effective Leader.docxApplying Evidence-Based Practice Evidence for Effective Leader.docx
Applying Evidence-Based Practice Evidence for Effective Leader.docx
 
Emotionally intelligent healthcare
Emotionally intelligent healthcareEmotionally intelligent healthcare
Emotionally intelligent healthcare
 

More from greg1eden90113

Analyze and describe how social media could influence each stage of .docx
Analyze and describe how social media could influence each stage of .docxAnalyze and describe how social media could influence each stage of .docx
Analyze and describe how social media could influence each stage of .docxgreg1eden90113
 
Analyze Delta Airlines, Inc public stock exchange NYSE- company’s pr.docx
Analyze Delta Airlines, Inc public stock exchange NYSE- company’s pr.docxAnalyze Delta Airlines, Inc public stock exchange NYSE- company’s pr.docx
Analyze Delta Airlines, Inc public stock exchange NYSE- company’s pr.docxgreg1eden90113
 
Analyze and Evaluate Human Performance TechnologyNow that you ha.docx
Analyze and Evaluate Human Performance TechnologyNow that you ha.docxAnalyze and Evaluate Human Performance TechnologyNow that you ha.docx
Analyze and Evaluate Human Performance TechnologyNow that you ha.docxgreg1eden90113
 
Analyze a popular culture reference (e.g., song, tv show, movie) o.docx
Analyze a popular culture reference (e.g., song, tv show, movie) o.docxAnalyze a popular culture reference (e.g., song, tv show, movie) o.docx
Analyze a popular culture reference (e.g., song, tv show, movie) o.docxgreg1eden90113
 
ANALYTICS PLAN TO REDUCE CUSTOMER CHURN AT YORE BLENDS Himabin.docx
ANALYTICS PLAN TO REDUCE CUSTOMER CHURN AT YORE BLENDS Himabin.docxANALYTICS PLAN TO REDUCE CUSTOMER CHURN AT YORE BLENDS Himabin.docx
ANALYTICS PLAN TO REDUCE CUSTOMER CHURN AT YORE BLENDS Himabin.docxgreg1eden90113
 
Analytics, Data Science, and Artificial Intelligence, 11th Editi.docx
Analytics, Data Science, and Artificial Intelligence, 11th Editi.docxAnalytics, Data Science, and Artificial Intelligence, 11th Editi.docx
Analytics, Data Science, and Artificial Intelligence, 11th Editi.docxgreg1eden90113
 
Analytical Essay One, due Sunday, February 24th at 1100 pmTopic.docx
Analytical Essay One, due Sunday, February 24th at 1100 pmTopic.docxAnalytical Essay One, due Sunday, February 24th at 1100 pmTopic.docx
Analytical Essay One, due Sunday, February 24th at 1100 pmTopic.docxgreg1eden90113
 
Analytical Essay Two, due Sunday, March 31st at 1100 pmTopi.docx
Analytical Essay Two, due Sunday, March 31st at 1100 pmTopi.docxAnalytical Essay Two, due Sunday, March 31st at 1100 pmTopi.docx
Analytical Essay Two, due Sunday, March 31st at 1100 pmTopi.docxgreg1eden90113
 
analytic 1000 word essay about the Matrix 1  Simple english .docx
analytic 1000 word essay about the Matrix 1  Simple english .docxanalytic 1000 word essay about the Matrix 1  Simple english .docx
analytic 1000 word essay about the Matrix 1  Simple english .docxgreg1eden90113
 
ANALYSIS PAPER GUIDELINES and FORMAT What is the problem or is.docx
ANALYSIS PAPER GUIDELINES and FORMAT What is the problem or is.docxANALYSIS PAPER GUIDELINES and FORMAT What is the problem or is.docx
ANALYSIS PAPER GUIDELINES and FORMAT What is the problem or is.docxgreg1eden90113
 
Analysis on the Demand of Top Talent Introduction in Big Dat.docx
Analysis on the Demand of Top Talent Introduction in Big Dat.docxAnalysis on the Demand of Top Talent Introduction in Big Dat.docx
Analysis on the Demand of Top Talent Introduction in Big Dat.docxgreg1eden90113
 
AnalysisLet s embrace ourdual identitiesCOMMUNITY COHE.docx
AnalysisLet s embrace ourdual identitiesCOMMUNITY COHE.docxAnalysisLet s embrace ourdual identitiesCOMMUNITY COHE.docx
AnalysisLet s embrace ourdual identitiesCOMMUNITY COHE.docxgreg1eden90113
 
Analysis of the Marketing outlook of Ferrari4MARK001W Mark.docx
Analysis of the Marketing outlook of Ferrari4MARK001W Mark.docxAnalysis of the Marketing outlook of Ferrari4MARK001W Mark.docx
Analysis of the Marketing outlook of Ferrari4MARK001W Mark.docxgreg1eden90113
 
Analysis of the Monetary Systems and International Finance with .docx
Analysis of the Monetary Systems and International Finance with .docxAnalysis of the Monetary Systems and International Finance with .docx
Analysis of the Monetary Systems and International Finance with .docxgreg1eden90113
 
Analysis of the Barrios Gomez, Agustin, et al. Mexico-US A New .docx
Analysis of the Barrios Gomez, Agustin, et al. Mexico-US A New .docxAnalysis of the Barrios Gomez, Agustin, et al. Mexico-US A New .docx
Analysis of the Barrios Gomez, Agustin, et al. Mexico-US A New .docxgreg1eden90113
 
Analysis of Literature ReviewFailure to develop key competencie.docx
Analysis of Literature ReviewFailure to develop key competencie.docxAnalysis of Literature ReviewFailure to develop key competencie.docx
Analysis of Literature ReviewFailure to develop key competencie.docxgreg1eden90113
 
Analysis Of Electronic Health Records System1C.docx
Analysis Of Electronic Health Records System1C.docxAnalysis Of Electronic Health Records System1C.docx
Analysis Of Electronic Health Records System1C.docxgreg1eden90113
 
Analysis of element, when we perform this skill we break up a whole .docx
Analysis of element, when we perform this skill we break up a whole .docxAnalysis of element, when we perform this skill we break up a whole .docx
Analysis of element, when we perform this skill we break up a whole .docxgreg1eden90113
 
Analysis of a Career in SurgeryStude.docx
Analysis of a Career in SurgeryStude.docxAnalysis of a Career in SurgeryStude.docx
Analysis of a Career in SurgeryStude.docxgreg1eden90113
 
Analysis Assignment -Major Artist ResearchInstructionsYo.docx
Analysis Assignment -Major Artist ResearchInstructionsYo.docxAnalysis Assignment -Major Artist ResearchInstructionsYo.docx
Analysis Assignment -Major Artist ResearchInstructionsYo.docxgreg1eden90113
 

More from greg1eden90113 (20)

Analyze and describe how social media could influence each stage of .docx
Analyze and describe how social media could influence each stage of .docxAnalyze and describe how social media could influence each stage of .docx
Analyze and describe how social media could influence each stage of .docx
 
Analyze Delta Airlines, Inc public stock exchange NYSE- company’s pr.docx
Analyze Delta Airlines, Inc public stock exchange NYSE- company’s pr.docxAnalyze Delta Airlines, Inc public stock exchange NYSE- company’s pr.docx
Analyze Delta Airlines, Inc public stock exchange NYSE- company’s pr.docx
 
Analyze and Evaluate Human Performance TechnologyNow that you ha.docx
Analyze and Evaluate Human Performance TechnologyNow that you ha.docxAnalyze and Evaluate Human Performance TechnologyNow that you ha.docx
Analyze and Evaluate Human Performance TechnologyNow that you ha.docx
 
Analyze a popular culture reference (e.g., song, tv show, movie) o.docx
Analyze a popular culture reference (e.g., song, tv show, movie) o.docxAnalyze a popular culture reference (e.g., song, tv show, movie) o.docx
Analyze a popular culture reference (e.g., song, tv show, movie) o.docx
 
ANALYTICS PLAN TO REDUCE CUSTOMER CHURN AT YORE BLENDS Himabin.docx
ANALYTICS PLAN TO REDUCE CUSTOMER CHURN AT YORE BLENDS Himabin.docxANALYTICS PLAN TO REDUCE CUSTOMER CHURN AT YORE BLENDS Himabin.docx
ANALYTICS PLAN TO REDUCE CUSTOMER CHURN AT YORE BLENDS Himabin.docx
 
Analytics, Data Science, and Artificial Intelligence, 11th Editi.docx
Analytics, Data Science, and Artificial Intelligence, 11th Editi.docxAnalytics, Data Science, and Artificial Intelligence, 11th Editi.docx
Analytics, Data Science, and Artificial Intelligence, 11th Editi.docx
 
Analytical Essay One, due Sunday, February 24th at 1100 pmTopic.docx
Analytical Essay One, due Sunday, February 24th at 1100 pmTopic.docxAnalytical Essay One, due Sunday, February 24th at 1100 pmTopic.docx
Analytical Essay One, due Sunday, February 24th at 1100 pmTopic.docx
 
Analytical Essay Two, due Sunday, March 31st at 1100 pmTopi.docx
Analytical Essay Two, due Sunday, March 31st at 1100 pmTopi.docxAnalytical Essay Two, due Sunday, March 31st at 1100 pmTopi.docx
Analytical Essay Two, due Sunday, March 31st at 1100 pmTopi.docx
 
analytic 1000 word essay about the Matrix 1  Simple english .docx
analytic 1000 word essay about the Matrix 1  Simple english .docxanalytic 1000 word essay about the Matrix 1  Simple english .docx
analytic 1000 word essay about the Matrix 1  Simple english .docx
 
ANALYSIS PAPER GUIDELINES and FORMAT What is the problem or is.docx
ANALYSIS PAPER GUIDELINES and FORMAT What is the problem or is.docxANALYSIS PAPER GUIDELINES and FORMAT What is the problem or is.docx
ANALYSIS PAPER GUIDELINES and FORMAT What is the problem or is.docx
 
Analysis on the Demand of Top Talent Introduction in Big Dat.docx
Analysis on the Demand of Top Talent Introduction in Big Dat.docxAnalysis on the Demand of Top Talent Introduction in Big Dat.docx
Analysis on the Demand of Top Talent Introduction in Big Dat.docx
 
AnalysisLet s embrace ourdual identitiesCOMMUNITY COHE.docx
AnalysisLet s embrace ourdual identitiesCOMMUNITY COHE.docxAnalysisLet s embrace ourdual identitiesCOMMUNITY COHE.docx
AnalysisLet s embrace ourdual identitiesCOMMUNITY COHE.docx
 
Analysis of the Marketing outlook of Ferrari4MARK001W Mark.docx
Analysis of the Marketing outlook of Ferrari4MARK001W Mark.docxAnalysis of the Marketing outlook of Ferrari4MARK001W Mark.docx
Analysis of the Marketing outlook of Ferrari4MARK001W Mark.docx
 
Analysis of the Monetary Systems and International Finance with .docx
Analysis of the Monetary Systems and International Finance with .docxAnalysis of the Monetary Systems and International Finance with .docx
Analysis of the Monetary Systems and International Finance with .docx
 
Analysis of the Barrios Gomez, Agustin, et al. Mexico-US A New .docx
Analysis of the Barrios Gomez, Agustin, et al. Mexico-US A New .docxAnalysis of the Barrios Gomez, Agustin, et al. Mexico-US A New .docx
Analysis of the Barrios Gomez, Agustin, et al. Mexico-US A New .docx
 
Analysis of Literature ReviewFailure to develop key competencie.docx
Analysis of Literature ReviewFailure to develop key competencie.docxAnalysis of Literature ReviewFailure to develop key competencie.docx
Analysis of Literature ReviewFailure to develop key competencie.docx
 
Analysis Of Electronic Health Records System1C.docx
Analysis Of Electronic Health Records System1C.docxAnalysis Of Electronic Health Records System1C.docx
Analysis Of Electronic Health Records System1C.docx
 
Analysis of element, when we perform this skill we break up a whole .docx
Analysis of element, when we perform this skill we break up a whole .docxAnalysis of element, when we perform this skill we break up a whole .docx
Analysis of element, when we perform this skill we break up a whole .docx
 
Analysis of a Career in SurgeryStude.docx
Analysis of a Career in SurgeryStude.docxAnalysis of a Career in SurgeryStude.docx
Analysis of a Career in SurgeryStude.docx
 
Analysis Assignment -Major Artist ResearchInstructionsYo.docx
Analysis Assignment -Major Artist ResearchInstructionsYo.docxAnalysis Assignment -Major Artist ResearchInstructionsYo.docx
Analysis Assignment -Major Artist ResearchInstructionsYo.docx
 

Recently uploaded

Class 11 Legal Studies Ch-1 Concept of State .pdf
Class 11 Legal Studies Ch-1 Concept of State .pdfClass 11 Legal Studies Ch-1 Concept of State .pdf
Class 11 Legal Studies Ch-1 Concept of State .pdfakmcokerachita
 
“Oh GOSH! Reflecting on Hackteria's Collaborative Practices in a Global Do-It...
“Oh GOSH! Reflecting on Hackteria's Collaborative Practices in a Global Do-It...“Oh GOSH! Reflecting on Hackteria's Collaborative Practices in a Global Do-It...
“Oh GOSH! Reflecting on Hackteria's Collaborative Practices in a Global Do-It...Marc Dusseiller Dusjagr
 
Mastering the Unannounced Regulatory Inspection
Mastering the Unannounced Regulatory InspectionMastering the Unannounced Regulatory Inspection
Mastering the Unannounced Regulatory InspectionSafetyChain Software
 
Proudly South Africa powerpoint Thorisha.pptx
Proudly South Africa powerpoint Thorisha.pptxProudly South Africa powerpoint Thorisha.pptx
Proudly South Africa powerpoint Thorisha.pptxthorishapillay1
 
Painted Grey Ware.pptx, PGW Culture of India
Painted Grey Ware.pptx, PGW Culture of IndiaPainted Grey Ware.pptx, PGW Culture of India
Painted Grey Ware.pptx, PGW Culture of IndiaVirag Sontakke
 
Hybridoma Technology ( Production , Purification , and Application )
Hybridoma Technology  ( Production , Purification , and Application  ) Hybridoma Technology  ( Production , Purification , and Application  )
Hybridoma Technology ( Production , Purification , and Application ) Sakshi Ghasle
 
Introduction to ArtificiaI Intelligence in Higher Education
Introduction to ArtificiaI Intelligence in Higher EducationIntroduction to ArtificiaI Intelligence in Higher Education
Introduction to ArtificiaI Intelligence in Higher Educationpboyjonauth
 
18-04-UA_REPORT_MEDIALITERAСY_INDEX-DM_23-1-final-eng.pdf
18-04-UA_REPORT_MEDIALITERAСY_INDEX-DM_23-1-final-eng.pdf18-04-UA_REPORT_MEDIALITERAСY_INDEX-DM_23-1-final-eng.pdf
18-04-UA_REPORT_MEDIALITERAСY_INDEX-DM_23-1-final-eng.pdfssuser54595a
 
SOCIAL AND HISTORICAL CONTEXT - LFTVD.pptx
SOCIAL AND HISTORICAL CONTEXT - LFTVD.pptxSOCIAL AND HISTORICAL CONTEXT - LFTVD.pptx
SOCIAL AND HISTORICAL CONTEXT - LFTVD.pptxiammrhaywood
 
call girls in Kamla Market (DELHI) 🔝 >༒9953330565🔝 genuine Escort Service 🔝✔️✔️
call girls in Kamla Market (DELHI) 🔝 >༒9953330565🔝 genuine Escort Service 🔝✔️✔️call girls in Kamla Market (DELHI) 🔝 >༒9953330565🔝 genuine Escort Service 🔝✔️✔️
call girls in Kamla Market (DELHI) 🔝 >༒9953330565🔝 genuine Escort Service 🔝✔️✔️9953056974 Low Rate Call Girls In Saket, Delhi NCR
 
Computed Fields and api Depends in the Odoo 17
Computed Fields and api Depends in the Odoo 17Computed Fields and api Depends in the Odoo 17
Computed Fields and api Depends in the Odoo 17Celine George
 
Organic Name Reactions for the students and aspirants of Chemistry12th.pptx
Organic Name Reactions  for the students and aspirants of Chemistry12th.pptxOrganic Name Reactions  for the students and aspirants of Chemistry12th.pptx
Organic Name Reactions for the students and aspirants of Chemistry12th.pptxVS Mahajan Coaching Centre
 
Blooming Together_ Growing a Community Garden Worksheet.docx
Blooming Together_ Growing a Community Garden Worksheet.docxBlooming Together_ Growing a Community Garden Worksheet.docx
Blooming Together_ Growing a Community Garden Worksheet.docxUnboundStockton
 
Final demo Grade 9 for demo Plan dessert.pptx
Final demo Grade 9 for demo Plan dessert.pptxFinal demo Grade 9 for demo Plan dessert.pptx
Final demo Grade 9 for demo Plan dessert.pptxAvyJaneVismanos
 
internship ppt on smartinternz platform as salesforce developer
internship ppt on smartinternz platform as salesforce developerinternship ppt on smartinternz platform as salesforce developer
internship ppt on smartinternz platform as salesforce developerunnathinaik
 
Incoming and Outgoing Shipments in 1 STEP Using Odoo 17
Incoming and Outgoing Shipments in 1 STEP Using Odoo 17Incoming and Outgoing Shipments in 1 STEP Using Odoo 17
Incoming and Outgoing Shipments in 1 STEP Using Odoo 17Celine George
 
Call Girls in Dwarka Mor Delhi Contact Us 9654467111
Call Girls in Dwarka Mor Delhi Contact Us 9654467111Call Girls in Dwarka Mor Delhi Contact Us 9654467111
Call Girls in Dwarka Mor Delhi Contact Us 9654467111Sapana Sha
 

Recently uploaded (20)

9953330565 Low Rate Call Girls In Rohini Delhi NCR
9953330565 Low Rate Call Girls In Rohini  Delhi NCR9953330565 Low Rate Call Girls In Rohini  Delhi NCR
9953330565 Low Rate Call Girls In Rohini Delhi NCR
 
Class 11 Legal Studies Ch-1 Concept of State .pdf
Class 11 Legal Studies Ch-1 Concept of State .pdfClass 11 Legal Studies Ch-1 Concept of State .pdf
Class 11 Legal Studies Ch-1 Concept of State .pdf
 
“Oh GOSH! Reflecting on Hackteria's Collaborative Practices in a Global Do-It...
“Oh GOSH! Reflecting on Hackteria's Collaborative Practices in a Global Do-It...“Oh GOSH! Reflecting on Hackteria's Collaborative Practices in a Global Do-It...
“Oh GOSH! Reflecting on Hackteria's Collaborative Practices in a Global Do-It...
 
Mastering the Unannounced Regulatory Inspection
Mastering the Unannounced Regulatory InspectionMastering the Unannounced Regulatory Inspection
Mastering the Unannounced Regulatory Inspection
 
Proudly South Africa powerpoint Thorisha.pptx
Proudly South Africa powerpoint Thorisha.pptxProudly South Africa powerpoint Thorisha.pptx
Proudly South Africa powerpoint Thorisha.pptx
 
Painted Grey Ware.pptx, PGW Culture of India
Painted Grey Ware.pptx, PGW Culture of IndiaPainted Grey Ware.pptx, PGW Culture of India
Painted Grey Ware.pptx, PGW Culture of India
 
Model Call Girl in Tilak Nagar Delhi reach out to us at 🔝9953056974🔝
Model Call Girl in Tilak Nagar Delhi reach out to us at 🔝9953056974🔝Model Call Girl in Tilak Nagar Delhi reach out to us at 🔝9953056974🔝
Model Call Girl in Tilak Nagar Delhi reach out to us at 🔝9953056974🔝
 
Hybridoma Technology ( Production , Purification , and Application )
Hybridoma Technology  ( Production , Purification , and Application  ) Hybridoma Technology  ( Production , Purification , and Application  )
Hybridoma Technology ( Production , Purification , and Application )
 
Introduction to ArtificiaI Intelligence in Higher Education
Introduction to ArtificiaI Intelligence in Higher EducationIntroduction to ArtificiaI Intelligence in Higher Education
Introduction to ArtificiaI Intelligence in Higher Education
 
18-04-UA_REPORT_MEDIALITERAСY_INDEX-DM_23-1-final-eng.pdf
18-04-UA_REPORT_MEDIALITERAСY_INDEX-DM_23-1-final-eng.pdf18-04-UA_REPORT_MEDIALITERAСY_INDEX-DM_23-1-final-eng.pdf
18-04-UA_REPORT_MEDIALITERAСY_INDEX-DM_23-1-final-eng.pdf
 
SOCIAL AND HISTORICAL CONTEXT - LFTVD.pptx
SOCIAL AND HISTORICAL CONTEXT - LFTVD.pptxSOCIAL AND HISTORICAL CONTEXT - LFTVD.pptx
SOCIAL AND HISTORICAL CONTEXT - LFTVD.pptx
 
call girls in Kamla Market (DELHI) 🔝 >༒9953330565🔝 genuine Escort Service 🔝✔️✔️
call girls in Kamla Market (DELHI) 🔝 >༒9953330565🔝 genuine Escort Service 🔝✔️✔️call girls in Kamla Market (DELHI) 🔝 >༒9953330565🔝 genuine Escort Service 🔝✔️✔️
call girls in Kamla Market (DELHI) 🔝 >༒9953330565🔝 genuine Escort Service 🔝✔️✔️
 
Computed Fields and api Depends in the Odoo 17
Computed Fields and api Depends in the Odoo 17Computed Fields and api Depends in the Odoo 17
Computed Fields and api Depends in the Odoo 17
 
Organic Name Reactions for the students and aspirants of Chemistry12th.pptx
Organic Name Reactions  for the students and aspirants of Chemistry12th.pptxOrganic Name Reactions  for the students and aspirants of Chemistry12th.pptx
Organic Name Reactions for the students and aspirants of Chemistry12th.pptx
 
TataKelola dan KamSiber Kecerdasan Buatan v022.pdf
TataKelola dan KamSiber Kecerdasan Buatan v022.pdfTataKelola dan KamSiber Kecerdasan Buatan v022.pdf
TataKelola dan KamSiber Kecerdasan Buatan v022.pdf
 
Blooming Together_ Growing a Community Garden Worksheet.docx
Blooming Together_ Growing a Community Garden Worksheet.docxBlooming Together_ Growing a Community Garden Worksheet.docx
Blooming Together_ Growing a Community Garden Worksheet.docx
 
Final demo Grade 9 for demo Plan dessert.pptx
Final demo Grade 9 for demo Plan dessert.pptxFinal demo Grade 9 for demo Plan dessert.pptx
Final demo Grade 9 for demo Plan dessert.pptx
 
internship ppt on smartinternz platform as salesforce developer
internship ppt on smartinternz platform as salesforce developerinternship ppt on smartinternz platform as salesforce developer
internship ppt on smartinternz platform as salesforce developer
 
Incoming and Outgoing Shipments in 1 STEP Using Odoo 17
Incoming and Outgoing Shipments in 1 STEP Using Odoo 17Incoming and Outgoing Shipments in 1 STEP Using Odoo 17
Incoming and Outgoing Shipments in 1 STEP Using Odoo 17
 
Call Girls in Dwarka Mor Delhi Contact Us 9654467111
Call Girls in Dwarka Mor Delhi Contact Us 9654467111Call Girls in Dwarka Mor Delhi Contact Us 9654467111
Call Girls in Dwarka Mor Delhi Contact Us 9654467111
 

DNP Role as Ethical, Transformative Nurse Leaders

  • 1. Enhancing Nurse Moral Agency: The Leadership Promise of Doctor of Nursing Practice Preparation ^ m d Abstract ...it is more critical than ever that we remain mindful about the demands of ‘good’ patient care. The development of knowledgeable and skillful nurse leaders is necessary to enhance interdisciplinary Pamela Grace, PhD, RN, FAAN An expansive and growing body of literature documents the problem of nurses’ moral distress when they are unable to carry out actions that they perceive to be in the best interests of patients. Further, nurse leaders and educators are not always well prepared to help nurses to develop moral
  • 2. agency. Moral agency is the ability to provide good care and overcome obstacles to good practice. One reason for the lack of preparation is that ethics education in academia, and in ongoing nurse education, has been inconsistent or has focused more on dilemmas than the ubiquitous everyday practice issues. The purpose of this article is to discuss goals of the nursing profession, contemporary challenges to good nursing practice, and leadership from those educated as Doctors of Nursing Practice (DNP). The author argues that the proliferation of (DNP) programs, focused as they are on leadership in practice settings, presents a unique opportunity to prepare nurse leaders who are, first and foremost, skilled and knowledgeable about the ethical content of everyday nursing practice. An ‘ethics matrix’ is described and proposed as an essential base for DNP education upon which all other knowledge is built, with specific discussion of types of leadership and the relationship of transformational learning to transformational leadership. Citation: Grace, P., (January 31, 2018) "Enhancing Nurse Moral Agency: The Leadership Promise of Doctor of Nursing Practice Preparation" OJIN: The Online Journal of Issues in Nursing Vol. 23, No. 1, Manuscript 4. DOI: 10.3912/OJIN.Vol23No01Man04 May I stress the need for courageous, intelligent, and dedicated leadership … leaders of sound integrity. Leaders not in love with publicity, but in love with justice. Leaders not in love with money, but in love with humanity. Leaders who can subject their particular egos to the greatness of the cause. (Dr. Martin Luther King, Jr. Challenge
  • 3. of the new age (speech on the Prayer Pilgrimage for Freedom in Washington, DC, May 17, 1956). Dr. King’s plea was for leadership during a troubling era. He hoped to change prevailing societal attitudes toward African American citizens of the United States (U.S.). His words remain cogent today for other settings where social justice and human dignity are at risk. For healthcare professionals, it is more critical than ever that we remain mindful about the demands of ‘good’ patient care. So many pressures exist (e.g., financial, political), and it can be expedient to neglect or even abandon professional goals and responsibilities (Bultas, Ruebling, Breitbach, & Carlson, 2016). Additionally, nursing leaders both in academic and clinical settings must often walk a tightrope between the economic or reputational/visibility demands of the institution or school, and upholding professional goals (Gaylord & Grace, 2018; Jacob, 2009; Lown, 2007). All of these factors add to the urgency of developing nurse leaders who have the knowledge and skills to educate and support point-of- care nurses in their work and their ability to advocate for good patient care at whichever level is required: immediate, institutional, or even policy. Skills of communication and collaboration are also important. The development of
  • 4. collaborations for quality, safe patient care. Goals of the Nursing Profession Nursing goals serve as the main anchors for understanding our ethical responsibilities... These three domains form an ethical matrix upon which to build other essential knowledge and skills for advanced nursing practice and leadership. ...it is important to confirm the DNP role as one of ethical knowledgeable and skillful nurse leaders is necessary to enhance interdisciplinary collaborations for quality, safe patient care. The purpose of this article is to present an argument that doctor of nursing practice (DNP) graduates focused, as
  • 5. they ostensibly are, on developing the expertise for good practice, should first and foremost be prepared for ethical leadership. As noted in the American Association of Colleges of Nursing’s (AACN) document, The Essentials of Doctoral Education for Advanced Nursing Practice (2006), promulgating the DNP degree was important for several reasons. Among the reasons was that “expansion of scientific knowledge [is] required for safe nursing practice [amid] growing concerns regarding the quality of patient care delivery and outcomes. Practice demands associated with an increasingly complex health care system created a mandate for reassessing the education for clinical practice for all health professionals, including nurses” (p.4). Logically then, DNP curricula must be firmly rooted in disciplinary knowledge; an understanding of responsibilities of the nursing profession to individuals and society; and a grasp of the role of interdisciplinary collaboration in achieving quality healthcare. The education of DNPs is an ethical undertaking because advanced nursing practice is no less about facilitating human health and well-being than are other nursing degrees. All subsequent specialty knowledge and skills needed for advanced practice should be built upon professional goals and from the unifying perspective of nursing as developed over time. The historically developed, central unifying focus of nursing has been articulated as “facilitating humanization, meaning, choice, quality of life, and healing in living and dying” (Willis, Grace, & Roy, 2008, p. E28). Further, I propose that DNPs can, and ought to, be developed as transformational leaders. Transformational leadership is the ability to empower and motivate others toward a common vision or common goals, as explained shortly (Gaylord & Grace, 2018). Ethical aims of nurses to provide humane, quality nursing care
  • 6. anchored in the goals and mandates of our profession should be front and center for all our initiatives including, and most importantly, the development of nurse educators and leaders (American Nurses Association [ANA], 2010; ANA 2015; Willis et al., 2008). As a reminder, these goals are “the protection, promotion and restoration of health and well-being; the prevention of illness and injury; and the alleviation of suffering” (ANA, 2015, p. vii). The types of influences that can distract us from maintaining a focus on ethical care are well documented in the literature and seem to be increasing despite the Institute of Medicine report (2010) outlining the nursing role in assuring quality care goals (Jurchak et al., 2017; Liaschenko & Peter, 2016; Miller, 2006; Starr, 2011). Nursing goals (ANA 2010; ANA 2015; International Council of Nursing, 2012) serve as the main anchors for understanding our ethical responsibilities and constitute the connecting fibers of what could be called an ‘ethics matrix.’ However, understanding ethical responsibilities, while necessary, is insufficient for good practice. Knowledge of ethics ‘language’ and skills is also critical. A grasp of the nuances of ethical principles and their relationship to ethical decision-making and moral agency (i.e., acting for the good) are also important as they provide a common language for team decisions. A third essential facet is the development of personal characteristics that motivate one to take action and persevere to complete needed actions. These three domains form an ethical matrix upon which to build
  • 7. other essential knowledge and skills for advanced nursing practice and leadership. An additional slate of knowledge and skills deemed essential for advanced practice nursing across settings is outlined in the AACN (2006) DNP ‘Essentials’ document. These more specialized knowledge and skills, such as “Scientific Underpinnings for Practice” (Essential I) and “Organizational and Systems Leadership…” (Essential II), along with the other essentials, should be firmly rooted in and emanate from the three-domain ethical matrix to provide cohesion among them. To state this another way, the Doctor of Nursing Practice degree is first and foremost a nursing degree predicated on furthering nursing goals. Those responsible for informing, revising, and/or developing national program and accreditation standards should consider building curricula essentials upon this ethical matrix as an integrating force. It is critical that emergent DNP leaders in the discipline are equipped with the knowledge, skills, and motivation to transform nursing practice and be instrumental in the development of ethically aware, motivated nurses. As DNP programs continue to proliferate, it is important to Being mindful of limited resources
  • 8. and justice in the allocation of them is also an ethical issue. transformative leadership... Contemporary Challenges to Good Nursing Practice ...[business] principles can sometimes collide with human- centered goals of quality patient healthcare. The Promise of DNP Leadership confirm the DNP role as one of ethical transformative leadership regardless of specialty practice area. Challenges posed by contemporary nursing practice environments require pro- active, transformative leaders who can facilitate nurses’ confidence in their ability to act for patients at the bedside, in the community, and in influencing policy making (Gaylord & Grace, 2018). There are knotty tensions between the need for cost-containment and profits in the U.S. healthcare system, and the reasons that healthcare professions and institutions exist. Stated another way, healthcare
  • 9. institutions, both inpatient and outpatient, exist because people have a critical need for them to assist in addressing a broad array of possible healthcare needs, not solely physical illness. The central unifying focus and nursing goals provide the broad perspective of nursing related to a focus on health and well-being that extends beyond illness. When the provision of healthcare becomes primarily a business, corporate goals of profits can overpower human service goals, straining clinicians’ ability to primarily focus on patients and their needs (Mechanic, 2006; Rosenthal, 2017; Starr, 2011). Therefore, persons with unmet healthcare needs depend on professionals and institutions that expressly exist to fulfil these needs to actually so do. The current situation in the U.S. is that a substantial portion of healthcare is susceptible to business principles and these principles can sometimes collide with human-centered goals of quality patient healthcare. This is not the same as saying that cost-effectiveness in healthcare is unimportant; it is of course a very important consideration. Being mindful of limited resources and justice in the allocation of them is also an ethical issue. Even countries without a profit incentive in the provision of healthcare have to ensure cost-effectiveness as a social justice issue, as discussed in detail elsewhere (Grace, 2018; Johnson & Stoskopf, 2010). However, the United States, it has been argued, does not have
  • 10. an integrated healthcare ‘system;’ we do not have an overarching organizing structure for healthcare delivery from cradle-to-grave or from promoting and maintaining health to acute and chronic illness care. This situation in the United States complicates the task of healthcare professionals to further goals of good healthcare for individuals and society (Chaufan, 2015; Elhauge, 2010; Powers & Faden, 2006). What nursing can do as a profession is to highlight and try to remedy injustices that interfere with people living a ‘minimally decent life’ by informing and influencing policy at the individual level, and advocating for good patient care (Grace & Willis, 2008; Powers & Faden, 2006). Recent moves to make a DNP degree the entry level education for advanced practice nursing, despite ongoing critiques, seem unstoppable at this point (Dracup, Crononwett, Melies, & Benner, 2005; Martsolf, Auerbach, Spetz, Pearson, & Muchow, 2015; McLeod-Sordjan, 2014; Miller, 2008). A positive aspect of this change in advanced practice preparation, with its emphasis on leadership, is the promise the movement holds for good (i.e., ethical) patient care and remediation of injustices for disadvantaged populations (as related to receiving quality healthcare, including primary care). Specifically, transformational leadership skills and characteristics are needed (Gaylord & Grace, 2018; Marshall & Broome; 2016). Coherent and comprehensive preparation for doctoral (i.e., DNP) level practice requires both a rigorous curriculum that prepares leaders who understand the nature of their role as embedded within the profession and its goals, and essential ingredients (i.e., knowledge and skills) for leading
  • 11. others. Fundamental to this preparation is, as noted earlier, an education rooted in an ethics matrix. Another way to view this idea of building ethical competence is to consider Rest’s (1982) four cognitive processes that give rise to moral agency. From an extensive review of interdisciplinary literature including that of the cognitive sciences, Rest, a cognitive psychologist, theorized four non-hierarchical, iterative, and interrelated processes that take place in the mind of a person engaged in moral decision-making with an intent to act (implying both cognitive and affective components). These processes are developmental in nature and can be cultivated. Described in numerical order below for discussion purposes, they are interactive processes and not linear in nature. First, Rest purports that there is an ‘interpretation of the situation’ that includes ethical aspects (moral sensitivity). Second, the person draws on prior knowledge to make sense of the situation and decide what should be done (moral reasoning). Third, a decision is made among competing actions to determine which is the likely best action given knowledge of the situation (motivation). Finally, one envisions the steps to take and obstacles to overcome A ‘Wake Up’ Call for the Profession of Nursing Building these skills should be an imperative of the ethics of the profession.
  • 12. A unifying core understanding of responsibilities of the profession coupled with fluency in ethics language and techniques can provide context, stability, and coherency... Rooting All Curricula in an Ethics Matrix: An Ethical Imperative Expedient actions are those based on convenience, efficiency, personal ease, or fear of (moral character) (Grace, 2018; Rest & Narvaez, 1993; Rest, 1982; 1983). Given the preparation that advances or refines a DNP’s capacity to engage in moral agency, development of a large cohort of ethically aware and skilled leaders is possible. This cohort can in turn serve to develop the ethical confidence of students, point-of-care nurses, colleagues, and allied professionals. If the doctor of nursing practice role is significantly one of leadership, then DNPs must understand the unique nature of their discipline and how nursing goals and perspectives are both separate from, but overlapping with, the goals of allied health professions. All healthcare professionals (self-evidently) share ultimate goals to improve the health of individuals and society, but they do so through the
  • 13. different lenses of their professions, and profession- specific aims. At times, these goals coalesce and require the pertinent professions to seek collaborative input to move an objective forward. The essential set of characteristics, knowledge, and skills needed for DNP ethical leadership is captured both by Rest’s (1982) processes and the previously discussed ethics matrix, which is informed by Rest’s work. It is critical to base the development of leadership skills in nursing goals and perspectives and attendant obligations, the demands of ethical practice, and the motivation to act to improve practice. This set of knowledge and skills should serve as the basis from which other essential knowledge, as outlined in the AACN (2006) ‘Essentials’ document, is built. Building these skills should be an imperative of the ethics of the profession. There are two senses of nursing ethics discernable in the literature. In the first sense, nursing ethics is the field of inquiry that seeks to define such things as good nursing care; the characteristics of good nurses; and how nurses should act, to name a few. This process of inquiry draws on moral philosophy and its’ derivative, professional ethics, and includes tools of analysis and synthesis. From nursing ethics, in this sense, we have developed codes of ethics. In the second sense, nursing ethics is about evaluation of nurses’ actions related to whether or not they are intentionally focused on meeting the historically developed goals of the nursing profession, as articulated earlier.
  • 14. As a simple example, we can ask whether a nurse is intentionally focused on trying to provide a good for or limit harms to a delirious patient in restraining him, or is he or she restraining the patient because it is the most expedient action (Grace, 2009). Ethics in this sense is the capacity and intent to further the goals of the profession and relies on both an understanding of the nature of the services nursing provides and responsibilities to provide these services in spite of obstacles. Thus, development of DNPs as ethics leaders necessarily includes both the nurturing and fortification of personal characteristics and predispositions (sometimes referred to as virtues) and a certain level of fluency in ethics language and associated skills (e.g., situation analysis, mediation, collaboration). A unifying core understanding of responsibilities of the profession coupled with fluency in ethics language and techniques can provide context, stability, and coherency for curricula, educational programs, and the support of point-of-care nurses. An underlying ethics matrix in which all other essential domains of content knowledge are rooted is critical (AACN, 2006). Together, the proposed unifying ethics matrix, insights from Rest’s (1982) processes of moral action, and the essential content domains and competencies of DNP programs (AACN, 2006) provide a strong basis for the development of transformational leaders and educators; those who can serve as ethics resources and build ethical decision- making and moral agency skills of students, peers, and allied professionals.
  • 15. All nurses’ actions are subject to appraisal based on the extent to which they align with nursing goals and perspectives, or not. We are responsible for furthering the best interests of patients and for working toward a healthy society (ANA, 2010; ANA, 2015; Grace, 2001; 2009; Grace and Milliken, 2016). Thus, actions based on expediency or other adverse influences that divert us from the goal of patient interests are problematic. Expedient actions are those based on convenience, efficiency, personal ease, or fear of censure rather than reactions to patient needs and concerns. For example, a terminally ill patient tells the nurse that she does not want any more aggressive treatment but is pressured by her family and the medical team to ‘continue to fight.’ The patient’s perspective and wishes are being disregarded but she is reluctant to cause a ‘fuss’ about it for her family’s sake. However, the nurse does censure rather than reactions to patient needs and concerns. Nurse Confidence in Ethical Decision Making: DNP as Transformational Leader ...even when nurses have had formal education in
  • 16. ethics in undergraduate curricula, confidence in ethical decision- making wanes over time. Nurses need preparation to exercise moral agency and to develop the skills to collaborate with others to articulate the goals and expected outcomes of actions. not help the patient to convey to the team her wishes because she does not want to alienate the family or physician with whom she must continue to work. Alternatively, this nurse may not have been adequately prepared to advocate for patients or has lacked support in advocating for patient good in the past, and perhaps has even received sanctions. Other examples of expedient actions include succumbing to pressures to complete tasks in a timely manner, but in the process neglecting the psychosocial or informational needs of a patient. Milliken (2018) expands on these ideas in her recent article on ethical awareness. In upcoming discussion, I will expand upon the argument for the central role of nurse leaders and educators, who will increasingly be prepared at the level of practice doctorates, to support and empower nurse
  • 17. moral agency using transformative leadership skills. Literature increasingly describes the problem of moral distress among all healthcare providers. Arguably, point of care nurses in critical or acute care settings are at highest risk for moral distress, because of their place in the healthcare hierarchy, and because they are often the ones most intimately aware of patient and family expressed preferences and worries (Robinson et al., 2014). They also do not always see themselves as having moral agency (Jurchak et al., 2017). There is an expanding body of knowledge about nurse preparation for ethical practice, and mounting evidence that, even when nurses have had formal education in ethics in undergraduate curricula, confidence in ethical decision- making wanes over time. This is especially true as the complexity of the environment increases (Jurchak et al., 2017). The following all point to the need for cohesive, sustained, multi-modal, ethics education and supports. First, there is increasing literature about nurse moral distress, where nurses experience a sense of powerlessness and disquiet when unable to do what they perceive as ‘the right thing.’ Second, over ten years of unpublished data from evaluations of a mandatory graduate ethics course (n = 447) point to the efficacy of this type of educational offering in building confidence in their moral agency (Grace, 2018). Third, a recent analysis of reasons that staff nurses and advanced practice nurses (total n = 67) wanted to join a year-long clinical ethics residency for nurses (Jurchak et al., 2017) highlighted the desperate need for more ethics education.
  • 18. Nurses may feel that they are silenced (Malloy et al., 2009) or perceive that their concerns are not heard and considered (Peter, Lunardi, & McFarlane, 2009; Taran, 2011). Thus, to sustain confidence in one’s moral agency and capacity for ethical decision-making in contemporary practice settings, more than formal ethics content knowledge is required. Traditional content, such as history of biomedical ethics; moral theory and principles; and analytic decision- making techniques are all valuable tools. Possession of these tools, while foundational for moral agency, is insufficient for consistent action to address problems (Grace & Milliken, 2016; Robinson et al., 2014). Nurses need preparation to exercise moral agency (Liaschenko & Peter, 2016) and to develop the skills to collaborate with others to articulate the goals and expected outcomes of actions. Knowledgeable and ethically competent educators and institutional leaders are important. Such leaders understand the goals and perspectives of the profession as well as those of allied professionals. They anchor their actions as educators, mentors, resources and supporters in the goals and perspectives of the profession. They employ the set of tools described above to gather more information; gain clarity about the issues; and to explore nuances of a situation. Further, they have leadership skills that empower others to develop their moral agency.
  • 19. Transformational leaders in nursing understand professional goals and the ethical warrants of nursing practice... Ethically Skilled Educators and Leaders: A Role for Doctors of Nursing Practice ...it is incumbent on the profession to ensure that the ongoing development of the DNP role reflects the ethical foundations of the profession... Transformational leadership skills are those most apt to develop the confidence and skills of others to achieve mutual goals (Marshall & Broome, 2016; Gaylord & Grace, 2018). Transformational leaders in nursing understand professional goals and the ethical warrants of nursing practice and are essential to development of nurses who are confident in their ethical skills and exercise them on behalf of good patient and healthcare. That is, transformational leaders are those who can develop and support the moral agency of nurses at all levels and areas of practice.
  • 20. Well-designed DNP programs will develop graduates who have gained such transformational leadership skills and the know how to continue to develop these abilities. Such graduates will be both visionary about what is good practice and have the ability to support it. From essential domains of knowledge, they will understand the big picture complexities of institutions; how to influence policy; design supportive work environments; and the necessities of good patient care. Using a sound understanding of nursing ethics,they will move seamlessly among these areas to educate and support others to develop moral agency. I believe that good practice is equivalent to ethical practice, as noted above, because good practice aims to meet the goals of patient and societal health, wellbeing, and the relief of suffering. As highlighted in the AACN Essentials of Doctoral Education for Advanced Nursing Practice (2006), doctoral education in nursing has typically been of two main types, research focused and practice focused. Prior to 2004, a few universities offered practice doctorates in nursing as distinct from research-intensive doctorates but not under a uniform title, leading to confusion (AACN, 2004; Reid Ponte & Nichols, 2013). The AACN Position Statement on the Practice Doctorate in Nursing (2004), among other sources, presented several reasons for rapidly developing more DNP programs. There is a growing perception of the need for more highly skilled nurse leaders. “Increased knowledge and skills [are becoming crucial] for clinical and administrative leadership across services and sites of healthcare delivery” (AACN, 2004, p.2). This requires advanced preparation in areas not typically covered in-
  • 21. depth in current nursing master’s programs. There is an ongoing faculty shortage and DNPs could fill a gap (Brown & Crabtree, 2013). Moreover, strong leadership is needed in institutional and other clinical settings. Master’s programs in nursing are already credit-intensive so moving to the DNP as entry level for advanced practice would better match program requirements, credits, and time with the credential earned. These credentials would also better match professional clinical doctorates in other disciplines (e.g., pharmacy, dentistry, physical/occupational therapy). Additionally, the DNP degree provides an avenue of scholarship and leadership that is not as acutely focused on empirical research as is contemporary PhD study (Grace, Willis, Roy & Jones, 2016), leaving room for development of sorely needed quality, educational, and safety improvement projects. “Preparation at the practice doctorate level includes advanced preparation in nursing, based on nursing science, and is at the highest level of nursing practice” (AACN, 2004, p. 3). The AACN statement also proposes that DNP preparation will improve the image of nursing. Additionally, PhD prepared nurse scholars are increasingly focused on developing research trajectories and pursuing necessary funding and resources. Such worthy aims can be all consuming and lessen available time for teaching (Grace, Willis, Roy & Jones, 2016) adding to the existing faculty shortage; this represents an area for DNP prepared nurses to make an important contribution. Since 2004 DNP programs have proliferated and now far outnumber programs offering a research focused PhD in nursing. There are “303 DNP programs are currently enrolling students at schools of nursing nationwide, and an
  • 22. additional 124 new DNP programs are in the planning stages (58 post-baccalaureate and 66 post-master’s programs)” (AACN, 2017, p. 3). Regardless of one’s perspective about whether the move to the DNP as entry-level advanced practice is a good thing for the profession, evidence suggests that in the coming years there will be a rapid increase in the number of those prepared at this level. Thus, it is incumbent on the profession to ensure that the ongoing development of the DNP role reflects the ethical foundations of the profession, and historical as well as contemporary reasons for its existence (Grace, 2001; 2018). Transactional leadership is, arguably, the most commonly seen in healthcare settings and is managerial in nature. Underlying, implicitly or explicitly, the achievement of each [DNP] essential is ethical expertise and leadership qualities. Types of Leadership Transformational leadership is
  • 23. aimed at change. Relationship of Transformational Learning to Transformational Leadership There are eight aspects of knowledge and expertise considered ‘essential’ for DNP graduates to possess in the current (first iteration) AACN (2006) document. Underlying, implicitly or explicitly, the achievement of each essential is ethical expertise and leadership qualities. However, how to achieve the essentials is still at least partially left to each school or college. In the following section, I outline what is known about leadership and leadership qualities and propose that the nursing profession should focus on developing ethically savvy, transformative leaders and that DNP programs are an appropriate medium for this initiative. Definitions of leadership vary according to author, style, and purpose. A synthesized definition, useful for nursing, is that leaders are effective in moving a group of people toward a shared goal (Curtis, de Vries, & Sheerin, 2011; Sullivan & Garland, 2010; Weihrich & Koontz, 2005). In a review of studies on the psychology of leadership, it is defined as “a process of social influence in which one person is able to enlist the aid and support of others in the accomplishment of a task or objective” (Chemers, 2001, p. 8580). Regarding the DNP role, I define leadership as both the capacity to anticipate and envision good practice using nursing goals, knowledge, and perspectives to shape ultimate aims, and the use of knowledge, skills, and expertise to motivate and empower moral agency in
  • 24. others. Inherent in this definition is the possession of an ability for critical questioning of personal motivations and a willingness to critique care environments for the ability to provide good care. While leadership types and characteristics necessarily overlap, two main types of leadership are evident in contemporary literature. These are ‘transactional’ and ‘transformative.’ Transactional leadership is, arguably, the most commonly seen in healthcare settings and is managerial in nature. In transactional leadership there is a power differential, the leader can direct actions based on a sort of ‘bartering’ system (Gaylord & Grace, 2018). For example, if you accomplish the task I have given you in a timely fashion, I will give you a bonus. Within transactional leadership there are three sub-types (Howell & Avolio, 1993). One focuses on reward, one focuses on negative feedback, and the third allows things to proceed without much direction but, when things go wrong, steps in to remediate. Transactional leadership, then, tends to be task- oriented rather than innovative, prescient, and creative (Howell & Avolio, 1993; Murphy, 2005). Transformational leadership is aimed at change (Gaylord & Grace, 2018). The change may involve all actors including the leader and the environment. Transformational leaders “energize and motivate their followers to achieve their
  • 25. goals, share their visions, and embrace empowerment” (Grimm, 2010, p.76). Transformational leadership is relationship based, and empowers others to actions of which they had not thought themselves capable (Bass & Avolio, 1994). Characteristics that are common in transformational leaders include: magnetism; possessing internal locus of control (i.e., see themselves as accountable for actions); offers inspiration; cognitively curious, questioning assumptions that are made and willing to be personally challenged by others; and the capacity to focus simultaneously both on the big picture and the needs of followers. In so doing, these leaders act as mentors and educators (Chemers, 2010; Cummings et al, 2010; Grimm, 2010). Among the goals of transformative leadership, related to the nursing profession, is the development of moral agency (i.e., motivation and ability to engage in ethical actions on behalf of self and others) in nurses (Blacksher, 2002; Liascheno & Peter, 2015). The concept of transformative learning is also important to develop transformational leaders. Those who aim to empower others need to know how it is possible to help others transform themselves into moral agents. Theories of transformational leadership have developed within the education discipline. Mezirow (2009) recognized this transformational side effect of good education after his wife returned to school to advance her education. Further research led to the development of the concept of transformational education; education that permits a person to develop, as such: Transformational learning is defined as the process by which we transform problematic frames of
  • 26. reference (mindsets, habits of mind, meaning perspectives) – sets of assumption and expectation – to make them more inclusive, discriminating, open reflective and emotionally able to change (Mezirow, 2009, p. 95). Nursing ethics is at the base of everything we do as nurses. Conclusion Author References One can deduce from this that the process of transformational learning is complex, takes time, and may involve some disorientation. Transformational education aims to broaden perspectives and develop increasing comfort with nuances and ‘grey areas.’ My colleagues and I discovered that our carefully designed, multi-modal, eight hour per month, 10-month long program, the Clinical Ethics Residency for Nurses (CERN), had a transformational effect upon our graduates, as evidenced in their discussions and evaluation of the program (Grace, Robinson, Jurchak, Zollfrank, & Lee, 2014; Robinson et al., 2014). They also evidenced decreased moral distress (Robinson et al., 2014) and increased their moral agency. Participants included both point of care and advanced practice nurses. End of program essays (analysis in process) also demonstrated that the majority of participants experienced personal and professional transformation.
  • 27. Questions remain about what is needed to ensure that DNP education prepares graduates to be transformational leaders; how can transformational leadership be maintained; and how can transformational leadership translate to practice and education settings? A starting place to find answers is to reinstitute the importance of an understanding of the profession of nursing's origins, evolution, and reasons for continued existence as a separate entity from other healthcare professions. We have a unique and central unifying focus on humanizing the healthcare environment and facilitating “meaning, choice, quality of life, and healing in living and dying” (Willis et al., 2008, p. E28). Perhaps even more important is that we continue to grow all of our education; curriculum development; research; and practice initiatives or directives from a nursing ethics matrix. The rapid proliferation of DNP programs means that, in the future, there could be a substantial cohort of persons prepared to provide ethics leadership in whatever clinical, institutional, or educational setting they are located. As transformational leaders they will be sensitive to the ethical nature of all nursing and healthcare practice and able to communicate this to colleagues, students, and important others as an essential starting point. They will facilitate the development and moral agency of students, peers, and interdisciplinary colleagues. Anecdotally, many nursing faculty still view ‘ethics’ as an esoteric topic that can be taught only by those with philosophy or applied ethics backgrounds. I believe this is a fallacy. Nursing ethics is at the base of everything we do as nurses. It is helpful to have knowledge of ethics language and skills in
  • 28. ethical decision-making, but acquiring this knowledge is not as difficult as sometimes supposed. It is critically important that DNP curricula, along with the expected knowledge and skills of graduates, are developed with the professional moral imperative for individual and social good in mind. We need to situate graduates so that they can envision, refine, facilitate, and meet nursing goals from a nursing perspective. Pamela Grace, PhD, RN, FAAN Email: [email protected] Pamela Grace is an Associate Professor of Nursing and Ethics at the William F. Connell School of Nursing Boston College. She is an experienced critical care and advanced practice nurse and educator. She holds a PhD is in Philosophy (1998) with a concentration in medical ethics. She has written and presented extensively on nursing and healthcare ethics. Her book, Nursing Ethics and Professional Responsibility in Advanced Practice, (2018) is now in its 3rd edition and is used internationally as a guide to ethics in advanced practice settings. American Association of Colleges of Nursing. (2004). AACN Position Statement on the practice doctorate in nursing. Retrieved from http://www.aacnnursing.org/DNP/Position-Statement American Association of Colleges of Nursing. (2006). The essentials of doctoral education for advanced nursing practice. Retrieved from http://www.aacnnursing.org/Portals/42/Publications/DNPEssenti als.pdf
  • 29. American Association of Colleges of Nursing. (2017). DNP fact sheet. Retrieved from http://www.aacnnursing.org/News-Information/Fact- Sheets/DNP-Fact-Sheet American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Silver Springs, MD: Author. American Nurses Association (2010). Nursing’s Social Policy Statement (3rd Ed.). Silver Springs, MD: Author. Bass, B.M., & Avolio, B.J. (1994). Improving organizational effectiveness through Transformational Leadership. London, UK; SAGE Publications. Blacksher, E. (2002). On being poor and feeling poor: Low socioeconomic status and the moral self. Theoretical Medicine and Bioethics, 23(6), 455-470. Brown, M. A., & Crabtree, K. (2013). The development of practice scholarship in DNP programs: A paradigm shift. Journal of Professional Nursing, 29(6), 330–337. doi:10.1016/j.profnurs.2013.08.003 Bultas, M.W., Ruebling, I., Breitbach, A. & Carlson, J. (2016). Views of the United States healthcare system: Findings from documentary analysis of an interprofessional education course, Journal of Interprofessional Care, 30(6), 762-768, doi:10.1080/13561820.2016.1206860 Chaufan, C. (2015). Why do Americans still need single-payer health care after major health reform? International Journal of Health Services, 45(1), 149-160.
  • 30. Chemers, M. M. (2001). The psychology of leadership. In N. J. Smelser & P. B. Baltes (Eds), International encyclopedia of the social and behavioral sciences (pp. 8580- 8583). Burlington, MA: Elsevier. Cummings, G. G., MacGregor, T., Davey, M., Lee, H., Wong, C. A., Lo, E., Muise, M., & Stafford, E. (2010). Leadership styles and outcome patterns for the nursing workforce and work environment: A systematic review. International Journal of Nursing Studies, 47(3), 363-385. doi:10.1016/j.ijnurstu.2009.08.006 Curtis, E. A., de Vries, J., & Sheerin, F. K. (2011). Developing leadership in nursing: Exploring core factors.British Journal of Nursing, 20(5), 306–309. Dracup, K., Cronenwett, L., Meleis, A. I., & Benner, P. E. (2005). Reflections on the doctorate of nursing practice. Nursing Outlook, 53(4), 177-182 doi:10.1016/j.outlook.2005.06.003 Elhauge, E. (2010). Why we should care about health care fragmentation and how to fix it.In E. Elhuage (Ed.) The Fragmentation of U.S. Health Care: Causes and Solution s (pp. 1-20). New York, NY: Oxford University Press. Gaylord, N., & Grace, P. J. (2018). Ethical leadership by advanced practice nurses. In P.J. Grace (Ed.). Nursing
  • 31. ethics and professional responsibility in advanced practice (3rd Ed.) (pp. 153-170). Burlington, MA: Jones & Bartlett Learning. Grace, P.J. (2009). Nursing ethics and professional responsibility in advanced practice (1st Ed). Burlington, MA: Jones & Bartlett Learning. Grace, P.J. (2018). Nursing ethics and professional responsibility in advanced practice (3rd Ed.).Burlington, MA: Jones & Bartlett Learning. Grace, P. (2018). A review of answers to one of the tailored questions on a series of anonymous end-of-course evaluations (2007-2017) for a course titled: Ethical issues in advanced practice nursing. Unpublished data, Boston College Connell School of Nursing, Boston, MA. Grace, P., & Milliken, A. (2016). Educating nurses for ethical practice in contemporary health care environments. Hastings Center Report, 46, S13–S17. doi:10.1002/hast.625 Grace, P. J., Robinson, E. M., Jurchak, M., Zollfrank, A. A., & Lee, S. M. (2014). Clinical ethics residency for nurses: An education model to decrease moral distress and strengthen
  • 32. nurse retention in acute care. Journal of Nursing Administration, 44(12), 640–646. doi:10.1097/NNA.0000000000000141 Grace, P.J., Willis, D.G., Roy, C., & Jones, D.A. (2016). Profession at the crossroads: A time of reckoning for nursing. Nursing Outlook, 64(1):61-70. doi:10.1016/j.outlook.2015.10.002 Grace, P. J., & Willis, D. G. (2012). Nursing responsibilities and social justice: An analysis in support of disciplinary goals. Nursing Outlook, 60(4), 198–207. doi:10.1016/j.outlook.2011.11.004 Grace, P. J. (2001). Professional advocacy: Widening the scope of accountability. Nursing Philosophy, 2(2), 151- 162. Grimm, J. W. (2010). Effective leadership: Making the difference. Journal of Emergency Nursing, 36(1), 74–77. doi:10.1016/j.jen.2008.07.012 Howell, J. M. & Avolio, B. J. (1993). Transformational leadership, transactional leadership, locus of control and support for innovation: Key predictors of consolidated business-
  • 33. unit performance. Journal of Applied Psychology, 78, 891-902. Institute of Medicine. (2010). The future of nursing leading change, advancing health. http://nacns.org/wp- content/uploads/2016/11/5-IOM-Report.pdf International Council of Nursing. (2012). The ICN code of ethics for nurses. Geneva, Switzerland Author. Jacob, M. (2009). On commodification and the governance of academic research. Minerva, 47(4), 391–405. doi:10.1007/s11024-009-9134-2. Johnson, J. A. & Stoskopf, C. H. (2010). Comparative health systems: Global perspectives. Burlington, MA:Jones & Bartlett. Jurchak, M., Grace, P. J., Lee, S., Willis, D. G., Zollfrank, A. & Robinson, E. (2017). Developing abilities to navigate through the grey zones in complex environments: Nurses reasons for applying to a clinical ethics residency for nurses. Journal of Nursing Scholarship, 49(4), 445-455.
  • 34. doi:10.1111/jnu.12297. Liaschenko, J., & Peter, E. (2016). Fostering nurses’ moral agency and moral identity: The importance of moral community. Hastings Center Report, 46, S18–S21. doi:10.1002/hast.626 Lown, B. (2007). The commodification of health care. Newsletter: Physicians for a National Health Program. Retrieved from http://www.pnhp.org/publications/the_commodification_of_heal th_care.php?page=all Malloy, D. C., Hadjistavropoulos, T., McCarthy, E. F., Evans, R. J., Zakus, D. H., Park, I., … Williams, J. (2009). Culture and organizational climate: Nurses’ insights into their relationship with physicians. Nursing Ethics, 16(6), 719–733. doi:10.1177/0969733009342636 Marshall, E. S., & Broome, M. E. (2016). Transformational leadership in nursing: From expert clinician to influential leader. NY, New York: Springer Publishing Company. Martsolf, G. R., Auerbach, D. I., Spetz, J., Pearson, M. L., & Muchow, A. N. (2015). Doctor of nursing practice by
  • 35. 2015: An examination of nursing schools’ decisions to offer a doctor of nursing practice degree. Nursing Outlook, 63(2), 219–226. doi:.1016/j.outlook.2015.01.002 McLeod-Sordjan, R. (2014). Transition to the DNP: Cultural conflict of the clinical doctorate in America. Online Journal of Cultural Competence in Nursing and Healthcare, 4(1), 17-28. doi:10.9730/ojccnh.org/v4n1a2 Mechanic, D. (2006). The truth about healthcare: Why reform is not working in America. New Brunswick, NJ: Rutgers, Mezirow, J. (2009). An overview of transformative learning. In K. Illeris (Ed.), Contemporary theories of learning: Learning theorists…in their own words (pp. 90-105). New York, NY: Routledge. Milliken, A. (2018). Ethical awareness: What it is and why it matters. OJIN: The Online Journal of Issues in Nursing, 23(1), Manuscript 1. doi:10.3912/OJIN.Vol23No01Man01 Miller, J. F. (2006). Opportunities and obstacles for good work in nursing. Nursing Ethics, 13(5), 471–487.
  • 36. doi:10.1191/0969733006nej894oa Miller, J. E. (2008). The doctor of nursing practice: recognizing a need or graying the line between doctor and nurse? Medscape Journal of Medicine, 10(11), 253. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2605113/?tool= pmcentrez Murphy, L. (2005). Transformational leadership: A cascading chain reaction. Journal of Nursing Management, 13(2), 128–136. Peter, E., Lunardi, V. L., & Macfarlane, A. (2004). Nursing resistance as ethical action: Literature review. Journal of Advanced Nursing, 46(4), 403-416. Powers, M., & Faden, R. R. (2006). Social justice: The moral foundations of public health and health policy.Oxford: Oxford University Press. Reid Ponte, P., & Nicholas, P. K. (2015). Addressing the confusion related to DNS, DNSc, and DSN degrees, with lessons for the nursing profession. Journal of Nursing Scholarship, 47(4), 347–353. doi:10.1111/jnu.12148
  • 37. Rest, J (1982). A psychologist looks at the teaching of ethics. Hastings Center Report, 12(1), 29-36. Rest, J. (1983). The major components of morality. In P. Mussen (Ed.), Manual of child psychology (Vol – Cognitive Psychology, pp. 556-629). New York, NY: Wiley. Rest, J R. & Narváez, D. (eds.) (1994). Moral development in the professions: Psychology and applied ethics.Hillsdale, NJ: Lawrence Erlbaum Associates Robinson, E. M., Lee, S. M., Zollfrank, A., Jurchak, M., Frost, D., & Grace, P. (2014). Enhancing moral agency: Clinical ethics residency for nurses. Hastings Center Report, 44(5), 12–20. doi:10.1002/hast.353 Rosenthal, E. (2017). An American sickness: How healthcare became big business and how you can take it back. New York, NY: Penguin. Sullivan, E. J., & Garland, G. (2010). Practical leadership and management in nursing. Harlow, UK: Pearson Education.
  • 38. Related Articles Identifying and Addressing Ethical Issues with Use of Electronic Health Records Susan McBride, Mari Tietze, Catherine Robichaux, Liz Stokes & Eileen Weber (January 31, 2018) Ethical Nursing Care Versus Cost Containment: Considerations to Enhance RN Practice Paula Kelly, MScN, BScN, RN & Caroline Porr, PhD, MN, RN (January 31, 2018) Ethics Education in Nursing: Instruction for Future Generations of Nurses Katelin Hoskins, MSN, MBE, CRNP; Christine Grady, PhD, RN; & Connie M. Ulrich, PhD, MSN, RN, FAAN (January 31, 2018)
  • 39. In Search of a Moral Community Lucia D. Wocial, PhD, RN, FAAN (January 31, 2018) Ethical Awareness: What It Is and Why It Matters Aimee Milliken, PhD, RN (January 31, 2018) Starr, P. (2011). Remedy and reaction: The peculiar American struggle over healthcare reform. New Haven, CT: Yale University Press. Taran, S. (2011). An examination of the factors contributing to poor communication outside the physician-patient sphere. McGill Journal of Medicine, 13(1), 86–91. Weihrich, H., & Koontz, H. (2005). Management: A global perspective (11th ed.). Singapore: McGraw-Hill. Willis. D. G., Grace, P.J., & Roy, C. (2008). A central unifying focus for the discipline: Facilitating humanization, meaning, choice, quality of life, and healing in living and dying. Advances in Nursing Science, 31(1), E28-E40.
  • 40. © 2018 OJIN: The Online Journal of Issues in Nursing Article published January 31, 2018 Follow Us on: © 2017 The American Nurses Association, Inc. All Rights Reserved American Nurses Association - 8515 Georgia Avenue - Suite 400 - Silver Spring, MD 20910 ISSN: 1091-3734 | 1-800-274-4ANA | Copyright Policy | Privacy Statement © 2018. This work is published under NOCC (the “License”). Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License. 1
  • 41. 2 Title That Fits on One Line Your Name Miami Regional University DNP Entrance Essay Date of Submission
  • 42. DNP Entrance Essay Intro here… Need for DNP-Prepared Nurses in the Current Healthcare System Paragraph here… Impact of the DNP Degree on your Career Paragraph here… Few Examples on Translation of Knowledge Acquired from DNP in the Current Workplace Paragraph here… References Grace, Pamela, PhD, R.N., F.A.A.N. (2018). Enhancing Nurse Moral Agency: The Leadership Promise of Doctor of Nursing Practice Preparation. Online Journal of Issues in Nursing, 23(1), 1-11. Moore, K. S., & Hart, A. M. (2021). Critical juncture: The
  • 43. doctor of nursing practice and COVID-19. Journal of the American Association of Nurse Practitioners, 33(2), 97-99.