UJIAN AKHIR SEMESTER (UAS)

Program Studi : Magister Keperawatan

Mata Kuliah : Kepemimpinan Dalam Pelayanan Keperawatan

Nama : Lia Yuliana

NPM : 2250311007

Semester : I (Satu )Kelas B

Soal

1. Analisis salah satu jurnal terkait aplikasi pelaksanaan kepemimpinan dalam kolaborasi, delegasi,

dan manajemen konflik pada pelayanan keperawatan di luar negeri (jurnal dilampirkan, upayakan

jurnal 5 tahun terakhir, atau maksimal 10 tahun terakhir) :

a. Jelaskan konsep isi jurnal dalam pelayanan keperawatan di luar negeri menurut jurnal tersebut

b. Kaji konsep berdasar referensi terkait jurnal

c. Kaji fenomena di Indonesia apabila dilaksanakan pada pelayanan keperawatan di Indonesia,

dalam keunggulan dan kelemahannya.

2. Jelaskan pengembangan EBP dalam Kepemimpinan seperti apa yang sebaiknya dilakukan, di

pelayanan dan pendidikan keperawatan. Lengkapi dengan referensi dan kebijakan di pelayanan dan

pendidikan. Dukung dengan minimal 3 refensi terkait 5 tahun terakhir baik dari text book,

permen/UU/standar/panduan, maupun dari jurnal. Tuliskan daftar referensi yang digunakan.

 TRANSFORMATIONAL LEADERSHIP TO PROMOTE NURSE PRACTITIONER

PRACTICE IN PRIMARY CARE

1. Analisis satu jurnal terkait aplikasi pelaksanaan kepemimpinan dalam kolaborasi, delegasi,

inovasi, dan manajemen konflik pada pelayanan keperawatan di luar negeri.

a) Jelaskan konsep isi jurnal dalam pelayanan keperawatan di luar negerimenurut jurnal

tersebut.

Dalam jurnal tersebut disampaikan bahwa kepemimpinantransformasional

mampu mengatur model asuhan keperawatan primeruntuk mempromosikan praktek

keperawatan yang profesional.Sebagaimana dijelaskan dalam jurnal ini empat faktor

kepemimpinantransformasional yaitu idealized influenza, inspirational

motivation,intelektual stimulation and individual consideration dalamimplementasinya

lebih mengutamakan kolaborasi dari pada kompetisi,proses delegasi maksimal karena

konsepnya memperlakukan perawatPetimussama dengan profesi lain seperti dokter

sebagai mitra perawat danketerbukaan informasi antara pimpinan dan bawahan,

Inovasi terusdikembangkan melalui intelektual stimulation dimana perawat

dirangsanguntuk mengeluarkan ide-ide briliannya dan manajemen konflik lebih efektif

karena dalam model kepemimpinan ini gesekan-gesekan sangatkecil sehingga konflik

yang timbul juga kecil, hal ini dikarenakanpengaruh pemimpin yang kharismatik yang

menciptakan lingkungan kerjayg kondusif,

Konsep penelitian ini adalah ingin mengembangkan danmempromosikan model

praktik klinis perawat primer. Alasanya adalahmeningkatnya permintaan pelayanan

kesehatan di Negara AmerikaSerikat dan terbatasnya providers perawatan primer.

Pengembangan.model asuhan keperawatan berbasis tim telah direkomendasikan

sebagaipendekatan terkait untuk meningkatkan kapasitas perawatan primer(Komite

Nasional untuk Quality Assurance, 2014). Dimana perawatprimer dalam model asuhan

berbasis tim adalah leader dari kelompok timtersebut yang tugasnya adalah melakukan

kolaborasi, koordinasi,pengambil keputusan, manajemen konflik, inovasi melalui

tindakankeperawatan berdasarkan evidence base.Penjelasan 4 faktor kepemimpinan

transformasional kaitanyadengan pelaksanaan kepemimpinan dalam kolaborasi,

delegasi, inovasidan manajemen konflik adalah sebagai berikut:

 1. Ideal Influenza didalamnya terjadi interaksi dan kolaborasi,informasi tentang

perubahan organisasi disampaikan,memperlakukan praktik perawat dan praktik dokter

sama sebagaimitra dan delegasi berjalan dengan maksimal sehingga organisasidan

keselamatan pasien lebih optimalkan.

2. Motivasi Inspirasional: didalamnya umpan balik tentang kinerjaperawatan tiap

individu disampaikan, anggota merasa terlibatdidalam pengembangan, evaluasi

dilakukan ditempat sehinggakinerja perawatan terukur dan mampu memotivasi untuk

lebih baiklagi. Suasana lebihbergairah dan kondusif yang berdampak padarendahnya

konflik dan penyelesaian konflik mudahkarenakharismatik pemimpim bisa menjadi

indikator motivasi daninspirasi untuk seperti pemimpinnya.

3. Stimulasi intelektual: didalamnya organisasi menciptakanlingkungan dimana

anggota bisa berlatih secara mandiri untukmenciptakan Inovasi-inovasi baru dalam

perawatan. Pemimpinmendorong praktik klinik untuk mengeluarkan ide-ide

untukmenciptakan inovasi. Kepemimpinan mendorong mempromosikanlingkungan

yang nyaman untuk bekerja agar konflik tidakberkembang dan cepat diselesaikan.

4. individual consideration: didalamnya kepemimpinan mendukunggagasan

anggota dan anggota merasa dihargai. Semuakeinginannya didengarkan dan

diupayakan diimplementasikan.

Para peneliti menyimpulkan bahwa pemimpin transformasionalmemiliki potensi

untuk gesekan perawat lambat dan mempertahankanperawat dengan menciptakan

lingkungan kerja yang positif (Brewer et al2016).

b) Kaji konsep berdasarkan refrensi terkait jurnal

1. Definisi Kepemimpinan Transformasional

(Sudarwan Danim, 2009) menjelaskan kepemimpinantransformasional

berasal dari kata "to transform" yang berartimentransformasikan atau mengubah

sesuatu menjadi bentuk yangberbeda. Misalnya mentransformasi visi menjadi

realita, potensimenjadi aktual, laten menjadi manifes dan sebagainya.Sedangkan

Tracy and Hinkin (Gill dkk, 2010) memaknaikepemimpinan transformasional

sebagai berikut: "The process ofinfluencing major changes in the attitudes and

assumptions ofchangesorganization members and building commitment for

 theorganization's mission or objectives".Menurut Minnah El Widdah, Asep

Suryana, dan KholidMusyaddad (2012, hlm. 85) yaitu: "kepemimpinan yang

mampumentransformasi dan memotivasi para pengikutnya dengan; (a)membuat

mereka lebih sadar mengenai pentingnya hasil-hasil suatupekerjaan, (b)

mendorong mereka untuk lebih mementingkanorganisasi atau tim daripada

kepentingan sendiri dan (c) mengaktifkankebutuhan-kebutuhan mereka pada yang

lebih tinggi."

2. Komponen Inti Kepemimpinan Tranformational

Menurut Bass dan Riggio (2006; 6-7), kepemimpinan transformasionaldalam

teorinya dapat dilihat ada empat komponen inti yang selalumelekat, yaitu:

a) Pengaruh idealis

Pemimpin transformasional berperilaku dengan cara

mempergaruhipengikut mereka sehinga pengikut dapat

mengagumi,menghormati, sehingga dapat dipercaya. Ada dua aspek

yangdilihat untuk pengaruh ideal ini, yaitu: perilaku pemimpin danunsur-unsur

yang dikaitkan denganpemimpin. Selain itu,pemimpin yang memiliki banyak

pengaruh ideal adalah bersediauntuk mengambil risiko dan konsisten dan tidak

sewenang-wenang. Mereka dapat diandalkan untuk melakukan hal yang

benarmenunjukkan standar perilaku etika dan moral.

b) Motivasi yang memberi Inspirasi.

Pemimpin transformasional berperilaku dengan cara yangmemberikan

motivasi dan menginspirasi orang-orang di sekitarmereka dengan memberikan

arti dan tantangan untuk bekerja.Semangat tim terangsang, antusiasme dan

optimisme akanditampilkan. Sehingga, pemimpin mendapatkan pengikut

yangaktif terlibat dengan pola komunikasi yang intens sertamenunjukkan

komitmen terhadap tujuan dan visi bersama.

c) Stimulasi Intelektual.

Pemimpin transformasional mendorong upaya pengikut merekauntuk

menjadi inovatif dan kreatif dengan mempertanyakanasumsi, reframing

masalah, dan mendekati situasi lama dengancara baru. Kreativitas didorong.

 Tidak ada kritik publik terhadapkesalahan individu anggotanya. Ide-ide baru

dan solusi masalahsecara kreatif dikumpulkan dari pengikut, termasuk dalam

prosesmengatasi masalah dan menemukan solusi. Pengikut didoronguntuk

mencoba pendekatan baru, dan ide-ide mereka tidak dikritikkarena mereka

berbeda dari ide-ide para pemimpin.

d) Pertimbangan Individual.

Pemimpin transformasional memberikan perhatian khusus

terhadapkebutuhan masing-masing pengikut individu untuk pencapaian

danpertumbuhan dengan bertindak sebagai pelatih atau mentor.Pengikut dan

rekan yang potensial dikembangkan pada tingkatyang lebih tinggi. Perilaku

pemimpin menunjukkan penerimaanterhadap perbedaan individu (misalnya,

beberapa karyawanmenerima lebih banyak dorongan, otonomi lebih banyak,

standaryang jelas). Komunikasi dua arah didorong serta Interaksi

denganpengikut dipersonalisasi (misalnya, pemimpin ingat

percakapansebelumnya, adalah menyadari masalah individu, dan melihat

individu sebagai manusia seutuhnya bukan hanya sebagai seorangkaryawan).

Pemimpin lebih banyak mendengar para pengikutnya.Pelimpahan tugas

sebagai sarana untuk mengembangkan tugasyang didelegasikan

denganmemantau apakah para pengikut perluarahan atau dukungan dan untuk

menilai kemajuan

3. Karakteristik Kepemimpinan Transformasional

(Tichy dan Devanna, 2015) mengemukakan karakteristik

pemimpintransformasional yang merekasebut sebagai protagonis atau

pelakuutama dalam drama sebagai berikut:

a) Mengidentifikasi dirinya sebagai agen perubahan

Mereka secara jelas mengidentifikasikan dirinya sebagai agen-agen

perubahan.

b) Individu pemberani Kebaranian bukan ketololan

Mereka pengambil risiko penuh hati-hati dan berani menghadapitantangan,

berani menghadapi status quo

 c) Mereka percaya sama orang

Para pemimpin transformasional bukan dictator. Mereka

sangatberkuasa sungguh pun demikian mereka sensitif kepada oranglain, dan

mereka berupaya untuk memberdayakan orang lain

d) Mereka adalah penarik nilai

Setiap pemimpin transformasional mampu menguraikan suatu setinti

nilai-nilai dan menunjukkan perilaku yang sesuai denganposisinya.

e) Mereka pembelajar sepanjang hayat

Semua pemimpin transformasional mampu berbicara

mengenaikesalahankeselahan yang mereka lakukan. Akan tetapi, mereka

takmemandang kegagalan tersebut sebagai suatu kegagalanmelainkan sebagai

pengalaman belajar

f) Mereka mempunyai kemampuan untuk berurusan dengankompleksitas,

ambiguitas, dan ketidakpastian.

Setiap pemimpin transformasional mampu untuk menghadapi

danmembingkai problem dalam dunia yang kompleks dan berubah

g) Mereka visionary.

Para pemimpin transformasional dapat bermimpi, mampumenjabarkan

impian dan citra sehingga orang berbagi dengan mereka

4. Prinsip-prinsip Kepemimpinan Transformasional

Paradigma baru dari kepemimpinan transformasional mengangkattujuh

prinsip untuk menciptakan kepemimpinan transformasional yangsinergis

sebagaimana di bawah ini (Erik Rees, 2001):

a) Simplifikasi, keberhasilan dari kepemimpinan diawali dengansebuah visi

yang akan menjadi cermin dan tujuan bersama.

b) Motivasi, kemampuan untuk mendapatkan komitmen dari setiaporang

yang terlibat terhadapvisi yang sudah dijelaskan adalah halkedua yang

perlu kita lakukan.

c) Fasilitasi, dalam pengertian kemampuan untuk secara efektifmemfasilitasi

"pembelajaran yang terjadi di dalam organisasisecara kelembagaan,

 kelompok, ataupun individual.

d) Inovasi, yaitu kemampuan untuk secara berani dan bertanggungjawab

melakukan suatuperubahan bilamana diperlukan danmenjadi suatu

tuntutan dengan perubahan yang terjadi.

e) Mobilitas, yaitu pengerahan semua sumber daya yang ada

untukmelengkapi dan memperkuat setiap orang yang terlibat di

alamnyadalam mencapai visi dan tujuan

f) Siap Siaga, yaitu kemampuan untuk selalu siap belajar tentang dirimereka

sendiri dan menyambut perubahan dengan paradigma baruyang positif.

g) Tekad, yaitu tekad bulat untuk selalu sampai pada akhir, tekadbukan untuk

menyelesaikan sesuatu dengan baik dan tuntas.

c) Kaji fenomena di Indonesia apabila dilaksanakan di Pelayanankeperawatan di

Indonesia, dalam keunggulan dan kelemahannya.

1) Keunggulannya

a. Kepemimpinan transformasional berpengaruh terhadap kinerjapelayanan

kesehatan di instansipelayanan Rumah Sakit danPuskesmas.

b. Kepemimpinan transformasional berperilaku sebagai Super Leaderartinya

seorang pemimpintransformasional dapat mengembangkansetiap orang

menjadi Self Leaadership.

c. Kepemimpinan transformasional sesuai atau cocok dengan kondisiyang terus

menerus berubahdalam pelayanan kesehatan.

d. Kepemimpinan transformasional akan merubah peran SDM tenagakesehatan

yang ada langsung menangani pasien baik di rumah sakitmaupun puskesmas

e. Kepemimpinan transformasional membuat para bawahan merasalebih dihargai

sehingga semakin banyak terlibat dalam berbagaipengambilan keputusan yang

berkaitan dengan bidang pelayanan dirumah sakit dan puskesmas.

f. Kepemimpinan transformasional mampu membangkitkan motivasidalam

melakukan perawatan dan pelayanan kepada pasien,melakukan inovasi untuk

beradaptasi dengan perubahan yang terusmenerus terjadi karena

perkembangan ilmu pengetahuan danteknologi.

 g. Komitmen yang timbul bersifat mengikat emosional

h. Mampu memberdayakan potensi staf keperawatan

i. Meningkatkan hubungan interpersonal antara staff danpimpinan/leader.

j. Ketika trust telah kuat maka individu dengan rela memberikankekayaan

intelektualnya kepada orang lain, dan begitu sebaliknya,individu tersebut akan

mau menggali informasi (pengetahuan)dariorang lain yang dipercayainya.

2) Kelemahannya

a. Ketika dalam sebuah lingkungan organisasi terjadi perubahansecara struktural,

dan berdampakpada pergantian personel makakepercayaan harus dibangun

lagi dari awal.

b. Pola kepercayaan terhadap atasan yang kurang kuat akanmenyebabkan

kepemimpinantransformasional tidak menemukanbentuk (performa)

terbaiknya.

c. Kepemimpinan baru memiliki pengaruh dalam perilaku organisasiapabila

telah terbentukhubungan pemimpin (atasan) dan pengikut(bawahan) yang

kuat.

d. Butuh waktu yang lama untuk menumbuhkan komitmen bawahanterhadap

pimpinan

e. Sulit dilakukan pada jumlah karyawan yang banyak.

f. Kurang efektif karena masih kuatnya mekanisme kontrol olehbirokrasi yang

bersifat sentralis,formalisasi, dan rutinisasi.

g. Hasil penelitian ditemukan bahwa kepemimpinan transformasionaltidak

signifikan dalammembentuk perilaku berbagi pengetahuan.

h. keberhasilan pola kepemimpinan ini juga bergantung padapengakuan dan

kepercayaan dari parabawahan

2. Jelaskan pengembangan inovasi kepemimpinan seperti apa yang sebaiknyadilakukan di

pepalayanan dan pendidikan keperawatan.

a. IPTEK Inovasi

Inovasi digital menjadi begitu penting untuk keberlangsungan sebuahorganisasi

pelayanankesehatanditengah-tengah perkembangan yangsemakin modern, jika tidak

melakukan dan mengikuti perkembanganteknologi maka akan kalah bersaing dengan

lawan-lawan atau kompetitordisekitarnya. Maka pemanfaatan transformasi digital juga

menjadiprogram pemerintah untuk penguatan pembangunan kesehatan

tahun2020-2024 (Kepmenkes No. 375/MENKES/SK/V/2009,2009)IPTEK Inovasi

dalam pelayanan kesehatan yang bisa dilakukan sebagaiberikut:

a) Digitaslisasi Rekam Medis

Sitem digitalisasi sangat efisien bagi pelayanan kesehatan.

- Kalau dilihat dari segia biaya sangat benayk menghemat biayakarena yang tadinya

menggunakan kertas berubah menjadipaperless. Jadi semua rekam medis punya

pasien masuk dalamprogram komputer.

- Kalau dilihat dari segi efektivitas pelayanan maka asuhan menjadilebih terintegrasi

artinya pelayana berfokus pada pasien (PCC)yang digagas oleh KARS dalam standar

akreditasi akan lebihterwujud dengan baik dan kepuasan pasien meningkat,

mutupelayanan meningkat, biaya asuhan menjadi lebih murah dankualitas hidup

pasien meningkat.

b) Sistem Rujukan Online

Sistem rujukan online sangat efisien dan lebih murah dan ini sudahdijalankan

namun belum merata disemua rumah sakit artinyapercepatan perlu dioptimalkan. Bagi

fasyankes tingkat pertama yangmengikuti progran JKN BPJS untuk rujukan online

berjenjang sudahdijalankan semua namun sistem rujukan dari fasyankes tingkat 2

keFasyankes rujukan pusat belum semua terfasilitasi. Pengalaman dariyang sudah

dijalankan menjadi lebih mudah dan lebih efisien baik darisegi biaya maupun waktu

dan tenaga.
b. Pengembangan Riset Sciences

Pelayanan kesehatan baik fasyankes tingkat 1, fasyankes tingkat 2 danfasyankes

tingkat 1 begitu juga perguruan tinggi saat ini diwajibkan olehbadan akreditasi untuk

melakukan penelitian sebagaiinovasi pelayanan difasyankes berbasis bukti. KARS

dalam pedoman KARS 1.1 tahun 2018sudah menyingung danmenyarankan agar

rumah sakit mengadakan danmelakukan riset-riset dan akan dipantau dalam survey

akreditasiberkelanjuta (KARS, 2018). Kama untuk menjadi bermutu dan diakui diluar

maka pengembangan riset menjadi keharusan.

c. Mengembangkan program" Eksekutif Fellowship Dalam Inovasi

Kepemimpinan Kesehatan.Inovasi dan kreatifitas merupakan bagian dari

kehidupan sehari-hari untuk perawat dalam memberikan pelayanan kesehatan pada

pasien.Dokter dan keperawatan terus berinovasi dan menciptakan hal baru

untukmemenuhi kebutuhan unik masing-masing pasien.

The Executive Fellowship Inovasi Kepemimpinan Kesehatan(EFIHL) adalah

sebuah program selama setahun, berbasis kohort yangbertujuan untuk mengekspos

Fellows untuk pemimpin industri bangsasehingga mereka dapat mengembangkan

keterampilan yang dibutuhkanuntuk "mempercepat kapasitas organisasi mereka

sendiri untukberinovasi. Fellows dalam kelompok penulis termasuk para

pemimpindari keperawatan, medis, psikologi, dan medan administrasi.

Fellowsdidorong untuk belajar dan menerapkan 7 karakteristik kepemimpinaninovasi:

spanning batas, pengambilan risiko, memanfaatkan peluang.Visioning, beradaptasi,

memfasilitasi, dan mengkoordinasikan informasifellow.

Berdasarkan hasil penelitian sebelumnya dijelaskan bahwa tigapemimpin

perawat mendiskusikan perjalanan mereka untuk membawainovasi ke dalam praktek

kepemimpinan mereka melalui partisipasi dalamprogram selama setahun, "Eksekutif

Fellowship dalam InovasiKepemimpinan Kesehatan." Para penulis berbagi wawasan

yangdiperoleh setelah mereka berpartisipasi dalam kohort pemimpinperawatan

kesehatan yang mengambil bagian dalam ini persekutuanselama setahun. Rincian dari

program fellowship dibahas, bersamadengan manfaat dari memasuki program tersebut.

Tiga proyek-proyekinovasi terpisah ditinjau. Di Iowa, Asisten Wakil Presiden

 Keperawatan memimpin restrukturisasi dan pengembangan peran dukungan

untukmenghapus tugas yang tidak perlu dari manajer perawat. Di California,Direktur

Pendidikan, Praktek, dan Informatika mengambi perjalananpobedipribadi untuk

meningkatkan keterampilan kepemimpinan senior nya. DiFlorida, seorang

Keperawatan Kepala Officer menciptakan sebuahprogram yang dirancang untuk para

pemimpin mengajar perawat untukProgram yangmenjadi inovatif dalam perawatan

kesehatan (Case, 2019).

d. Kebijakan Penerapan MAKP Berbasis Pelayanan Perawat Primer

Berdasarkan hasil penelitian kebutuhan perawatan perawat primer sangatpenting

karena Model Asuhan Keperawatan Primer lebih meningkatkankepuasan pasien dan

meningkatkan kepercayaan terhadap organisasikarena efek dari kepuasan pasien

(Poghosyan & Bernhardt, 2018). Dengna penerapan perawat primer dibanntu perawat

vokasi dalam UU 38Tahun 2014 perawat vokasi adalah lulusan D 3 Keperawatan dan

PerawatPrimer sama dengan perawat profesional (UU RI no. 38, 2014).Direncanakan

untuk memenuhinya perbandingan adalah 60:40 perawatprimer dan perawat

vokasional. Trens yang terjadi saat ini adalahpelayanan model keperawatan berbasis

perawat primer belum bisadiaplikasikan secara maksimal.

Received: 13 July 2017 | Revised: 4 December 2017 | Accepted: 26 February 2018

O R I G I N A L AR T I C L E

Transformational leadership to promote nurse

practitionerpractice in primary care

Lusine Poghosyan1 | Jean Bernhardt2

1 Columbia
Abstract
University

School of Aim: This study investigated transformational leadership from the perspectives of primary

Nursing, care nurse practitioners.

New York,

New York
Background: The growing workforce of nurse practitioners in the United States could play a

critical role in meeting the increasing demand for primary care. Little is known about how
2 MGH

leadership within primary care practices could promote nurse‐ practitioner care.
Institute of

Transformational leadership is a widely recognized leadership style that affects clinician

Health

Professions, practice and outcomes.

Boston,
Method: A cross‐sectional survey design was used to collect data from nurse practi‐ tioners in
Massachuse

tts
New York state in 2012. The online survey containing measures of nurse practitioners and

leadership relationships was completed by 278 nurse practitioners.

Correspondence
Results: The four factors of transformational leadership—idealized influence, inspira‐ tional

Lusine motivation, intellectual stimulation, and individual consideration—were recog‐ nized by

Poghos nurse practitioners. Almost half of nurse practitioners reported that leadership did not
yan,
share information equally between nurse practitioners and physi‐ cians (idealized influence),
Columb
and 45.9% reported that nurse practitioners were not rep‐ resented on important
ia
organisational committees (intellectual stimulation).

Conclusion: Transformational leadership can be applied to promote nurse practi‐ tioner

practice in primary care. Future research should explore how transformational leadership
Universi

ty

School

of

Nursing,

New

York, NY.

Email:

lp2475

@colu

mbia.e

du

Funding information

This study

was

supported

by a grant

from

Columbia

University

School of

Nursing.
1 | INT R OD U C T ION the primary care capacity (Institute of Medicine, 2011; National
Committee for Quality Assurance, 2014). The NP workforce in the
The United States is facing a shortage of primary care provid‐ ers
United States is expected to increase by 93% between 2013 and 2025,
given the increased demand for health care services (Sargen, Hooker,
and many health care organisations will see an increase in the
& Cooper, 2011). Expansion of the nurse practitioner (NP) workforce
numbers of NPs in their staffing mix (Health Resources and Services
and development of team‐ based care‐ delivery models have been
Administration, 2016). However, the expansion of the NP workforce
recommended as two related approaches to increase
and development of team‐ based care models will not address quality

© 2018 John Wiley & Sons Ltd | 1

J Nurs Manag. 2018;1–8. wileyonlinelibrary.com/journal/jonm
POGHOSYAN AND BERNHARDT
and access‐ to‐ care challenges facing primary care as studies demon‐
strate that NPs face major barriers within their employment settings,
such as lack of support from and poor relationships with leadership,
which limit their contributions to optimal team‐ based care (Pasarón,
2013; Poghosyan, Nannini, Stone, & Smaldone, 2013). Nurse practi‐
tioners’ advanced skills and training are often not optimally utilized
within their organisations. Organisational leadership either lacks
awareness about NP competencies or does not provide NPs with
access to resources. For example, leaders within health care organi‐
sations such as practice managers or medical directors do not share
information with NPs to support their care delivery or take NPs’
concerns seriously (Poghosyan, Nannini, Stone, et al., 2013). Such
poor organisational attributes and relationships between NPs and
administrators not only negatively impact the practice of NPs but also
undermine teamwork between NPs and physicians (Poghosyan & Liu,
2016).
For decades, business management and organisational research‐
ers have explored the role of leadership in the success of individ‐ uals,
teams, and organisations (Bass, 1985; Wang, Sui, Luthans, Wang, &
Wu, 2014). Leaders are capable of motivating their follow‐ ers,
supporting their work performance, and helping the team and the
organisations achieve the best outcomes (Bass, 1990; Herold, Fedor,
& Caldwell, 2008). One of the most recognized forms of leadership,
transformational leadership, has been highlighted as an effective
leadership style to maximize the performance and out‐ comes of
individuals and teams (Avolio & Yammarino, 2013; DeRue, Nahrgang,
Wellman, & Humphrey, 2011; Piccolo et al., 2012; Wang, Oh,
Courtright, & Colbert, 2011). Transformational leaders within various
organisations are capable of encouraging their followers to strive for,
and achieve, the common mission (Van Dierendonck, Stam, Boersma,
deWindt, & Alkema, 2014). In addition, they take their followers’
concerns seriously and address them (Kouzes & Posner, 2002).
Transformational leadership is associated with job satisfaction among
the followers and improved team performance (Braun, Peus,
Weisweiler, & Frey, 2013; Dust, Resick, & Mawritz, 2013). In the
health care sector, the significance of transformational leadership as it
relates to organisational commitment, productivity, job satisfaction,
and performance of clinicians and its impact on pa‐ tient safety and
outcomes are widely recognized (Lyder et al., 2012; McFadden,
Henagan, & Gowen, 2009; Vogus, Sutcliffe, & Weick, 2010).
Researchers concluded that transformational leaders have the
potential to slow nurses’ attrition and retain nurses by creating a
positive work environment (Brewer et al., 2016; Weberg, 2010).
Furthermore, a systematic review of evidence demonstrates that
transformational leadership is associated with positive patient out‐
comes such as low rates of mortality, medication errors, falls, and
infections (Wong, Cummings, & Ducharme, 2013). The Institute of
Medicine (2001) identified transformational leadership, in its work on
patient safety, as a solution to poor leadership outcomes, such as
weakened trust, lack of feedback, minimal employee involvement in
developing change initiatives, and limited voice on committees.
Researchers have studied the role of transformational leadership in
promoting the practice of registered nurses (Casida, Crane, Walker,
| 2
& Wargo, 2012; Cummings et al., 2010; Weberg, 2010), but to date
little attention has been given to the importance of transformational
leadership in promoting the practice of advanced practice registered
nurses (APRN) such as NPs despite the fact that the researchers in‐
dicate the critical value transformational leadership has on maximiz‐
ing the potential of APRNs (Kapu & Jones, 2016). The purpose of this
study is to investigate transformational leadership in primary care
practices from the perspectives of NPs.
| Conceptual framework
Transformational leadership was first conceptualized by John
McGregor Burns as leaders and followers moved together toward
enhanced purpose and inspiration (Burns, 1978). Burns stated that, in
order to enhance effective leadership, leaders should focus on
meeting the followers’ needs so they are motivated to align their
values with those of an organisation. Burns noted that transfor‐
mational leaders embodied qualities that motivated followers.
Transformational leaders also elevate the followers’ interests and
increase their awareness and commitment to the group’s mission.
Bass (1985) developed concepts related to how transformational
leaders have an impact on the development and performance of fol‐
lowers and stated that if individuals were aware of how their out‐
comes could make a difference they would be more motivated to
achieve them. Furthermore, Northouse emphasized that leaders can
motivate followers by emphasizing their value and increasing follow‐
ers’ awareness about their capabilities (Northouse, 2013). Leaders
create an organisational culture through their impact on followers and
seek to empower them in an exchange between themselves and
followers, which mobilizes followers to value collaboration instead of
competition. Moreover, if followers are engaged in the mission of the
group or the organisation, then they are inspired to deliver their best.
Such empowered followers model the behaviours of the leader and
develop a sense of group identity. Followers know the leader is
invested in the achievement of their goals, which results in their
motivation to achieve a collective purpose (Bennis & Nanua, 1995;
Kouzes & Posner, 2002).
Four transformational leadership factors have been identified
by Bass as promoting followers (Bass, 1985). First, idealized influ‐
ence—followers seek to model the behaviours of a transformational
leader and perceive their leader as trustworthy and respectful.
Followers believe that their leader prioritizes their needs, which
promotes the follower’s sense of loyalty to the leader. Followersare
inspired to do what it takes and make the extra effort to achieve the
desired results because the leader has convinced them that together
they can achieve important goals. Second, inspirational
motivation—the leader provides followers with a clear messagethat
the collective purpose is greater than individual contributions.
Inspirational motivation is operationalized as clear communication
about high expectations and achieving the current and future goals of
the organisation. Followers push themselves to reach goals when they
receive such feedback. Third, intellectual stimulation—follow‐ ers are
intellectually stimulated to solve problems. Intellectual
POGHOSYAN AND BERNHARDT
stimulation is reflected in statements about creativity and testing of
ideas. Followers seek out challenges and strive for improvement. For
followers to be intellectually stimulated, they must have a sense that
the structures and processes are orderly and rational. Last,
individualized considerations—the leader focuses on the followers’
needs to ensure they are fulfilled. Individualized considerations in‐
clude leaders’ supportive behaviours such as listening, advising, and
mentoring to help followers grow.
In this study, the four transformational leadership factors are
framed through the responses of NP followers about the organisa‐
tional leadership in primary care practices.
2 | ME T HO D
| Design
This study is a part of a large investigation of NP practise within pri‐
mary care practices. A cross‐ sectional survey design was used to col‐
lect data from NPs practising in one state in the United States (New
York State) in 2012. We specifically limited the data collection to one
state because state‐ level policy regulations governing NP practice
vary across states within the United States (Robert Wood Johnson
Foundation, 2017). The study was approved by the Institutional
Review Board of [Columbia University Medical Center].
| Sample
Primary care NPs were recruited from the membership list of the New
York Nurse Practitioner Association (NYNPA), the NP advocacy
organisation in New York State. Only NPs who had one of the fol‐
lowing specializations—adult, family, paediatric, women’s health or
gerontology—were invited to participate in the study because NPs
from these specialties are more likely to deliver primary care (Health
Resources and Services Administration, 2002). The NYNPA mem‐
bership list included 1,950 NPs within these specialties. The NYNPA
sent an email invitation to NPs with a link to the online survey askingfor
their participation. In addition, the survey asked NPs to self‐ iden‐ tify
whether they practise in a primary care setting and deliver pri‐ mary
care services. Overall, 278 eligible NPs completed the survey. It was
not possible to compute the response rate as we were unable to
determine how many emails were active or reached NPs.
| Survey tool
Nurse practitioners were asked to complete a survey tool that con‐
tained NP demographic measures such as age, sex, education, and
years of experience, and work characteristics such as the location and
type of organisation (e.g., physician practice). The survey also contained a
series of questions generated from the existing evidence and qualita‐
tive interviews with NPs (Poghosyan, Nannini, Stone, et al., 2013) on
their employment settings, organisational structures, and leadership,
some of which were designed for developing the Nurse Practitioner
Primary Care Organisational Climate Questionnaire (NP‐ PCOCQ)—a
| 3
measure of NP organisational climate (Poghosyan, Nannini, Finkelstein,
Mason, & Shaffer, 2013). The NP‐ PCOCQ has been validated as a
measure of organisational climate and its internal consistency, reli‐
ability, construct, discriminant, and predictive validity has been estab‐
lished (Poghosyan, Chaplin, & Shaffer, 2017). One of the subscales of
the tool called NP‐ Administration Relations measures various aspects
of the relationship between NPs and organisational leaders such as
whether leaders share ideas with NPs or create a comfortable environ‐
ment for NPs to practise (Poghosyan, Nannini, Finkelstein, et al., 2013).
All survey items had a four‐ point Likert scale ranging from “strongly
agree” to “strongly disagree.”
The authors took two approaches, conceptual and empirical, to
ensure that the survey items could be grouped and used to provide
evidence about transformational leadership from the perspectivesof
NPs. First, they each independently reviewed the survey items
completed by NPs and mapped the items on each transformational
leadership factor. They had regular conference calls to review the
alignment of the items on each transformational leadership factor and
resolve discrepancies. The authors achieved consensus re‐ garding
which items conceptually map to which transformational leadership
factors. After the mapping, the authors took an empiri‐ cal approach
and computed the internal consistency reliability co‐ efficients,
Cronbach’s alphas, of the item groupings to demonstrate how well the
items measure the same construct (Cronbach, Gleser, Nanda, &
Rajaratnam, 1972).
| Data collection
We used electronic survey methods to collect data from NPs. A survey
was developed in SurveyMonkey—a web‐ based platform for
administrating surveys and collecting participants’ responses. The
NYNPA sent an email invitation with the online survey link to NPs
within the five primary care specialties. The invitation de‐ scribed the
study, its purpose, as well as participants’ rights, and asked that only
eligible NPs participate in the study. The first screen in the online
survey contained the eligibility questions for NPs practising in primary
care settings. The NPs’ responses to these questions determined
whether they could proceed to the full survey. The survey took
15–20 min to complete. We followed a modified Dillman process for
online surveys and sent reminders to achieve a maximum response
rate (Dillman, Smyth, & Christian, 2009).
3 | DATA ANA LYSIS
We analysed the survey data using SPSS 24 statistical software
(https://www.ibm.com/analytics/us/en/technology/spss/). After
mapping the survey items on each transformational leadership fac‐
tor, we computed Cronbach’s alphas. Then we dichotomized each
survey item by combining “strongly disagree” and “disagree” re‐
sponses into a “disagree” category, and “strongly agree” and “agree”
responses into an “agree” category. We computed the proportions
POGHOSYAN AND BERNHARDT | 4

of NPs agreeing and disagreeing with each statement. Descriptive
statistics were computed on all demographic variables. Categorical
variables such as sex and education were studied via frequency ta‐
bles. The distributions of the continuous variables such as age were
examined by means and standard deviations.
4 | RESULT S
primary care practices affiliated with hospitals. The rest practisedin
community health centres, which are practices receiving govern‐
ment funding.
Table 2 presents NP responses to the items mapped on each
transformational leadership factor and their respective Cronbach’s
alphas, which were above 0.70 (Cronbach et al., 1972). The
Cronbach’s alphas ranged from 0.785 to 0.902 and provided empiri‐
cal evidence that the items measure the same construct.

Overall, 342 NPs accessed the survey; out of which 64 reportedthey

did not deliver primary care and 278 NPs completed the sur‐ vey.
TA B L E 2 Nursing practitioners’ responses to the survey items
Table 1 demonstrates the demographic and work characteris‐ tics of
assessing each dimension of transformational leadership
the study participants. Ninety per cent of the participants were white
and female, with an average age of 52 years. Fifteen per cent of the NP responses (Percent
Transformational leadership factors disagreeing) % (n)
NPs had less than one year of experience in their cur‐ rent position.
Most NPs (53%) practised in physician offices—clin‐ ics owned by Idealized influence (Cronbach's alpha = 0.895)

physicians. Thirty‐ four per cent of NPs practised in

Leadership informs NPs about changes 29.9 (83)
TA B L E 1 Demographic and work characteristics of the NPs taking place in the organisation

Leadership takes NP concerns 33.1 (88)

from New York

seriously
Characteristics N = 278
Leadership shares information equally 50.6 (133)
Demographics with NPs and physicians
Age (years) Leadership treats NPs and physicians 57.4 (147)
Mean (SD) 52.03 (9.56) equally

Range 24–75
Inspirational motivation (Cronbach's alpha =
0.785)
Sex % (n)
My contributions to the organisationare 9.0 (25)
Female 90.2 (220) visible
I am able to review outcome measures 30.3 (77)
Race % (n)
of my care

White 92.8 (219)

Highest nursing degree % (n) In my organisation, there is a system in place 32.7 (86)
to evaluate my care

I regularly get feedback about my 33.8 (94)

performance in my organisation
Intellectual stimulation (Cronbach's alpha
Master's degree/post‐ master's certificate 84 (205)
Doctor of nursing practice (DNP) 7 (18) = 0.830)
Other 9 (21) My organisation creates an environ‐ 15.8 (42)
Work characteristics ment where I can practice
independently
Years in the current position % (n) 25.8 (66)

Less than 1 year 15 (37)

Leadership promotes an environment that
1–6 years 41 (99) is comfortable to work in
More than 6 years 44 (107) Leadership encourages NPs to share 39.8 (102)
Average hours worked per week % (n) their ideas
45.9 (122)
Less than 20 hr 17 (43)
NPs are represented in important
20–40 hr 43 (104)
committees in my organisation
More than 40 hr 40 (97)
Main practice site % (n) Individual consideration (Cronbach's alpha =
Physician's office 53 (98) 0.902)

Community health centre 13 (25) I feel valued by my organisation 24.4 (62)

Hospital‐ affiliated practice 34 (63)

POGHOSYAN AND BERNHARDT | 5

In my organisation, leadership 35.2 (84)

supports NP ideas

Leadership pays attention to NP 35.2 (88)

requests

In my practice setting, leadership 38.0 (95)

listens to NPs
POGHOSYAN AND BERNHARDT
On the four items on the idealized influence dimension, the re‐
sponses of NPs varied widely, from about 30% to 57% of NPs dis‐
agreeing with the statements. The majority of NPs reported that their
leadership informs NPs about changes taking place in their
organisations, with about 30% of NPs disagreeing with this state‐
ment. Similarly, almost one‐ third of the participants reported that
leadership did not take their concerns seriously. More than half of the
NPs reported that their leadership did not share information equally
with NPs and physicians. Nurse practitioners’ responses to the items
mapped to the inspirational motivation domain also ranged very widely
with more positive response from NPs. Between 9% and about 34% of
NPs disagreed that aspects of inspirational motiva‐ tion do not exist
in their practices. For example, only about 9% of NPs reported that
their contributions to the organisation were not visible; however,
33.8% of NPs reported not receiving performance feedback.
Nurse practitioners’ responses to the items in the intellectual
stimulation domain also had a wide range. Only about 15% of NPs
reported that their organisation lacked an environment where NPs
could practise independently. However, more than 45% of the NPs
reported that NPs were not represented on important organisational
committees. About 40% of the NPs reported that their administra‐
tion did not encourage NPs to share their ideas.
On the individualized consideration factor, the responses were
more similar with between 25% and 38% of NP reporting negative
findings. About one quarter of NPs reported being valued by their
organisations. Almost 40% of NPs indicated that leaders in their or‐
ganisations did not listen to NPs. More than 35% of NPs responded
that their leadership did not support their ideas or pay attention to
NPs’ requests.
5 | D I SC U SS I O N
Transformational leadership is an effective style of leadership in health
care organisations. It has also been recognized as an effec‐ tive
strategy to maximize the contributions of APRNs to patient care
(Kapu & Jones, 2016). As far as we are aware, this is thefirst study
that investigated transformational leadership from the perspectives of
primary care NPs to provide insights to help pro‐ mote NP practice. As
more NPs are being employed in different types of primary care
practices in the United States, it is criti‐ cal to understand how to
enhance NP practice through effective leadership.
Our findings indicate that NPs recognize the presence or ab‐ sence
of the four factors of transformational leadership and appear to
understand their purpose and roles as followers to advance the
mission of the organisation and help achieve the organisationalgoals.
However, we found a wide variation in NPs’ responses re‐ garding
aspects of transformational leadership. While many NPs agree that
their leaders exhibit qualities of a transformational leader, such as
making NPs’ contributions to the organisation visible or creating an
environment where NPs can practise independently,
| 6
others indicate opportunities for their leaders to more fully apply the
factors of transformational leadership such as treating NPs and
physicians equally and sharing the resources between these clini‐
cians in a similar manner. Nurse practitioners’ responses indicate that
transformational leadership aspects exist in their practices—
particularly inspirational motivation, which received most positive
responses from NPs. Transformational leadership has the potential to
motivate NPs and promote NP practice to achieve the collec‐ tive
purpose of primary care practices—ensuring better care for patients.
6 | IMP L IC AT IONS F OR NU RS ING
M ANAG EM ENT
Our findings inform practice leaders about the perception of NPs
regarding the leader qualities in their practices. Nurse prac‐ titioner
responses indicate that many aspects of transformation leadership are
present in their work settings. However, there are aspects that
require attention. A hallmark of transforma‐ tional leadership is the
motivation to follow the leader because the leader is trustworthy and
respected (idealized influence). Perceptions of unequal treatment of
NPs and physicians and lack of communication between NPs and
leadership observed in this study may prevent NPs from following
the leader and believing that they can achieve the results needed. For
example, approxi‐ mately half of the NPs did not feel that their leaders
share infor‐ mation with them or treat them equally as compared to
physicians within their organisations. If NPs do not have access to
resources such as information and perceive they are not being
treated equally, NPs may not find their leaders trustworthy and will
not have a sense of loyalty to their leaders. The perception of unequal
access to resources may breed competition between NPs and
physicians rather than collaboration. Barriers, such as not sharing
information or resources with NPs, should be addressed as it may
affect NPs’ ability to make the extra effort to meet organisational and
patient expectations.
Many NPs reported that their leaders indeed exhibited qual‐
ities consistent with the inspirational motivation factor of trans‐
formational leadership. Yet, a third of NPs reported that their
organisations did not have a system to evaluate the care they provide
nor did NPs receive feedback about their performance. Feedback is a
necessary part of the inspirational motivation needed to encourage
NPs to achieve higher expectations through participation in problem
solving and practice‐ improvement initia‐ tives. Thus, leaders should
provide NPs with timely and construc‐ tive feedback.
Similarly, most NPs reported that their organisations create an
environment where NPs can practise independently (intellectual
stimulation). However, a large number of NPs reported that their
leaders did not encourage NPs to share their ideas or NPs werenot
represented in important organisational committees. Leaders have
the capacity to promote intellectual stimulation by creating a
POGHOSYAN AND BERNHARDT
positive work environment that supports NPs. They can also cre‐ ate
opportunities to involve NPs in important committees where practice
issues related to NP care can be raised and addressed. In addition,
NPs’ input on patient care may be sought by encouraging NPs to share
their ideas to benefit patient care. Leaders will benefit from improved
engagement of and direct input from NPs in their organisations.
Transformational leadership can create a positive work environment
to retain nurses (Brewer et al., 2016). Promoting transformational
leadership in primary care practices may thus also promote NP
retention as many NPs report intending to leave their job (Poghosyan,
Liu, Shang, & D’Aunno, 2017).
The responses of NPs to the individual consideration items were
more comparable. Most NPs felt valued by their organisations.
However, a significant proportion of NPs reported that leadership was
not engaged in listening to NPs or paying attention to NP re‐ quests.
In order to ensure that NPs are effective members of organ‐ isations,
leaders need to be aware of and address NPs’ concerns by seeking this
information from NPs.
Leaders can provide NPs with timely individual feedback about
their care and create mechanisms to evaluate NP care. Such feed‐
back will provide opportunities for improvement. In addition, the
leaders can ensure that NPs have similar access to organisational
resources as other team members taking on similar primary care
provider roles. As primary care is being transformed into care de‐
livered by teams, assuring that NPs are supported in these teams is
critical. Leaders can apply transformational leadership as a process to
improve teamwork. The recommendations from the Institute of
Medicine’s landmark report (Institute of Medicine, 2011) also called
for leaders to expand opportunities at all levels for nurses including
NPs. Our results indicate that leaders can make greater efforts to
empower NPs and help them to become highly productive members in
health care teams focused on improving quality of patient care and
outcomes.
7 | IMP L IC AT IONS F OR RE SE ARC H
Researchers can study the relationship between organisational
structures, leader behaviours, and NP practice. As NPs are em‐ ployed
in various types of primary care practices, it is important to
understand whether the transformational leadership processes are
applied differently in these settings and how they affect NP practice.
The small sample size in this study did not allow such analysis. The
investigation of leadership qualities might inform our understanding of
how to better engage and train leaders in practices employing NPs as
they might not be familiar with the NP role, competencies, and needs.
It is critical for practices to train leaders to meet the needsof NPs in
order to retain NPs and enhance their individual and team
performance. It is thus also important to assess the impact of leader
behaviours on their followers. There are tools to measure transfor‐
mational leadership (Bass & Avolio, 1995; Edwards, Knight, Broome,&
Flynn, 2010) but these tools were not applicable to this study as one of
them was specifically for substance‐ abuse programmes and
| 7
the other one requires the followers to rate the observed behaviour of
a specific leader, which was not the purpose of this study. Rather we
attempted to capture the interpretation of leadership behaviours by
assessing NPs’ perceptions. Our tool can serve a foundation for future
NP‐ specific tools.
8 | L IMIT AT IONS
The study has several limitations. We did not gather data from lead‐
ers; rather, we assessed transformational leadership from the per‐
spectives of NP followers. The study relied on self‐ reports of NPs,
which might affect findings because of social desirability and fear of
being identified; NPs might have sought to ensure a positive image of
their leaders in case their employers gained access to their responses
(Donaldson & Grant‐ Vallone, 2002). Gathering data from NPs about
their organisations is important as individuals can provide valuable
information about their organisations and how organisations affect
their practice and performance (Aiken & Sloane, 1997). We did not
conduct subsample analysis by practice setting type due to small sam‐
ple size. The survey items were also not initially designed to measure
transformational leadership, although this is not a major limitation.
We took both a conceptual and an empirical approach to assure the
item groupings are measuring transformational leadership factors.
Finally, we were not able to compute the response rate for NPs.
9 | CO N CL USIO N
Transformational leadership can be applied in primary care settings to
promote NP practice. Nurse practitioners’ perceptions of leaders’
behaviours identify opportunities for greater collaboration between
leaders and NPs. Future research should explore how transforma‐
tional leadership affects NP practice and outcomes.
E T HI C AL A PP R O V A L
The study was approved by the Columbia University Medical Center
(AAAI9654).
ORC I D
Lusine Poghosyan http://orcid.org/0000‐0002‐0529‐8171
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POGHOSYAN AND BERNHARDT | 12

Nurs Admin Q

Vol. 43, No. 3, pp. 267–273

Copyright Ⓧ
c 2019 Wolters Kluwer Health, Inc. All rights
reserved.

Innovation in Nursing
Leadership: A Skill That Can
Be Learned
Michelle Machon, MSN, RN; Denise Cundy, MS, RN; Helen
Case, DNP, MA, RN

Innovation and creativity are part of everyday life for the bedside nurse. Nursing clinicians
contin- uously innovate and create to meet each patient’s unique needs. However, policies,
regulations, and drama can inhibit that creativity when clinicians move into management.
Three nurse leaders discuss their journeys to bring innovation into their leadership practices
through participation in a yearlong program, the “Executive Fellowship in Innovation Health
Leadership.” The authors share insights gained after they participated in a cohort of health
care leaders who took part in this yearlong fellowship. Details of the fellowship program are
discussed, along with the benefits of entering such a program. Three separate innovation
projects are reviewed. In Iowa, an Assis- tant Vice President of Nursing led the restructure and
development of a support role to remove unnecessary tasks from nurse managers. In
California, a Director of Education, Practice, and Infor- matics took a personal journey to
enhance her senior leadership skills. In Florida, a Chief Nursing Officer created a program
designed to teach nurse leaders to be innovative in health care. Each author addresses the
innovation model/methodologies that they applied in the execution of their individual
projects. Key words: innovation, leadership, nursing

Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
POGHOSYAN AND BERNHARDT
NNOVATION is “a continuous state of
I reimagining what is possible.”1 The In- ternational
Council of Nurses reports that nurses are “critically
positioned to provide creative and innovative
solutions that make a real difference to the
day-to-day lives of our patients, organizations,
communities, and profession.”2 Yet innovation in
nursing lead-ership can be challenging, a challenge
that many leaders can be slow to embrace.3-5 Stud-ies
have shown that there are significant differ-ences
between general leadership behaviors and the
behaviors of an “innovation leader.”3
Author Affiliations: Kaiser Permanente, Roseville,
California (Ms Machon); UnityPoint Health, Des
Moines, Iowa (Ms Cundy); and Nemours Children’s
Hospital, Orlando, Florida (Dr Case).
The authors declare no conflicts of interest.
Correspondence: Michelle Machon, MSN, RN, Director
of Clinical Education, Practice and Informatics, Patient
Care Services, Kaiser Permanente, Roseville, CA 95661
(Michelle.m.machon@kp.org).
DOI: 10.1097/NAQ.0000000000000361
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Nursing continues to have a “unifocal, tradi- tional
bedside” culture, where the time spent away from
the bedside working on strategy, education,
innovation, and planning is labeled “nonproductive”
time.6 In the UK, the Na- tional Health Service
promoted a new lead- ership style in the 1990s, by
bringing “man- agerialism” to nursing leadership.
This was based on the belief that the use of profes-
sional managers would innovate the delivery of
nursing care.7 However, operational needs, staffing
pressures, changing reimbursements, declining staff
engagement, rising labor costs, and senior nurse
turnover still place so much pressure on nurse
leaders that they struggle to find the time to
innovate.8 In fact, some experts say that innovation
is “countercul- ture” in health care because health
care is risk-averse, evidence-based, slow-paced, and
compliance-focused. This contrasts to an in-
novation culture that is interested in risk and is
hypothesis-based, fast-paced, receptive to change,
and improvement-focused.9
267
 POGHOSYAN AND BERNHARDT
268 NURSING A DMINISTRATION Q UARTERLY/J ULY–S EPTEMBER 2019
Nurse leaders must be able to define and
implement innovations in their organizations if they
are to solve the challenging issues of today’s health
care environment. There are a variety of courses and
fellowships that aim toincrease leaders’ competency
in this skill. This article details the journeys of 3 nurse
leaders who sought to position themselve s as inno-
vators. They undertook a yearlong fellowship in
health care innovation leadership in one of these
programs.
THE FELLOWSHIP
The Executive Fellowship in Innovation Health
Leadership (EFIHL) is a yearlong, cohort-based
program that seeks to exposeits Fellows to the
nation’s industry leaders so that they may develop
the skills needed to “accelerate their own
organizations’ capacity to innovate.”10 The EFIHL is
offered by Arizona State University (ASU) in collabo-
ration with the American Organization of Nurse
Executives (AONE) and the Amer- ican Association
for Physician Leadership (AAPL). The program offers
mentorship from world-renowned faculty who
provide insight into their experiences with
innovation, on topics ranging from leveraging
existing infrastructures to delivering innovation in
organizations. The nursing mentors are
doctorate-level leaders in health care and disruptive
innovation. They include nursing consultants, clinical
professors and faculty, authors, former chief nurses,
and managing directors. Their nursing wisdom,
advice, and collective knowledge are shared during
quarterly immersions and on monthly calls between
immersions. They advise Fellows to use radical
innovation methodologies by dis- rupting the
competitive landscape rather than using normal
“incremental’ business models. The mentors are
skilled at ensuring that the Fellows became prepared
to view well-known situations, such as staffing
issues, leadership challenges, and budgetary
concerns, througha new lens. EFIHL’s goal is for
graduates to develop the critical-thinking skill sets
needed to address new care delivery approaches
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
in their organizations in terms of quality and
cost. In addition to the 4 scheduled immersions, the
program includes readings, online educational
content, and peer-to-peer mentoring. Fellows are
encouraged to learn and apply the 7 characteristics
of innovation leadership: boundary spanning,
risk-taking, leveraging opportunities, visioning,
adapting, facilitating, and coordinating information
flow.10 Immersions are designed to expose
participants to innovative companies and practices
within and outside health care.
Fellows in the authors’ cohort included leaders
from the nursing, medical, psychol- ogy, and
administration fields. The Fellows benefited from
sharing intradisciplinary per- spectives that
challenge the status quo inside and outside the
nursing profession. The ad- vantage of the mix of
Fellows was that it brought differing viewpoints and
a diversity of thought that was uniquely beneficial to
the whole cohort.
Tony Hsieh, CEO of Zappos, adopts the phi-losophy
that “most innovation comes from outside your
industry applied to your own.” 11 The immersive
experiences for the Innova- tion Fellowship are
therefore planned in both health care and non-health
care industries. Each Fellow is paired with a mentor,
and visits a variety of organizations to learn about
inno- vation and innovative practices. These range
from institutions of higher learning to innova- tion
centers to research laboratories to inno- vative
businesses.
In addition to site visits, the mentors, pre-
senters, and faculty provide participants with an
extensive and wide-ranging collection of reading
material. This list includes books, pub- lications,
podcasts, articles, and TV shows.
THE PROJECTS
Each Fellow is required to develop a project that
brings innovation to his or her work or organization.
The following first-person ac- counts of the
methodologies and results from the authors’ projects
are shared as an example of innovation led by a nurse
leader.
POGHOSYAN AND BERNHARDT
Innovation in Nursing Leadership: That’s no Oxymoron!
Denise Cundy, MS, RN, Assistant Vice Pres-
ident, Nursing Excellence and Care Coor-
dination, UnityPoint Health, Des Moines,
Iowa.
Over the past 2 years, the nurse managers in our
organization have repeatedly reported that they
“have too much to do” and “can’t get it all done.” To
address this, an exercise was conducted with the
nurse managers to identify what tasks or
responsibilities could be removed from their
accountability. The results showed that nurse
managers are of- ten involved in tasks that do not
require a nurse manager, or even a nurse, to
complete. In response, a support role for nurse
man- agers was developed that would allow them to
complete their necessary tasks while afford- ing them
time and freedom to lead their teams. We gathered a
group of nurse managers to assist in defining this
support role. We went back to review the list of
“tasks” that they had identified to “come off their
plates.” We brain-stormed further as to what would
make their leadership work more meaningful. The
man- agers believed that if they could be relieved of
the most time-consuming tasks on the list, they
would be able to get out of their offices to perform
both employee and patient round- ing. They would
have time to lead their teams in execution of quality
and process improve- ment initiatives. They felt that
these leader-ship activities would make the most
impact on staff engagement, staff retention, and
qual-
ity of patient care.
The time-consuming tasks to be given up were
identified as: creating staff schedules, the ongoing
maintenance of schedules, day-to- day staffing
issues, payroll activities, absence tracking, and data
mining to drive practice and decision-making.
(These tasks do not re- quire a manager, or even a
nurse, to perform them.) We explored roles and
structures in other organizations, and took a “field
trip” to observe a similar role recently implemented
in another organization.
The identified non-management-level activ- ities
culminated in a job description for a System
Scheduler. Essential functions of this new role
include: balancing of the schedule
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
269
after self-scheduling is completed; finalizing and
publishing of the schedule; maintaining an accurate
and current schedule within the program at all times
as it relates to schedule changes, sick calls, etc;
negotiating to fill gaps in the schedule; assuring
accurate timekeep- ing through the payroll system in
regard to hours worked, paid time off, charge and
pre- ceptor pay, incentive pay, etc; tracking of oc-
currences of absences and alerting the man- ager
when related policy violations need to be addresse d
with a specific employee; and tracking of licensure
and certifications. While there is no specific education
or background requirement for this role, it has bee n
deter- mined that a bachelor’s degree and/or a busi-
ness or analytics experience is helpful. For
standardization of how the role is utilized, all
system schedulers report to one individ- ual, rather
than to each leader. However, the system schedulers
are very much integrated within the teams they
serve. They visit the de- partments daily on various
shifts, and attend department meetings to develop
relationships with the staff.
In order to support the full-time equiv-alents
needed for the new role, managers were assigned to
oversee 2 nursing units, rather than 1. The
reduction in the number of managers was
accomplished through at- trition. Each nursing unit
retained the clini- cal supervisor role that was
already in place. When planning for implementation,
we antici- pated 4 outcomes: improved manager
satisfac- tion, improved manager effectiveness
scores on our employee engagement survey, im-
proved nurse sensitive indicator metrics, and
decreased nursing labor costs related to the
standardization of scheduling practices.
Two system schedulers were hired in May of
2018. The role’s original primary focus was
scheduling, payroll, and absence track- ing. There
was a transitional period during which staff learned
to go to the system sched- uler for scheduling needs,
and nurse managers learned to concede that
responsibility. One of the 2 original System
schedulers did not stay in the role. That position was
refilled, and 2 additional schedulers have been
added.
 POGHOSYAN AND BERNHARDT
270 NURSING A DMINISTRATION Q UARTERLY/J ULY–S EPTEMBER 2019
As anticipated, there has been a signif- icant
learning curve for all involved. Early observations
point toward the role’s success in providing leaders
the time to lead their teams rather than complete
tasks. Anecdotal feedback from the nurse managers
involved indicates that they are happy with the
change, although issues remain to be resolved as the
position matures. A second “pulse survey”
measuring manager effectiveness in October of 2018
demonstrated improved scores for the managers
utilizing this role. Other nurse leaders who have
observed the process have eagerly asked for a system
scheduler for them- selves. The impact on
nurse-sensitive indica- tors and labor costs is yet to
be determined.
Michelle Machon, MSN, RN, Director of Ed-
ucation, Practice and Informatics, Patient
Care Services, Kaiser Permanente, Roseville,
California.
My Fellowship was a highly personal jour- ney to
innovate my own leadership style. Twoyears ago, I
was intrigued by one sentence from my Chief
Nurse, who stated that she was looking forward to
working with me to “hone my senior leadership
skills.” This com-ment led to some deep
introspection. I real-ized I needed to develop more
senior leader-ship skills to progress in my
profession. My
Figure 1. Microclimate model.12
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Fellowship mentor and I used the concepts of
human-centered design to leverage Zuber’s
microclimate model for innovation. 12 We ac- tively
applied this model as a guide to developsenior
leadership skills over the yearlong pro- gram, which
was placed in a framework called“situational
intentional leadership.” Together, we created a
framework of personal leader- ship innovation by
applying the model, usingintentionality, and
introspection as tools for improvement.
The microclimate model (Figure 1) usesa
combination of advocate support, enabling
conditions, and change agent behaviors to cre- ate an
atmosphere for human-centered design to
flourish.12,13
The resulting framework for “situational,
intentional leadership” has 6 potential steps for
nurse leaders seeking to refine their lead- ership
skills.
1. Seek honest feedback. At the start of
the Fellowship, I approached the
members of my teams: my supervisor
(the Chief Nurse Executive); my peers
(Nursing Di- rectors) in Nursing
Administration; and my team in
Education, Practice, and In- formatics. I
discussed the Fellowship and said that I
would be asking for their honest
feedback after interactions,
POGHOSYAN AND BERNHARDT
Innovation in Nursing Leadership: That’s no Oxymoron!
Figure 2. Situational intentional leadership frame-
work.
meetings, and discussions over the next few
months. I received positive feed- back, but,
the point of the fellowship was to innovate
and improve those leadership skills, even if my
colleagues’ perceptions of current skills was
positive.
2. Deep introspection. This step was very
difficult for me, as my style is to be
more a “doer” and less of an “intro-
spector.” Journaling was never a strong
point for me, and internal observations
on my leadership style were
uncomfort- able, which in itself was a
learning. I set time aside to observe
other leaders in action. I also reviewed
my communi- cation style, appearance,
and emotions. I contemplated how I
could incorpo- rate these observations
mindfully into my leadership practice.
3. Extensive reading about leadership
styles. As an educator, I am aware that
anything you want to improve must be
studied. For my Fellowship work, this
step involved reading hundreds of arti-
cles on leadership styles, behaviors,
and specific areas that I knew I
particularly needed to improve on.
These included showing emotions at
work, having cru- cial conversations,
C-suite-level commu-
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
271
nication skills, and intentional change theory.
Many of these articles and books were not
related to health care. I no- ticed that there is
significant research about leadership
development in gen- eral but much less
information about developing senior nursing
leadership skills.
4. Interviewing the experts. This step was
accomplished by conducting in- terviews with
4 highly respected se- nior leaders (C-suite) in
my organization. The interviews focused on
how these leaders had developed their
leadership styles, the lessons they had
learned over time from great mentors, and
their feedback/advice to me personally about
my leadership style. While at times it was a
little uncomfortable for both in- terviewer and
interviewee, this last step was vital in
determining what I needed to do to improve
my senior leadership skills.
5. Test changes. Part of Zuber’s microcli-
mate model 12 involves prototyping per-
sonal change. This requirement led me
to make the changes I was learning
about in my everyday work life. I uti-
lized the advice given to me in the
interviews and made the small recom-
mended changes to my appearance,
per- sonal presentation, and
communication skills. I also spent
significant time learn- ing how to
manage my reactions in dif- ficult
situations.
6. Check results. Toward the end of the
fellowship, I went back to my peers and
colleagues and again sought their feed-
back on my leadership style. However,
their feedback was not my only means
of appraising success. It was also
apparent to me, as I communicated
with different groups, that I had indeed
changed over the year and that my
communication and leadership style
had improved. It is now more
deliberate, intentional, and based on
the work situation in which I find
myself at any given time.
The result for me has been a positive and
transformational experience. Seeking
 POGHOSYAN AND BERNHARDT
272 NURSING A DMINISTRATION Q UARTERLY/J ULY–S EPTEMBER 2019
deliberate input into one’s performance, ask- ing
very specific advice that relates to you as a leader,
introspecting on that advice, making recommended
changes and then reflecting on the results of those
changes has been an exer- cise that I have never
taken the time to do in my career, yet it has offered
so much to me as I move forward in nursing
leadership.
Helen Case, DNP, MA, RN, Chief Nurs- ing
Officer and Operational Vice Presi- dent,
Nemours Children’s Hospital, Orlando,
Florida.
In 2017, I received notice that an organiza - tional
engagement survey revealed the direct reports in my
department had a significant decrease in
engagement from previous Na- tional Database of
Nursing Quality Indicators satisfaction survey results.
When I asked the nursing leadership team members
what they believed was the underlying cause for this
downturn, I received these reasons: policies,
procedures, regulations. and lack of auton- omy for
the nursing staff. I know that all of these have a
potential to stifle creativity and organizational
engagement. In retrospect, this outcome could
have been expected, as the organization is only 6
years old. There had been ongoing creativity,
innovation, and en- gagement in building a beautiful
new hospital. Now, however, the reality of managing
it was taking hold . . . and day-to-day management of
an existing organization did not match the
excitement of building something new.
I determined to search for a way to reignite the
creativity of our nurse leaders. The first step was to
have each leader complete the StrengthsFinder14
survey. This tool was ex- tremely important, as our
diverse team had only been together for less than 2
years. The tool identified our individual strengths to
help us understand our team dynamics and fully uti-
lize each team member’s talents. The survey results
provided a method to leverage each person’s
strengths. I was fortunate to find and participate in
the ASU/AONE EFIHL program to guide me in this
work.
During our first class (October 2017 in Phoenix), I
learned I needed to increase my innovation skills.
When the instructor gave me a bag filled with
different objects and told
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
me to assemble them, I asked “where are the
instructions?” Clearly, I had missed thepoint about
innovation! There were 3 addi- tional cohort
meetings spread throughout the year in various
states that had excellent cen-ters where creativity
and innovation thrived.My program mentor
provided much needed encouragement when I got
bogged down.
We were just beginning our organization’s Magnet
journey. My challenge was to translate what I learned
in my Fellowship into actions that would support my
goal of enhancing my direct reports’ engagement. I
gleaned from the program that passion is the key to
engage- ment. By tapping into each leader’s passion
for nursing, my team could unite in a way that
would be unique and innovative while achieving the
goal of advancing the nursing department on its
Magnet journey. Key steps included establishing a
vision (to define a clear direction for the journey) and
creating a path- way for mission, vision, and strategic
planningin an environment of optimism. Innovation
and creativity do not result in “big bang” in-
stantaneous change. That requires an ongoing
application of hard work and perseverance. After all,
Edison did not invent the light bulb in one try; it took
him hundreds of failures be- fore he was successful. I
needed to keep that in mind as I pursued my nurse
leader engage- ment goal.
The outcome of applying my learning ex-
perience to our organization’s journey was
achievement of essential building blocks for
achieving Magnet status. These included de-
velopment of the Nursing Professional Prac- tice
Model, mission, vision, and key elements of the
strategic plan. Early indications were that real
progress was being made toward im- proved
engagement among the team.
Overall, this outcome is no small accom-
plishment. These key elements needed to be
completed. I validated that opening your eyes and
seeing things differently takes practice. The team
took the essence of the Professional Practice Model
and designed one that is responsive to the changing
landscape of a growing professional practice. As we
com- plete those building blocks, intense leader
work has not yet assisted leaders in fully
 POGHOSYAN AND BERNHARDT

Innovation in Nursing Leadership: That’s no Oxymoron! 273

regaining their engagement in the organiza- tion. A

follow-up “pulse survey” demonstrated that there wa s CONCLUSION
a continued decrease in engage- ment. This was
followed by an annual survey completed after an The Institute of Medicine report “The Fu- ture of
additional 6 months that demonstrated Nursing, Leading Change, Advanc- ing Health”
gradually increasing engagement. summarizes the need for nurs- ing innovation in
We are not “there” yet, but our journey to both health care: “the future of health care rests solidly
Magnet and engagement continues. The next steps with the strength nursing brings in holistic care,
will be to continue to engage the leaders in ability to col- laborate and innovate from the
innovative learnings, building on what engagement bedside to the community, and the ability to adapt
looks like to them. We will continue to build the to the changing environment.”15 Three nurse leaders
structures that sup- port innovation and change. We have embarked on journeys to bring the spirit of
have realized that achieving change and learning to innovation to nursing leader- ship in their
think differently are not easy tasks. We will keep the organizations. They have learned that the skills
conversation going about innovation, and promote necessary for this work can be learned. The
interprofessional education on inno- vation. It will authors’ recommendation is that nurse leaders study
take patience, persistence, and coalition building, industries and or- ganizations both inside and outside
but innovation must occurfor the good of patients, health care to learn how to thrive by innovating
organizations, and nurses. from within. All of us can become more innovative
through study, education, and mentoring.

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