Enhancing Nurse Moral Agency: The
Leadership Promise of Doctor of
Nursing Practice Preparation

^ m d

Abstract

…it is more critical
than ever that we
remain mindful
about the demands
of ‘good’ patient
care.

The development
of knowledgeable
and skillful nurse
leaders is
necessary to
enhance
interdisciplinary

Pamela Grace, PhD, RN, FAAN

An expansive and growing body of literature documents the problem of nurses’ moral distress when
they are unable to carry out actions that they perceive to be in the best interests of patients.
Further, nurse leaders and educators are not always well prepared to help nurses to develop moral
agency. Moral agency is the ability to provide good care and overcome obstacles to good practice.
One reason for the lack of preparation is that ethics education in academia, and in ongoing nurse
education, has been inconsistent or has focused more on dilemmas than the ubiquitous everyday
practice issues. The purpose of this article is to discuss goals of the nursing profession,
contemporary challenges to good nursing practice, and leadership from those educated as Doctors
of Nursing Practice (DNP). The author argues that the proliferation of (DNP) programs, focused as
they are on leadership in practice settings, presents a unique opportunity to prepare nurse leaders
who are, first and foremost, skilled and knowledgeable about the ethical content of everyday
nursing practice. An ‘ethics matrix’ is described and proposed as an essential base for DNP
education upon which all other knowledge is built, with specific discussion of types of leadership and
the relationship of transformational learning to transformational leadership.

Citation: Grace, P., (January 31, 2018) “Enhancing Nurse Moral Agency: The Leadership Promise of Doctor of
Nursing Practice Preparation” OJIN: The Online Journal of Issues in Nursing Vol. 23, No. 1, Manuscript 4.

DOI: 10.3912/OJIN.Vol23No01Man04

May I stress the need for courageous, intelligent, and dedicated leadership … leaders of sound integrity. Leaders
not in love with publicity, but in love with justice. Leaders not in love with money, but in love with humanity.
Leaders who can subject their particular egos to the greatness of the cause. (Dr. Martin Luther King, Jr. Challenge
of the new age (speech on the Prayer Pilgrimage for Freedom in Washington, DC, May 17, 1956).

Dr. King’s plea was for leadership during a troubling era. He hoped to change
prevailing societal attitudes toward African American citizens of the United States
(U.S.). His words remain cogent today for other settings where social justice and
human dignity are at risk. For healthcare professionals, it is more critical than
ever that we remain mindful about the demands of ‘good’ patient care. So many
pressures exist (e.g., financial, political), and it can be expedient to neglect or
even abandon professional goals and responsibilities (Bultas, Ruebling, Breitbach,
& Carlson, 2016).

Additionally, nursing leaders both in academic and clinical settings must often walk
a tightrope between the economic or reputational/visibility demands of the
institution or school, and upholding professional goals (Gaylord & Grace, 2018;
Jacob, 2009; Lown, 2007). All of these factors add to the urgency of developing
nurse leaders who have the knowledge and skills to educate and support point-of-
care nurses in their work and their ability to advocate for good patient care at
whichever level is required: immediate, institutional, or even policy. Skills of
communication and collaboration are also important. The development of

collaborations for
quality, safe patient
care.

Goals of the Nursing Profession

Nursing goals serve
as the main
anchors for
understanding our
ethical
responsibilities…

These three
domains form an
ethical matrix upon
which to build
other essential
knowledge and
skills for advanced
nursing practice
and leadership.

…it is important to
confirm the DNP
role as one of
ethical

knowledgeable and skillful nurse leaders is necessary to enhance interdisciplinary
collaborations for quality, safe patient care.

The purpose of this article is to present an argument that doctor of nursing practice (DNP) graduates focused, as
they ostensibly are, on developing the expertise for good practice, should first and foremost be prepared for
ethical leadership. As noted in the American Association of Colleges of Nursing’s (AACN) document, The Essentials
of Doctoral Education for Advanced Nursing Practice (2006), promulgating the DNP degree was important for
several reasons. Among the reasons was that “expansion of scientific knowledge [is] required for safe nursing
practice [amid] growing concerns regarding the quality of patient care delivery and outcomes. Practice demands
associated with an increasingly complex health care system created a mandate for reassessing the education for
clinical practice for all health professionals, including nurses” (p.4). Logically then, DNP curricula must be firmly
rooted in disciplinary knowledge; an understanding of responsibilities of the nursing profession to individuals and
society; and a grasp of the role of interdisciplinary collaboration in achieving quality healthcare.

The education of DNPs is an ethical undertaking because advanced nursing practice is no less about facilitating
human health and well-being than are other nursing degrees. All subsequent specialty knowledge and skills
needed for advanced practice should be built upon professional goals and from the unifying perspective of nursing
as developed over time. The historically developed, central unifying focus of nursing has been articulated as
“facilitating humanization, meaning, choice, quality of life, and healing in living and dying” (Willis, Grace, & Roy,
2008, p. E28). Further, I propose that DNPs can, and ought to, be developed as transformational leaders.
Transformational leadership is the ability to empower and motivate others toward a common vision or common
goals, as explained shortly (Gaylord & Grace, 2018).

Ethical aims of nurses to provide humane, quality nursing care anchored in the goals and mandates of our
profession should be front and center for all our initiatives including, and most importantly, the development of
nurse educators and leaders (American Nurses Association [ANA], 2010; ANA 2015; Willis et al., 2008). As a
reminder, these goals are “the protection, promotion and restoration of health and well-being; the prevention of
illness and injury; and the alleviation of suffering” (ANA, 2015, p. vii). The types of influences that can distract us
from maintaining a focus on ethical care are well documented in the literature and seem to be increasing despite
the Institute of Medicine report (2010) outlining the nursing role in assuring quality care goals (Jurchak et al.,
2017; Liaschenko & Peter, 2016; Miller, 2006; Starr, 2011).

Nursing goals (ANA 2010; ANA 2015; International Council of Nursing, 2012)
serve as the main anchors for understanding our ethical responsibilities and
constitute the connecting fibers of what could be called an ‘ethics matrix.’
However, understanding ethical responsibilities, while necessary, is insufficient for
good practice. Knowledge of ethics ‘language’ and skills is also critical. A grasp of
the nuances of ethical principles and their relationship to ethical decision-making
and moral agency (i.e., acting for the good) are also important as they provide a
common language for team decisions. A third essential facet is the development of
personal characteristics that motivate one to take action and persevere to
complete needed actions.

These three domains form an ethical matrix upon which to build other essential
knowledge and skills for advanced nursing practice and leadership. An additional
slate of knowledge and skills deemed essential for advanced practice nursing
across settings is outlined in the AACN (2006) DNP ‘Essentials’ document. These
more specialized knowledge and skills, such as “Scientific Underpinnings for
Practice” (Essential I) and “Organizational and Systems Leadership…” (Essential
II), along with the other essentials, should be firmly rooted in and emanate from
the three-domain ethical matrix to provide cohesion among them. To state this
another way, the Doctor of Nursing Practice degree is first and foremost a nursing
degree predicated on furthering nursing goals.

Those responsible for informing, revising, and/or developing national program and
accreditation standards should consider building curricula essentials upon this
ethical matrix as an integrating force. It is critical that emergent DNP leaders in
the discipline are equipped with the knowledge, skills, and motivation to transform
nursing practice and be instrumental in the development of ethically aware,
motivated nurses. As DNP programs continue to proliferate, it is important to

Being mindful of
limited resources
and justice in the
allocation of them
is also an ethical
issue.

transformative
leadership…

Contemporary Challenges to Good Nursing Practice

…[business]
principles can
sometimes collide
with human-
centered goals of
quality patient
healthcare.

The Promise of DNP Leadership

confirm the DNP role as one of ethical transformative leadership regardless of
specialty practice area.

Challenges posed by contemporary nursing practice environments require pro-
active, transformative leaders who can facilitate nurses’ confidence in their ability
to act for patients at the bedside, in the community, and in influencing policy
making (Gaylord & Grace, 2018). There are knotty tensions between the need for
cost-containment and profits in the U.S. healthcare system, and the reasons that
healthcare professions and institutions exist. Stated another way, healthcare
institutions, both inpatient and outpatient, exist because people have a critical
need for them to assist in addressing a broad array of possible healthcare needs,
not solely physical illness. The central unifying focus and nursing goals provide the
broad perspective of nursing related to a focus on health and well-being that
extends beyond illness.

When the provision of healthcare becomes primarily a business, corporate goals of profits can overpower human
service goals, straining clinicians’ ability to primarily focus on patients and their needs (Mechanic, 2006;
Rosenthal, 2017; Starr, 2011). Therefore, persons with unmet healthcare needs depend on professionals and
institutions that expressly exist to fulfil these needs to actually so do.

The current situation in the U.S. is that a substantial portion of healthcare is
susceptible to business principles and these principles can sometimes collide with
human-centered goals of quality patient healthcare. This is not the same as saying
that cost-effectiveness in healthcare is unimportant; it is of course a very
important consideration. Being mindful of limited resources and justice in the
allocation of them is also an ethical issue. Even countries without a profit incentive
in the provision of healthcare have to ensure cost-effectiveness as a social justice
issue, as discussed in detail elsewhere (Grace, 2018; Johnson & Stoskopf, 2010).
However, the United States, it has been argued, does not have an integrated
healthcare ‘system;’ we do not have an overarching organizing structure for
healthcare delivery from cradle-to-grave or from promoting and maintaining

health to acute and chronic illness care. This situation in the United States complicates the task of healthcare
professionals to further goals of good healthcare for individuals and society (Chaufan, 2015; Elhauge, 2010;
Powers & Faden, 2006). What nursing can do as a profession is to highlight and try to remedy injustices that
interfere with people living a ‘minimally decent life’ by informing and influencing policy at the individual level, and
advocating for good patient care (Grace & Willis, 2008; Powers & Faden, 2006).

Recent moves to make a DNP degree the entry level education for advanced practice nursing, despite ongoing
critiques, seem unstoppable at this point (Dracup, Crononwett, Melies, & Benner, 2005; Martsolf, Auerbach, Spetz,
Pearson, & Muchow, 2015; McLeod-Sordjan, 2014; Miller, 2008). A positive aspect of this change in advanced
practice preparation, with its emphasis on leadership, is the promise the movement holds for good (i.e., ethical)
patient care and remediation of injustices for disadvantaged populations (as related to receiving quality
healthcare, including primary care). Specifically, transformational leadership skills and characteristics are needed
(Gaylord & Grace, 2018; Marshall & Broome; 2016).

Coherent and comprehensive preparation for doctoral (i.e., DNP) level practice requires both a rigorous curriculum
that prepares leaders who understand the nature of their role as embedded within the profession and its goals,
and essential ingredients (i.e., knowledge and skills) for leading others. Fundamental to this preparation is, as
noted earlier, an education rooted in an ethics matrix.

Another way to view this idea of building ethical competence is to consider Rest’s (1982) four cognitive processes
that give rise to moral agency. From an extensive review of interdisciplinary literature including that of the
cognitive sciences, Rest, a cognitive psychologist, theorized four non-hierarchical, iterative, and interrelated
processes that take place in the mind of a person engaged in moral decision-making with an intent to act
(implying both cognitive and affective components). These processes are developmental in nature and can be
cultivated. Described in numerical order below for discussion purposes, they are interactive processes and not
linear in nature.

First, Rest purports that there is an ‘interpretation of the situation’ that includes ethical aspects (moral sensitivity).
Second, the person draws on prior knowledge to make sense of the situation and decide what should be done
(moral reasoning). Third, a decision is made among competing actions to determine which is the likely best action
given knowledge of the situation (motivation). Finally, one envisions the steps to take and obstacles to overcome

A ‘Wake Up’ Call for the Profession of Nursing

Building these skills
should be an
imperative of the
ethics of the
profession.

A unifying core
understanding of
responsibilities of
the profession
coupled with
fluency in ethics
language and
techniques can
provide context,
stability, and
coherency…

Rooting All Curricula in an Ethics Matrix: An Ethical Imperative

Expedient actions
are those based on
convenience,
efficiency, personal
ease, or fear of

(moral character) (Grace, 2018; Rest & Narvaez, 1993; Rest, 1982; 1983). Given the preparation that advances or
refines a DNP’s capacity to engage in moral agency, development of a large cohort of ethically aware and skilled
leaders is possible. This cohort can in turn serve to develop the ethical confidence of students, point-of-care
nurses, colleagues, and allied professionals.

If the doctor of nursing practice role is significantly one of leadership, then DNPs must understand the unique
nature of their discipline and how nursing goals and perspectives are both separate from, but overlapping with, the
goals of allied health professions. All healthcare professionals (self-evidently) share ultimate goals to improve the
health of individuals and society, but they do so through the different lenses of their professions, and profession-
specific aims. At times, these goals coalesce and require the pertinent professions to seek collaborative input to
move an objective forward.

The essential set of characteristics, knowledge, and skills needed for DNP ethical
leadership is captured both by Rest’s (1982) processes and the previously
discussed ethics matrix, which is informed by Rest’s work. It is critical to base the
development of leadership skills in nursing goals and perspectives and attendant
obligations, the demands of ethical practice, and the motivation to act to improve
practice. This set of knowledge and skills should serve as the basis from which
other essential knowledge, as outlined in the AACN (2006) ‘Essentials’ document,
is built. Building these skills should be an imperative of the ethics of the
profession.

There are two senses of nursing ethics discernable in the literature. In the first sense, nursing ethics is the field of
inquiry that seeks to define such things as good nursing care; the characteristics of good nurses; and how nurses
should act, to name a few. This process of inquiry draws on moral philosophy and its’ derivative, professional
ethics, and includes tools of analysis and synthesis. From nursing ethics, in this sense, we have developed codes
of ethics. In the second sense, nursing ethics is about evaluation of nurses’ actions related to whether or not they
are intentionally focused on meeting the historically developed goals of the nursing profession, as articulated
earlier.

As a simple example, we can ask whether a nurse is intentionally focused on trying to provide a good for or limit
harms to a delirious patient in restraining him, or is he or she restraining the patient because it is the most
expedient action (Grace, 2009). Ethics in this sense is the capacity and intent to further the goals of the profession
and relies on both an understanding of the nature of the services nursing provides and responsibilities to provide
these services in spite of obstacles. Thus, development of DNPs as ethics leaders necessarily includes both the
nurturing and fortification of personal characteristics and predispositions (sometimes referred to as virtues) and a
certain level of fluency in ethics language and associated skills (e.g., situation analysis, mediation, collaboration).

A unifying core understanding of responsibilities of the profession coupled with
fluency in ethics language and techniques can provide context, stability, and
coherency for curricula, educational programs, and the support of point-of-care
nurses. An underlying ethics matrix in which all other essential domains of content
knowledge are rooted is critical (AACN, 2006). Together, the proposed unifying
ethics matrix, insights from Rest’s (1982) processes of moral action, and the
essential content domains and competencies of DNP programs (AACN, 2006)
provide a strong basis for the development of transformational leaders and
educators; those who can serve as ethics resources and build ethical decision-
making and moral agency skills of students, peers, and allied professionals.

All nurses’ actions are subject to appraisal based on the extent to which they align with nursing goals and
perspectives, or not. We are responsible for furthering the best interests of patients and for working toward a
healthy society (ANA, 2010; ANA, 2015; Grace, 2001; 2009; Grace and Milliken, 2016). Thus, actions based on
expediency or other adverse influences that divert us from the goal of patient interests are problematic.

Expedient actions are those based on convenience, efficiency, personal ease, or
fear of censure rather than reactions to patient needs and concerns. For example,
a terminally ill patient tells the nurse that she does not want any more aggressive
treatment but is pressured by her family and the medical team to ‘continue to
fight.’ The patient’s perspective and wishes are being disregarded but she is
reluctant to cause a ‘fuss’ about it for her family’s sake. However, the nurse does

censure rather than
reactions to patient
needs and
concerns.

Nurse Confidence in Ethical Decision Making: DNP as Transformational Leader

…even when
nurses have had
formal education in
ethics in
undergraduate
curricula,
confidence in
ethical decision-
making wanes over
time.

Nurses need
preparation to
exercise moral
agency and to
develop the skills
to collaborate with
others to articulate
the goals and
expected outcomes
of actions.

not help the patient to convey to the team her wishes because she does not want
to alienate the family or physician with whom she must continue to work.

Alternatively, this nurse may not have been adequately prepared to advocate for patients or has lacked support in
advocating for patient good in the past, and perhaps has even received sanctions. Other examples of expedient
actions include succumbing to pressures to complete tasks in a timely manner, but in the process neglecting the
psychosocial or informational needs of a patient. Milliken (2018) expands on these ideas in her recent article on
ethical awareness. In upcoming discussion, I will expand upon the argument for the central role of nurse leaders
and educators, who will increasingly be prepared at the level of practice doctorates, to support and empower nurse
moral agency using transformative leadership skills.

Literature increasingly describes the problem of moral distress among all healthcare providers. Arguably, point of
care nurses in critical or acute care settings are at highest risk for moral distress, because of their place in the
healthcare hierarchy, and because they are often the ones most intimately aware of patient and family expressed
preferences and worries (Robinson et al., 2014). They also do not always see themselves as having moral agency
(Jurchak et al., 2017).

There is an expanding body of knowledge about nurse preparation for ethical
practice, and mounting evidence that, even when nurses have had formal
education in ethics in undergraduate curricula, confidence in ethical decision-
making wanes over time. This is especially true as the complexity of the
environment increases (Jurchak et al., 2017).

The following all point to the need for cohesive, sustained, multi-modal, ethics education and supports. First, there
is increasing literature about nurse moral distress, where nurses experience a sense of powerlessness and disquiet
when unable to do what they perceive as ‘the right thing.’ Second, over ten years of unpublished data from
evaluations of a mandatory graduate ethics course (n = 447) point to the efficacy of this type of educational
offering in building confidence in their moral agency (Grace, 2018). Third, a recent analysis of reasons that staff
nurses and advanced practice nurses (total n = 67) wanted to join a year-long clinical ethics residency for nurses
(Jurchak et al., 2017) highlighted the desperate need for more ethics education.

Nurses may feel that they are silenced (Malloy et al., 2009) or perceive that their
concerns are not heard and considered (Peter, Lunardi, & McFarlane, 2009; Taran,
2011). Thus, to sustain confidence in one’s moral agency and capacity for ethical
decision-making in contemporary practice settings, more than formal ethics
content knowledge is required. Traditional content, such as history of biomedical
ethics; moral theory and principles; and analytic decision-making techniques are
all valuable tools. Possession of these tools, while foundational for moral agency,
is insufficient for consistent action to address problems (Grace & Milliken, 2016;
Robinson et al., 2014). Nurses need preparation to exercise moral agency
(Liaschenko & Peter, 2016) and to develop the skills to collaborate with others to
articulate the goals and expected outcomes of actions.

Knowledgeable and ethically competent educators and institutional leaders are important. Such leaders understand
the goals and perspectives of the profession as well as those of allied professionals. They anchor their actions as
educators, mentors, resources and supporters in the goals and perspectives of the profession. They employ the set
of tools described above to gather more information; gain clarity about the issues; and to explore nuances of a
situation. Further, they have leadership skills that empower others to develop their moral agency.

Transformational
leaders in nursing
understand
professional goals
and the ethical
warrants of nursing
practice…

Ethically Skilled Educators and Leaders: A Role for Doctors of Nursing Practice

…it is incumbent
on the profession
to ensure that the
ongoing
development of the
DNP role reflects
the ethical
foundations of the
profession…

Transformational leadership skills are those most apt to develop the confidence
and skills of others to achieve mutual goals (Marshall & Broome, 2016; Gaylord &
Grace, 2018). Transformational leaders in nursing understand professional goals
and the ethical warrants of nursing practice and are essential to development of
nurses who are confident in their ethical skills and exercise them on behalf of
good patient and healthcare. That is, transformational leaders are those who can
develop and support the moral agency of nurses at all levels and areas of practice.

Well-designed DNP programs will develop graduates who have gained such transformational leadership skills and
the know how to continue to develop these abilities. Such graduates will be both visionary about what is good
practice and have the ability to support it. From essential domains of knowledge, they will understand the big
picture complexities of institutions; how to influence policy; design supportive work environments; and the
necessities of good patient care. Using a sound understanding of nursing ethics,they will move seamlessly among
these areas to educate and support others to develop moral agency. I believe that good practice is equivalent to
ethical practice, as noted above, because good practice aims to meet the goals of patient and societal health,
wellbeing, and the relief of suffering.

As highlighted in the AACN Essentials of Doctoral Education for Advanced Nursing Practice (2006), doctoral
education in nursing has typically been of two main types, research focused and practice focused. Prior to 2004, a
few universities offered practice doctorates in nursing as distinct from research-intensive doctorates but not under
a uniform title, leading to confusion (AACN, 2004; Reid Ponte & Nichols, 2013). The AACN Position Statement on
the Practice Doctorate in Nursing (2004), among other sources, presented several reasons for rapidly developing
more DNP programs.

There is a growing perception of the need for more highly skilled nurse leaders.
“Increased knowledge and skills [are becoming crucial] for clinical and
administrative leadership across services and sites of healthcare delivery” (AACN,
2004, p.2). This requires advanced preparation in areas not typically covered in-
depth in current nursing master’s programs. There is an ongoing faculty shortage
and DNPs could fill a gap (Brown & Crabtree, 2013). Moreover, strong leadership
is needed in institutional and other clinical settings.

Master’s programs in nursing are already credit-intensive so moving to the DNP as entry level for advanced
practice would better match program requirements, credits, and time with the credential earned. These credentials
would also better match professional clinical doctorates in other disciplines (e.g., pharmacy, dentistry,
physical/occupational therapy). Additionally, the DNP degree provides an avenue of scholarship and leadership that
is not as acutely focused on empirical research as is contemporary PhD study (Grace, Willis, Roy & Jones, 2016),
leaving room for development of sorely needed quality, educational, and safety improvement projects.

“Preparation at the practice doctorate level includes advanced preparation in nursing, based on nursing science,
and is at the highest level of nursing practice” (AACN, 2004, p. 3). The AACN statement also proposes that DNP
preparation will improve the image of nursing. Additionally, PhD prepared nurse scholars are increasingly focused
on developing research trajectories and pursuing necessary funding and resources. Such worthy aims can be all
consuming and lessen available time for teaching (Grace, Willis, Roy & Jones, 2016) adding to the existing faculty
shortage; this represents an area for DNP prepared nurses to make an important contribution.

Since 2004 DNP programs have proliferated and now far outnumber programs offering a research focused PhD in
nursing. There are “303 DNP programs are currently enrolling students at schools of nursing nationwide, and an
additional 124 new DNP programs are in the planning stages (58 post-baccalaureate and 66 post-master’s
programs)” (AACN, 2017, p. 3). Regardless of one’s perspective about whether the move to the DNP as entry-level
advanced practice is a good thing for the profession, evidence suggests that in the coming years there will be a
rapid increase in the number of those prepared at this level. Thus, it is incumbent on the profession to ensure that
the ongoing development of the DNP role reflects the ethical foundations of the profession, and historical as well
as contemporary reasons for its existence (Grace, 2001; 2018).

Transactional
leadership is,
arguably, the most
commonly seen in
healthcare settings
and is managerial
in nature.

Underlying,
implicitly or
explicitly, the
achievement of
each [DNP]
essential is ethical
expertise and
leadership
qualities.

Types of Leadership

Transformational
leadership is
aimed at change.

Relationship of Transformational Learning to Transformational Leadership

There are eight aspects of knowledge and expertise considered ‘essential’ for DNP
graduates to possess in the current (first iteration) AACN (2006) document.
Underlying, implicitly or explicitly, the achievement of each essential is ethical
expertise and leadership qualities. However, how to achieve the essentials is still
at least partially left to each school or college. In the following section, I outline
what is known about leadership and leadership qualities and propose that the
nursing profession should focus on developing ethically savvy, transformative
leaders and that DNP programs are an appropriate medium for this initiative.

Definitions of leadership vary according to author, style, and purpose. A synthesized definition, useful for nursing,
is that leaders are effective in moving a group of people toward a shared goal (Curtis, de Vries, & Sheerin, 2011;
Sullivan & Garland, 2010; Weihrich & Koontz, 2005). In a review of studies on the psychology of leadership, it is
defined as “a process of social influence in which one person is able to enlist the aid and support of others in the
accomplishment of a task or objective” (Chemers, 2001, p. 8580). Regarding the DNP role, I define leadership as
both the capacity to anticipate and envision good practice using nursing goals, knowledge, and perspectives to
shape ultimate aims, and the use of knowledge, skills, and expertise to motivate and empower moral agency in
others. Inherent in this definition is the possession of an ability for critical questioning of personal motivations and
a willingness to critique care environments for the ability to provide good care.

While leadership types and characteristics necessarily overlap, two main types of
leadership are evident in contemporary literature. These are ‘transactional’ and
‘transformative.’ Transactional leadership is, arguably, the most commonly
seen in healthcare settings and is managerial in nature. In transactional
leadership there is a power differential, the leader can direct actions based on a
sort of ‘bartering’ system (Gaylord & Grace, 2018). For example, if you accomplish
the task I have given you in a timely fashion, I will give you a bonus. Within
transactional leadership there are three sub-types (Howell & Avolio, 1993). One
focuses on reward, one focuses on negative feedback, and the third allows things
to proceed without much direction but, when things go wrong, steps in to
remediate. Transactional leadership, then, tends to be task-oriented rather than
innovative, prescient, and creative (Howell & Avolio, 1993; Murphy, 2005).

Transformational leadership is aimed at change (Gaylord & Grace, 2018). The
change may involve all actors including the leader and the environment.
Transformational leaders “energize and motivate their followers to achieve their
goals, share their visions, and embrace empowerment” (Grimm, 2010, p.76).
Transformational leadership is relationship based, and empowers others to actions
of which they had not thought themselves capable (Bass & Avolio, 1994).

Characteristics that are common in transformational leaders include: magnetism; possessing internal locus of
control (i.e., see themselves as accountable for actions); offers inspiration; cognitively curious, questioning
assumptions that are made and willing to be personally challenged by others; and the capacity to focus
simultaneously both on the big picture and the needs of followers. In so doing, these leaders act as mentors and
educators (Chemers, 2010; Cummings et al, 2010; Grimm, 2010). Among the goals of transformative leadership,
related to the nursing profession, is the development of moral agency (i.e., motivation and ability to engage in
ethical actions on behalf of self and others) in nurses (Blacksher, 2002; Liascheno & Peter, 2015).

The concept of transformative learning is also important to develop transformational leaders. Those who aim to
empower others need to know how it is possible to help others transform themselves into moral agents. Theories
of transformational leadership have developed within the education discipline. Mezirow (2009) recognized this
transformational side effect of good education after his wife returned to school to advance her education. Further
research led to the development of the concept of transformational education; education that permits a person to
develop, as such:

Transformational learning is defined as the process by which we transform problematic frames of
reference (mindsets, habits of mind, meaning perspectives) – sets of assumption and expectation –
to make them more inclusive, discriminating, open reflective and emotionally able to change
(Mezirow, 2009, p. 95).

Nursing ethics is at
the base of
everything we do
as nurses.

Conclusion

Author

References

One can deduce from this that the process of transformational learning is complex, takes time, and may involve
some disorientation. Transformational education aims to broaden perspectives and develop increasing comfort with
nuances and ‘grey areas.’ My colleagues and I discovered that our carefully designed, multi-modal, eight hour per
month, 10-month long program, the Clinical Ethics Residency for Nurses (CERN), had a transformational effect
upon our graduates, as evidenced in their discussions and evaluation of the program (Grace, Robinson, Jurchak,
Zollfrank, & Lee, 2014; Robinson et al., 2014). They also evidenced decreased moral distress (Robinson et al.,
2014) and increased their moral agency. Participants included both point of care and advanced practice nurses.
End of program essays (analysis in process) also demonstrated that the majority of participants experienced
personal and professional transformation.

Questions remain about what is needed to ensure that DNP education prepares graduates to be transformational
leaders; how can transformational leadership be maintained; and how can transformational leadership translate to
practice and education settings? A starting place to find answers is to reinstitute the importance of an
understanding of the profession of nursing’s origins, evolution, and reasons for continued existence as a separate
entity from other healthcare professions. We have a unique and central unifying focus on humanizing the
healthcare environment and facilitating “meaning, choice, quality of life, and healing in living and dying” (Willis et
al., 2008, p. E28). Perhaps even more important is that we continue to grow all of our education; curriculum
development; research; and practice initiatives or directives from a nursing ethics matrix.

The rapid proliferation of DNP programs means that, in the future, there could be a substantial cohort of persons
prepared to provide ethics leadership in whatever clinical, institutional, or educational setting they are located. As
transformational leaders they will be sensitive to the ethical nature of all nursing and healthcare practice and able
to communicate this to colleagues, students, and important others as an essential starting point. They will
facilitate the development and moral agency of students, peers, and interdisciplinary colleagues.

Anecdotally, many nursing faculty still view ‘ethics’ as an esoteric topic that can be
taught only by those with philosophy or applied ethics backgrounds. I believe this
is a fallacy. Nursing ethics is at the base of everything we do as nurses. It is
helpful to have knowledge of ethics language and skills in ethical decision-making,
but acquiring this knowledge is not as difficult as sometimes supposed. It is
critically important that DNP curricula, along with the expected knowledge and
skills of graduates, are developed with the professional moral imperative for
individual and social good in mind. We need to situate graduates so that they can
envision, refine, facilitate, and meet nursing goals from a nursing perspective.

Pamela Grace, PhD, RN, FAAN
Email: [email protected]

Pamela Grace is an Associate Professor of Nursing and Ethics at the William F. Connell School of Nursing Boston
College. She is an experienced critical care and advanced practice nurse and educator. She holds a PhD is in
Philosophy (1998) with a concentration in medical ethics. She has written and presented extensively on nursing
and healthcare ethics. Her book, Nursing Ethics and Professional Responsibility in Advanced Practice, (2018) is
now in its 3rd edition and is used internationally as a guide to ethics in advanced practice settings.

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