This document discusses the need for Doctor of Nursing Practice (DNP) programs to focus on preparing nurse leaders with strong ethical foundations. It argues that DNP curricula should be built upon an "ethics matrix" consisting of understanding nursing goals and responsibilities, ethics language and decision-making skills, and the motivation to act ethically. This ethics matrix would provide context and stability for other skills taught in DNP programs. The document also notes contemporary challenges like cost pressures that can interfere with ethical nursing practice, and argues that DNP-prepared nurses are well-positioned to provide transformative leadership that enhances nurses' ability to advocate for patients.
Enhancing Nurse Moral Agency TheLeadership Promise of Docto.docx
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
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38. Related Articles
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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
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Katelin Hoskins, MSN, MBE, CRNP; Christine Grady, PhD,
RN; & Connie M. Ulrich, PhD, MSN, RN, FAAN (January
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39. In Search of a Moral Community
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Ethical Awareness: What It Is and Why It Matters
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Starr, P. (2011). Remedy and reaction: The peculiar American
struggle over healthcare reform. New Haven, CT:
Yale University Press.
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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.
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.