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.
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).
...it is more critical than ever that we remain mindful about the demands of ‘good’ patient care. 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).
The development of knowledgeable and skillful nurse leaders is necessary to enhance interdisciplinary collaborations for quality, safe patient care. 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 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).
Goals of the Nursing Profession
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 serve as the main anchors for understanding our ethical responsibilities... 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. 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.
...it is important to confirm the DNP role as one of ethical transformative leadership... 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 confirm the DNP role as one of ethical transformative leadership regardless of specialty practice area.
Contemporary Challenges to Good Nursing Practice
...[business] principles can sometimes collide with human-centered goals of quality patient healthcare. 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.
Being mindful of limited resources and justice in the allocation of them is also an ethical issue. 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).
The Promise of DNP Leadership
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 (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.
A ‘Wake Up’ Call for the Profession of Nursing
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.
Building these skills should be an imperative of the ethics of the profession. 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... 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.
Rooting All Curricula in an Ethics Matrix: An Ethical Imperative
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. 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 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).
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. 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 need preparation to exercise moral agency and to develop the skills to collaborate with others to articulate the goals and expected outcomes of actions. 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... 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.
Ethically Skilled Educators and Leaders: A Role for Doctors of Nursing Practice
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.
...it is incumbent on the profession to ensure that the ongoing development of the DNP role reflects the ethical foundations of the profession... 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).
Underlying, implicitly or explicitly, the achievement of each [DNP] essential is ethical expertise and leadership qualities. 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.
Types of Leadership
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.
Transactional leadership is, arguably, the most commonly seen in healthcare settings and is managerial in nature. 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. 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).
Relationship of Transformational Learning to Transformational Leadership
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).
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.
Nursing ethics is at the base of everything we do as nurses. 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
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/DNPEssentials.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 Solutions (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_health_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.
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.