Tuesday, May 8, 2012

Core Measures in Psychiatric Nursing

Jessica A. Ebsen, RN, BSN

College of Saint Mary

Explanation of Critical Issue

            Core measures are a valuable and necessary tool for evaluating the quality and effectiveness of health care.  The Joint Commission has developed the Specifications Manual for National Hospital Inpatient Quality Measures, which contains common data terms, measures and collection forms.  The goal is to establish common measures, minimize data collection efforts, and use the data to improve the health care delivery process.  The current core measure sets include the areas of substance use, tobacco treatment, venous thromboembolism, pneumonia, immunization, acute myocardial infarction, children’s asthma care, heart failure, surgical care, perinatal care, stroke, hospital outpatient department, and hospital-based inpatient psychiatric services (Joint Commission, 2012).

            The hospital-based inpatient psychiatric services (HBIPS) consist of seven core measures.  The measures include (1) admission screening for violence risk, substance use, psychological trauma history and patient strengths; (2) hours of physical restraint use; (3) hours of seclusion use; (4) patients discharged on multiple antipsychotic medications; (5) patients discharged on multiple antipsychotic medications with appropriate justification; (6) post discharge continuing care plan created; and (7) post discharge continuing care plan transmitted to next level of care provider upon discharge.  The risk assessment must include a minimum of two strengths, complete history of psychological trauma, use of drugs and alcohol for the past twelve months, and risk of violence to self or others for the past six months.  The minutes in restraints and seclusion must include the total time that all patients were held in personal or mechanical restraints or seclusion, the start and stop times for all restraint and seclusion events, and a ratio measure per 1,000 hours.  Measures 4 and 5 must include the total of all patients discharged on two or more antipsychotic medications and the justification for use.  Patients who are discharged on two or more antipsychotics must be justified by three or more trials of monotherapy with the failed trial medications listed, plans to taper to mono therapy in progress with medications listed, or a listed medication augmented with Clozapine.  Measure 6 requires a completed continuing care packet which must include a discharge diagnosis, reason for hospitalization, recommendation for the next level of care, and a list of patient’s medications including dosage and rational for each medication.  Measure 7 requires that the complete continuing care packet must contain all elements, and must be sent to the medication provider or therapist within five days of discharge.  Patients sent to corrections or who have left against medical advice are not excluded from this requirement (The Joint Commission, 2012).

Population Affected

            The population affected by the implementation of quality measures includes both patients and providers.  The core measures can help to standardize care, and will ideally improve care and patient outcomes.  These core measures have recently been developed and are in process of implementation.  Implementation of new standards of care and data collection can be quite stressful on organizations and employees.  There is a learning curve associated with new procedures, and the process of change is complex.  This requires hours of education, policy development and revision, and reinforcement.  The hope is to improve patient care and outcomes.


Health Care Policies

            The requirement of reporting HBIPS core measures is driving the development of organizational health care policies and procedures.  In order to achieve and maintain Joint Commission accreditation, organizations now must report and meet expectations of these core measures.   These measures will help to provide standardized care throughout the United States and throughout the world.  A study conducted in South Africa demonstrated the cross-cultural effectiveness of implementing core measures in the psychological clinical setting (Campbell & Young, 2011).


            Main variables that affect the implementation of these core measures include funding, availability of resources, and the current organizational culture.  Facilities must have funding available to implement new standards and policies.  They will also need to have personnel available to learn requirements, educate other employees, and implement the data collection and reporting of data.  According to Rao, Hendry & Watson (2008), routine outcome measurement is a significant undertaking that “requires the development of a culture of clinical curiosity, proactive and committed management approach, and adequate resources, positive engagement of practitioners and users, and robust strategy to overcome challenges.”  Facilities with less financial and personnel resources will find difficulty with implementing the core measures.

Access to Care

            One argument about implementing core measures is the possibility of decreased patient contact.  Time is a limited resource.  If nurses are required to spend more time documenting core measures, there may be less time available to spend with patients.  An essential aspect of psychiatric nursing is spending time talking with patients and developing therapeutic relationships.  If nurses have to spend some of that time focused on data collection and documentation, patients may not have as much access to the therapeutic relationship.  Despite the worry of access to care, research has demonstrated that consumers are in favor of routine measures in psychiatric care.  According to Guthrie, McIntosh, Callaly, Trauer, & Coombs (2008), sixty six percent of consumers consulted believed that routine measures improved their care.

Current Trends

            A significant trend in nursing is to collect and analyze data.  Purposes of this are to gain a better understanding of the environment and challenges, decrease costs, and improve patient outcomes. 

Financial Implications

            Financial implications of these requirements can be astronomical for an organization.  The cost of personnel to plan, develop, implement and educate others of this change can be huge.  But with improved outcomes, streamlined processes and efficient and effective care, long term costs can hopefully be contained or reduced. 

Ethical Issues

            There is an ethical responsibility to provide effective, quality care.  These core measures are an indication of the quality and effectiveness of inpatient psychiatric care provided.  With the development and use of core measures for inpatient psychiatric services, there is opportunity to evaluate and improve patient care and outcomes.

Theory in Mental Health Nursing

            A standard theory in mental health nursing is Barker’s Tidal Model of Mental Health Nursing.  Barker defined it as “a philosophical approach to the discovery of mental health. It emphasizes helping people reclaim the personal story of mental distress, by recovering their voice. By using their own language, metaphors and personal stories people begin to express something of the meaning of their lives. This is the first step towards helping recover control over their lives" (Current Nursing, 2012).  Barker also stated that it provides a practice framework to explore the patient’s needs and provide individualized care (Current Nursing, 2012).

            The Tidal Model is applied through six assumptions. The model assumes a belief in the virtue of curiosity to learn a person’s individual story, recognition of the power of resourcefulness rather than a focus on weakness, respect for the patient’s wishes, acceptance of the paradox of crisis as opportunity, acknowledgement of patient’s goals, and pursuance of the simplest means toward achieving goals.  Individuals are represented by three personal domains: self, world and others, and a person’s sense of well-being depend on their individual life experiences.  The model is distilled into ten commitments, which are to value the voice, respect the language, develop genuine curiosity, become the apprentice, reveal personal wisdom, be transparent, use the available toolkit, craft the step beyond, give the gift of time, and know that change is constant.  The model then elaborates twenty competencies for a practitioner to develop in order to facilitate those commitments.  Competencies include such things as active listening, showing interest and willingness to help, develop a care plan, and helping the person to develop awareness and identify strengths and weaknesses, ability to help themselves, problems and possible changes to be made (Current Nursing, 2012).

Theory Analysis


            This theory is very clear in definitions and the role of the mental health provider.  It clearly identifies the goal of the nurse, and provides guidelines for providing optimum therapeutic care.  Concepts are clearly defined and explained. The theory is simple, logical, and easy to understand.  It provides a clear and easy to follow guideline for mental health nursing, with a focus on patient-centered individualized care. The theory can also be generalized within areas of psychiatric nursing, and nursing in general.  All nursing should be patient centered and individualized.  Nurses in all areas should facilitate patients’ healing and independence. The Tidal Model lacks empirical precision.  It is difficult to assign quantitative measures to this theory.  The derivable consequence of this theory is great.  It is widely accepted and used in the practice of mental health nursing, and is accepted to encourage positive outcomes.


            Often in nursing, there seems to be a bit of a gap between theory and practice in regards to the implementation of core measures for psychiatric services.  Lakeman (2004) asserts that “routine standardized outcome measurement in its current form can only provide a crude and narrow lens through which to witness recovery.”  Much of psychiatric nursing is qualitative, rather than quantitative.  Quantitative measures such as time spent in restraints or number of antipsychotic medications prescribed do not capture the qualitative art of psychiatric nursing.  Core measures are essential in providing standardized care, and analysis and improvement of services.


Campbell, M. M., & Young, C. (2011). Introducing the CORE-OM in a South African context: validation of the CORE-OM using a South African student population sample. South African Journal Of Psychology, 41(4), 488-502.

Current Nursing (2012). http://currentnursing.com/nursing_theory/Tidal_Model.html

Guthrie, D., McIntosh, M., Callaly, T., Trauer, T., & Coombs, T. (2008). Consumer attitudes towards the use of routine outcome measures in a public mental health service: a consumer-driven study. International Journal Of Mental Health Nursing, 17(2), 92-97.

The Joint Commission (2012). http://www.jointcommission.org/core_measure_sets.aspx

Lakeman, R. (2004). Standardized routine outcome measurement: Pot holes in the road to recovery. International Journal Of Mental Health Nursing, 13(4), 210-215. doi:10.1111/j.1445-8330.2004.00336.x.

Rao, A. S., Hendry, G., & Watson, R. (2010). The implementation of routine outcome measures in a Tier 3 Psychological Therapies Service: The process of enhancing data quality and reflections of implementation challenges. Counselling & Psychotherapy Research, 10(1), 32-38. doi:10.1080/14733140902886893.
in Healthcare

Becoming One of the Herd

Windy R. Munderloh

 College of Saint Mary



Mandatory Uniforms in Healthcare, Becoming One of the Herd

The purpose of this blog is to discuss critical issues in nursing. Mandatory uniforms in healthcare are a pressing issue in many healthcare facilities today, while this issue may seem like a positive step in the direction of professionalism, a closer look reveals conformity does not necessarily create professionalism. An unspoken hierarchy has developed, dividing healthcare workers and redefining the healthcare team.

Mandatory uniforms in healthcare date back to the 1800’s when the mother of nursing, Florence Nightingale insisted that the nurses working in her ranks present themselves as professionals and dress uniformly with a clean and hygienic appearance. It was then that Florence Nightingale’s Nursing Environment Theory was born. Mandatory uniforms were designed to bring professionalism to the healthcare team. This blog will discuss why recent changes make mandatory uniforms for healthcare workers a critical issue.

So what is the big deal, why are mandatory healthcare uniforms a critical issue in nursing? Chances are that everyone reading this blog has visited a hospital or physician’s office at least once in his or her life. The public can easily identify a member of the healthcare team by the uniform scrub that was functionally designed and designated as the appropriate attire for individuals performing patient care. The healthcare scrub comes in many colors and styles, and can vary greatly in cost. Many healthcare facilities permit the healthcare team to wear any color or style of scrub as long as facility policies for cleanliness and hygiene are enforced. Who wouldn’t want their nurse to have a neat and clean appearance? However, with the push for achieving and maintaining Magnet status being a hot topic today, and an increasing emphasis on patient satisfaction, many facilities are ramping up the professional appearance of the healthcare team by creating a color coordinated unspoken hierarchy within the health care team. This leads to the question does this new color coordinated world within the healthcare facility create unity or division among healthcare workers?

The current trend is to conform, change and adapt in a utilitarian approach to professionalism. The premise for color-coded departments is primarily for ease of recognition of an individual in scrubs. According to a recent research study, “The current multi-variant uniform styles worn by care providers make it difficult to identify the Registered Nurse. Appearance and image are important concepts in nonverbal communication” (Bednarski, and Rosenberg 2008). While this theory of ease of identification of the Registered Nurse sounds good, does it work? Will a patient, during a time of illness and recovery glean the notion that all of the Registered Nurses’ at his or her hospital of choice wear pewter gray while the Certified Patient Aids’ wear olive green? Unless a patient frequents a healthcare facility, all signs point to no. In a recent research study (Wocial, Albert, Fettes, Birch, Howey & Trochelman, 2010) researchers concluded that the patient population paid little attention to what the healthcare team wore as long as it was neat and clean. Many participants in this study could not even recall what the healthcare team member was wearing let alone what color it was, professionalism, was determined by these participants in terms of cleanliness and attitude.

So what determines professionalism? Professionalism is determined greatly upon attitude, pride in appearance, job and cleanliness. There are many variables influencing the need to mandate uniforms however, becoming “one of the herd” does not necessarily mean one will become professional. There will always be those who sift through the laundry basket for something to wear to work, the un-showered, the wrinkled, the odoriferous and the faded-worn-out-should-be-retired-uniforms. These variables can very easily continue to be a problem long after transitioning into mandatory uniforms. As stated in a recent nursing article, “A uniform does not maketh the nurse” (Poultney, 2009). Professionalism comes from the inside out.  

One Midwest facility has found that the transition to color coordinated departments is not one of smooth sailing but rather a bumpy road met with resistance and dysfunction, because let’s face it, there is no delicate way to take away freedom of choice. People in general enjoy the personal freedom of choice –no matter how small. For a facility to transition from personal preferences to an inflexible designated dress code, one must expect some resistance. The road to mandatory color-coded uniforms for this facility has been long and tumultuous. Many balked the notion of mandatory uniforms due to the loss of individuality, personal choice, and cost. Others felt that the democratic framework of shared governance had been taken away as healthcare members were not given the opportunity to vote on the topic. Regardless of resistance the facility persevered and behold the mandatory color coded uniforms are here to stay. Did the facility consider the ethical implications of taking away the employees right to be heard and vote via shared governance? It would appear as though they may have overlooked the importance of the democracy that shared governance brings to the healthcare organization.   

Mandatory uniforms in healthcare affect the healthcare team as a whole. The healthcare team itself is one that is ideally utopian, where each team member works cohesively with one another. The beauty of the healthcare team is that it is multifaceted, with many different departments with many different jobs all working together with the same goal in mind, excellent patient care. The healthcare team itself consists of individuals in various stages of life with varying levels of education ranging from certificate degrees to upper-level degrees and graduate degrees. When transitioning into a mandatory uniform requirement it is important to consider the impact of the change and who will be responsible for purchasing and maintaining the newly required uniforms, in short the healthcare team members will be responsible for them and therefore are the affected population.

The financial implications can be costly. In one Midwest facility, healthcare team members are not only responsible for purchasing one color, one brand, one style of uniform but they are also responsible for the embroidery of the facility logo at a cost of $7.00 per uniform. There seems to be a gap in the consideration of the lower lever pay scale employees and the rising cost of living when these new costs were deemed acceptable. Let’s not forget the single parent employees and those who live pay check to pay check. Something should be done to meet these team members half way.

Healthcare policies in many facilities have a professional appearance policy. Insisting that team members take pride in not only their work but their appearance as well. This is vital to the professionalism of the organization and the healthcare field as a whole. Some polices take it a step further and place standards on facial hair and the use of facial jewelry as well as a no tattoo policy. According to one nursing article, “hiding tattoos will help maintain a professional appearance” (Scovell, 2010).

Access to health care population does not apply to this critical issue. 

Clarity: Florence Nightingale’s Nursing Environment Theory stresses the importance of cleanliness and professionalism. With mandatory nursing uniforms the healthcare team members appear to be unified and driven to provide excellent patient care. The presence of a tidy and polished healthcare member emanates aseptic technique

Simplicity: of Nightingale’s Nursing Environment Theory consists of the following three main concepts:

·         Environment to patient

·         Nurse to environment

·         Nurse to patient

Nightingale believed strongly that the environment was a major factor in illness and disease. Nightingale was ahead of her time when she recognized the potential harm of the environment and worsening of illness vs. recovery.

            Generality: of Nightingale’s Nursing Environment Theory is still considered a corner stone in the foundation of nursing. In nursing today, aseptic technique and frequent hand washing are the key components in preventing illness and disease. Nightingale is also a founder in the professional appearance in nursing today with her high standards for nurses. 

Empirical Precision: of Nightingale’s Nursing Environment Theory in regard to testability it is evident that a clean environment is a healthy environment as bacteria and germs thrive in unclean conditions.

Derivable Consequences: in Nightingale’s Nursing Environment Theory it can be determined through multiple examples that Nightingale’s theory is proven to be accurate, helpful and consistent. Nightingale directed nursing to a higher standard of care with her ideas and nursing practices. Nightingale was able to prove her theory was effective in her nursing practice with an increased survival rate of patients’ and a decreased mortality rate.

Evaluation of desired outcome: Professionalism in nursing does not necessarily mean matching uniforms, although uniforms do have a greater appearance of unity. Professionalism in the healthcare team starts on the inside as an inherent desire to achieve one’s personal best and maintains a reputation of greatness. Professionalism starts with the individual and should to be maintained by the individual. Nightingale’s Nursing Environment Theory has been a part of the nursing and healthcare community for over 150 years Nightingale’s insistence and high standards for the professional appearance of nurses’ will remain strong for many years to come


Barkley, E.F. (2010). Student engagement techniques (1st ed.). San Francisco, CA: Jossey Bass Publisher.

Bastable, S.B. (2008). Nurse as educator: Principles of teaching and learning for practice (3rd edt). Sudbury, MA: Jones and Bartlett Publishers.

Bates, J. (2007). Dress to impress. Nursing Standard, 21(20), 29.

Bednarski, D., & Rosenberg, P. (2008). Nurses' Uniforms and Perceptions of Nurse Professionalism. Nephrology Nursing Journal, 35(2), 169.

Brady, M. (2009). Hospitalized children’s view of the good nurse. Nursing Ethics, 16(5), 543-560

Fray, B. (2011). Evaluating Shared Governance: Measuring Functionality of Unit Practice Councils at the Point of Care. Creative Nursing, 17(2), 87-95. doi:10.1891/1078-4535.17.2.87

Haughton, G. (2006). Uniform approval. Nursing Standard, 20(25), 26-27.

Poultney, J. (2009). Pride in nursing is more important than uniforms. Nursing Standard, 23(41), 33.

Scovell, S. (2010). Mark of prejudice. Nursing Standard, 24(23), 26-27.

Singleton, C., Lehane, M., Justice, S., & Jeffs, L. (2006). Tailored response. Nursing Standard, 20(29), 26-27.

Wocial, L., Albert, N. M., Fettes, S., Birch, S., Howey, K., Jie, N., & Trochelman, K. (2010). Impact of Pediatric Nurses' Uniforms on Perceptions of Nurse Professionalism. Pediatric Nursing, 36(6), 320-326

Monday, May 7, 2012

Transformational Leadership

Carrie Nowatzke, BSN, RN
 Michelle Leinen, BSN, RN
                                                                                  Rick Perez, BSN, RN

           Many problems exist today in the way nurses are managed.  There are many different types of leaders and leadership styles.  Motivating staff is becoming harder and harder.  Transformational leadership was first brought up in the 1970’s.  It continues to be at the forefront of nursing issues.  It is a type of leadership style that “draws on leaders’ moral values and exploits their ability to set examples and articulate goals to instigate positive change within social structures and individuals’ behaviors (Thompson, p. 21).  It is focused on the relationship between leaders and staff.  It is not a surprise that in today’s nursing world there are complex nursing styles and along with that are complex leadership styles. Transformational leadership is meant to help the staff to thrive and decrease or eliminate the negative attitudes in the workplace.  It is meant to create a motivating environment where staff members want to work and want to do an excellent job.  This type of leadership fosters creativity and new opportunities.  Healthcare is ever changing and in order for the changes to be successful, it is imperative that leaders find a necessity in transformational leadership.

Many times in the nursing world, there are leaders who are satisfied with the same results day after day.  In transformational leadership, leaders want change and they aren’t afraid to make it happen.  They can be the most radical type of leaders.

The population affected by this issue is the staff and also the leaders themselves.  Leaders are not born, they are made therefore, and they must be on board with this type of change as well.  However, the staff is affected most.  They are the ones who will benefit from this type of leader.  Desired outcomes for this issue are as follows: staffing changes that will benefit the nurses, higher employee engagement, and increased self-efficacy for the nurse and increased job satisfaction.  It is amazing that one manager can do all of these things!  When the staff is motivated by their leader, they in turn will make a positive change for their patients.  Therefore, the patients will also benefit from this type of leadership.  It is safe to say that transformational leadership will cause positive outcomes for the patient as well as the staff.

“Nurse Managers will feel more comfortable and confident by adopting the qualities of a transformational leader when engaging in the development of healthcare policies and the ever-changing components of healthcare technology” (Smith, 2011, p.44).  Transformational leaders feel they are able to make changes and see the benefit of these changes.  They also are able to motivate their staff to see the good in these changes and assist them in smooth transition.  They are able to overcome resistance.

Variables that affect transformational leadership are broad and complex themselves!  Variables such as demographics and culture can be difficult to change.  However, it was a belief of Burns that transformational leaders will be able to effectively create change in different cultures because they are essentially working for the good of the people.  There will always be staff that will not accept change either.  However, the transformational leader, if effective, should be able to motivate a high percentage of those.   Institutional policies may also be a variable that the transformational leader will have to tackle.  Motivation and inspiration are key elements in this type of leadership.

Access to health care does not necessarily apply to this topic.  If anything, transformational leaders will change the way healthcare is administered to everyone.  There is no prejudice in this type of healthcare.  These leaders want change for the better that will benefit everyone.  Transformational leaders may be able to change policies and budget, therefore making healthcare more accessible to everyone.

Today’s health care environment is experiencing unprecedented, intense reform and it is becoming increasingly more complex. Hospital and healthcare systems have become much more complex than in years past. Trends for transformational leadership include the need to focus on the promotion of innovation and change (Carroll, 2006). The American Nurses Credentialing Center (2008) stated, Nurses are faced with increasing demands and today’s leaders are required to transform their organization’s values, beliefs, and behaviors. It is somewhat easy to lead people where they want to go, but the transformational leader must lead people to where they need to be in order to meet the demands of the future. This requires vision, influence, clinical knowledge, and a strong expertise relating to professional nursing practice.

Transformational leadership encompasses skills, behaviors and characteristics that are critical for transformational leaders to have a positive impact on followers (Rosebach, Sashkin and Harburg, 1996). Specifically, transformational leaders convey the connection between the organization’s philosophy and shared values, and embedded in those values in organizational rules and actions in order to communicate meaning and inspire (Bennis & Nanus, 1985).  

For the organization that is able to successfully implement and sustain transformational leadership, there will be immediate return on their investment simply with the ability to retain employees. There is such focus on first year turn-over in hospitals and new employees want to feel empowered, they want to be paid for their expertise, but what will initially attract people to the nursing profession is the chance to make a difference in people’s lives.  Effective leadership on individual nursing units directly affects nursing staff satisfaction. Employees are interested in managers who can lead in a positive and encouraging manner. Nurses who are content in their positions correlate to a reduction in staff turnover and improve retention. When the nursing staff is satisfied with their employment, patient satisfaction rises.

Health care organizations can see this trickle-down effect through increases in patient satisfaction scores over time. The promotion of effective communication and positive attitudes enhances a healthy environment for all employees and staff. Health care organizations should evaluate individual nurse managers on units to promote transformational leadership qualities; this will directly result in staff satisfaction, staff retention, and patient satisfaction (Robbins & Davidhizar, 2007). This will directly affect the bottom line of any organization.

In comparison to other aspects of leaders or leadership, relatively little discussion is devoted to the ethical responsibilities of those who lead or to the ethical aspects of the process of leadership, which makes it important to discuss possible ethical issues of leadership. First, professions have a duty to maintain and protect public trust. Society empowers professions such as nursing to meet its specialized needs. Such empowerment creates a moral bond between the professions and the members of society it serves.  Health care institutions are powerful organizations that influence the quantity and quality of available health care services. Leaders who understand the ethical dimensions of making such decisions are important in shaping the structure of health care organizations.

Nurses are continuously faced with constant ethical issues and dilemmas in their practice and leaders will need to assist them in addressing the ethical dimensions of their practice (Cassidy & Koroll, 1994). An example of these ethical issues would be caring for the chronically ill, older adult populations, health care rationing and resource allocation. Because transformational leaders are in a unique situation to motivate, and empower staff, they must function as moral agents for the staff fulfilling their role as leader being responsible for and assisting staff when ethical issues arise.   Transformational leaders can be instrumental in helping define he ethical standards of the profession in a changing healthcare environment (Cassidy & Koroll, 1994).

Effective leadership styles among nurse managers have been associated with staff job satisfaction and retention. There is evidence that transformation leadership style is linked to employee psychological well-being.  Despite transformational leadership styles have been described as effective, it is still unclear which nurse leadership behaviors contribute most to nurse retention or well-being. Transformational leadership could provide a new optimism in a changing health care environment. Through partnering efforts, sharing information and sharing power, the transformational leadership can increase staff satisfaction, alleviate the burden of staff shortages and resource constraints while creating work environments that benefit nurses and ultimately patients.

 Bass’s Transformational Leadership Theory

Bass (1985), defined transformational leadership in terms of how the leader affects followers, who are intended to trust, admire and respect the transformational leader.

He identified three ways in which leaders transform followers:

·       Increasing their awareness of task importance and value.

·       Getting them to focus first on team or organizational goals, rather than their own interests.

·       Activating their higher-order needs.

Bass noted that authentic transformational leadership is grounded in moral foundations that are based on four components:

·       Idealized influence

·       Inspirational motivation

·       Intellectual stimulation

·       Individualized consideration

...and three moral aspects:

·       The moral character of the leader.

·       The ethical values embedded in the leader’s vision, articulation, and program (which followers either embrace or reject).

·       The morality of the processes of social ethical choice and action that leaders and followers engage in and collectively pursue.

Model of Transformational Leadership

                                                                          (“Transformational”, 2008)

Bass saw these aspects of transformational leadership:

  1. Individual consideration, where there is an emphasis on what a group member needs. The leader acts as a role model, mentor, facilitator, or teacher to bring a follower into the group and be motivated to do tasks.
  2. Intellectual stimulation is provided by a leader in terms of challenge to the prevailing order, task, and individual. S/he seeks ideas from the group and encourages them to contribute. Learn, and be independent. The leader often becomes a teacher.
  3. Inspirational motivation by a leader means giving meaning to the follows of a task. This usually involves providing a vision or goal. The group is given a reason or purpose to do a task or even be in the organization. The leader will resort to charismatic approaches in exhorting the group to go forward.
  4. Idealized influenced refers to the leader becoming a full-fledged role model, acting out and displaying ideal traits of honesty, trust, enthusiasm, pride, and so forth.

Transformation is synonymous with change and we are concerned with how people participate in change.  A Transformational Leader can have a great effect on people’s casual effort to change but how can we encourage people to change from within? 

Barrett Power as Knowing Participation in Change Theory

© 2009 Dr. Elizabeth Ann Manhart Barrett. All rights reserved.

          Barrett’s Theory describes power as the capacity to participate knowingly in the nature of change.  There are four dimensions of power: 1. Awareness 2. Choices 3. Freedom to act intentionally 4. Involvement in creating change.  This mid-range theory is based on Martha E. Roger’s axiom that humans can participate knowingly in change. According to Rogers' Science of Unitary Human Beings, humans cannot participate in change unless their participation is of a knowing nature (Barrett, 2009).

To make change a reality, Barrett suggests people must knowingly participate in creating their experience by being aware of what one is choosing to do, making choices based on that awareness, feeling free to act, and acting intentionally to create change.

Barrett describes power-as-freedom not power-as-control.  She describes power-as-freedom where change is innovative, creative, and unpredictable. 

By applying Barrett’s theory, a transformational leader can promote change and encourage adoption of evidence-based practice in individual staff, units, and hospital systems.

Analysis of Barrett’s Theory

Clarity/ Simplicity

Concepts in Barrett’s theory are given simple operational and theoretical definitions to describe how they are being used. Concepts in the theory are related to each other, are clearly stated, and a simple diagram is used to illustrate relationships between the concepts. Since there are only four dimensions, there are not too many interacting factors to confuse the concept.


Barrett’s power theory and/or the Power as Knowing Participation in Change Tool (PKPCT) has been validated cross culturally via its use in the United States, Germany, Korea and Brazil. It has been used in the homeless, cardiac rehab, breast cancer survivors, and critical care nurses. The theory is not limiting, it can be applied to numerous aspects of nursing and to diverse patient populations.

Empirical Precision

Barrett’s power theory and/or the PKPCT have been used as conceptual, theoretical, and empirical structure for research in more than 50 (qualitative and quantitative) studies (Kim, 2009).  Concepts are operationally defined and the use of the PKPCT helps measure the four dimensions of power.  It generates theoretical hypotheses and adds to the body of nursing knowledge.

Barbara W. Wright RN PhD FAAN (2010) cites, “In over 20 years of serving in elected office … and member of the legislature, I expressed my power as I participated knowingly in the process of change. The lens through which I participated was influenced by the science of unitary human beings, and more specifically by my research on trust and power.”  Barrett’s influence on Wright’s practice demonstrates and supports the theory’s empirical precision and its ability to affect change even in the political arena.

Derivable Consequences

The theory has implications for education, practice, and administration. Barrett’s theory can be readily adopted by transformational leaders. It has been shown in practice among critical care nurses to help create a nurse-to-nurse caring environment.  France, Byers, Kearney, & Myatt, (2011) indicate that to create environments for healing, administrators must be open to empowering the registered nurse (RN) and encourage RNs to be accountable and responsible to design quality nursing care.

Findings in this study include, trust, respect and empowerment/power are essential structures to create a healing environment for nurses, patients, families, and healthcare team members. The RNs who participated in this study made choices, which influenced and transformed their environment.  Implications from this study address the need for nurse educators to create positive nurse-to-nurse relationships. The study indicates that education on empowerment and nurse-to-nurse caring is imperative to break the cycle of nurses eating their young (France, Byers, Kearney, & Myatt, 2011).

                                     Evaluation of Outcomes in Relation to Theory

Transformational leaders can make staff aware of issues, ask for input and allow staff to make choices regarding solutions for managing issues, allow staff freedom to act, and encourage staff to be actively involved in creating change.  Just by applying, the simple principles of transformational leadership and Barrett’s Power theory leaders may see increased employee engagement, increased nurse self-efficacy, increased job satisfaction, and quality patient outcomes.  In a sense, a leader can empower and transform an individual, a unit, or whole hospital system to meet the complex needs of staff and patients in today’s ever changing healthcare system.


Barrett, E.M. (2009). Summary of the Barrett Power as Knowing Participation in Change Theory. Retrieved from http://www.drelizabethbarrett.com/background/power-knowing-participation-change-theory

              Bennis, W., & Nanus, B. (1985). Leaders: The strategies for taking charge. New York: Harper & Row.

Carroll, P. L. (2006). Nursing Leadership and management: A practical guide. New York, NY: Thomson Delmar Learning.

Cassidy, V. R., & Koroll, C. J. (1994). Ethical aspects of transformational leadership. Nurse Management, 9(1), 41-47.

Farren, A. T. (2010). Power in breast cancer survivors: A secondary analysis. Visions: The Journal of Rogerian Nursing Science, 17(1), 29-43. doi:10.1177/0894318404263303

France, N., Byers, D., Kearney, B., & Myatt, S. (2011). Creating a healing environment: nurse-to-nurse caring in the critical care unit. International Journal for Human Caring, 15(1), 44-48.

              Kim, T.S. (2009). The theory of power as knowing participation in change: A literature review       update.        Visions: The Journal of Rogerian Nursing Science, 16(1), 19-39. Retrieved from     http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=2010713200&site=nrc-live

Robbins, B., & Davidhizar, R. (2007). Transformational Leadership in Healthcare Today. Health Care Manager, 26(3), 234-239. doi: 10.1097/01.HCM.0000285014.e7

Rosenbach, W., Sashkin, M., & Harburg, F. (1996). The leadership profile. Seabrook, MD: Ducochon Press.

             Smith, M.K. (2011).  Are you a transformational leader?  Nursing Management, 42(9), 44-50.

             Thompson, J. (2012).  Transformational leadership can improve workflow      competencies. Nursing Management-UK, 18(10), 21-24.              

Trofino, J. (1995). Transformational Leadership in Healthcare. Nurse Management, 26(8), 42-47.

Wright, B. W. (2010). Power, Trust, and Science of Unitary Human Beings Influence Political Leadership: A Celebration of Barrett's Power Theory. Nursing Science Quarterly, 23(1), 60-62. doi: 10.1177/0894318409353794