1. O'Neal, Pamela V. PhD, RN
  2. Bianchi, Ann PhD, RN
  3. Adams, Ellise D. PhD, CNM


A transformative approach to influence change


Article Content

Nurse leaders are needed to encourage new ideas about managing and caring for complex patients in a dynamic healthcare system. The Institute of Medicine Future of Nursing report states that nurses are in a position to lead change and the cultivation of more nurse leaders is needed.1 We provide a model for how to become a PRO leader: People, puRpose, and pOssibility. (See Figure 1.) When these three elements are systematically constructed, PRO leaders emerge.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.
Figure 1:. PRO leade... - Click to enlarge in new windowFigure 1:. PRO leader model

How do you spell PRO?

The PRO leader takes action to develop innovative solutions to address common healthcare problems, such as reducing falls in both the inpatient and home settings. Falls are reported as the most common adverse event in inpatient settings.2,3 That's why change is needed to adequately assess fall risk and implement strategic interventions to prevent patient falls from occurring. See Fall risk assessment and prevention vignette for an illustration of how nurses in a variety of positions can be instrumental in acquiring a PRO leader skill set to impact patient outcomes.


The PRO leader can be a nurse in any position at a variety of healthcare organizations who's interested in developing the ability to lead an interprofessional team for creating innovative solutions. For example, the charge nurse can be a leader in securing adequate staffing based on patient acuity as a fall risk prevention strategy; the nurse manager can be a leader in allocating funds to purchase heavy lift equipment, supporting clinical nurses to reduce patient falls and increase patient mobility; and the chief operating nurse can be a leader in supporting innovation in improving patient outcomes and promoting safe patient care. The PRO leader influences change by recruiting the right people, establishing a common purpose, and being open to new possibilities to discover solutions to complex system problems.



The first critical action to address any problem requires gathering a team of people. What does it take to successfully lead a team? For a PRO leader, it begins by having a good grasp of each person's values, strengths, culture, and belief systems. Knowing who brings the best assets to the team and appreciating the diversity of each member enables the PRO leader to assemble a strong team. Challenging traditional thinking and working to place the right people in the right place on the team are vital.4 Networking, engaging, and meeting with the performance team are critical to establish a sense of community. Interprofessional and interdisciplinary teams are ideal for developing new solutions to solve problems. Developing creative solutions or practice change begins with the end in mind.


Once the PRO leader has assessed what's needed for the development of the fall prevention plan, the next step is to bring together the right mix of people with the right skills to develop novel solutions to improve the discharge process for these patients. The PRO leader may consider including a clinical nurse who knows firsthand the challenges that patients face when they're ready to return home. A nurse educator may be invited to the team to contribute fall risk resources for clinical nurses to use in the discharge instructions. Other team members may include a case manager to pull together community resources to support patients' needs as they transition to the home environment and a nurse administrator to set policies for implementing a new discharge plan.


After the team is selected, the PRO leader works to bring the team together and guide the process, making sure that each member is supported and offered the resources needed to develop a new solution. It's the differences and diversity of its members that make the team strong and unique in approaching the identified goal. Leadership success is demonstrated when the team members move together as one toward a common purpose.



The PRO leader supports the team to find momentum, fosters an environment that allows each member to contribute in a unique way, and works with people to establish a clear purpose to influence change.


He or she encourages the team to develop a unique rhythm by brainstorming, gathering evidence from different disciplines, and synthesizing data to refine the desired outcome. The team decides what process is needed to develop an achievable plan.


After the people and purpose are established, the next step is to identify innovative possibilities and new solutions to prevent fall risk in the home setting.



The PRO leader challenges the team to be open to nontraditional and progressive possibilities. There's often a gap between evidence, patient needs, and desired interventions.5 The possibility becomes the mechanism to close the gap by employing innovation and change. He or she can direct the team in innovative problem solving by describing and exploring what the impossible may be, and then supporting and making the way for the impossible to become possible.


The PRO leader guides the team to develop transformative solutions that are reasonable, cost effective, accessible, and available to the patient and caregiver. A successful and innovative leader moves forward to find future solutions related to patient care initiatives. A PRO leader is an ideal leader for nursing science, nursing practice, administration, and policy making.


Like a PRO

PRO leaders gather the right people, formulate the purpose, and create innovative possibilities to address common clinical problems such as falls. The fall risk and prevention vignette provided identifies how the PRO leader model can be applied in a clinical setting. PRO leaders are successful in addressing change through transformative approaches. They embrace change, thrive on productive discourse, respect diversity, establish a common goal, and create new solutions. PRO leaders move nursing into new frontiers with innovative solutions, influencing changes in healthcare organizations and patient outcomes.


Fall risk assessment and prevention vignette

A unit at a large hospital has seen an increase in readmissions of patients who've had repeated falls in the home following a hospital stay. The nurse manager questions if discharge planning for these patients needs to be reevaluated. Discharge goals include that patients are better informed about decreasing their fall risk and they have the resources needed to increase safety in their home environment. A well-developed fall prevention discharge plan for patients returning home needs to be developed.


People forming the team to address patient falls include a clinical nurse, nurse educator, case manager, and nurse administrator. This is a diverse team and each person brings different strengths, such as bedside nursing experience, knowledge related to the discharge process, access to community resources, and administrative requirements. The PRO leader encourages this unique team's purpose: to develop a customized, comprehensive fall prevention discharge plan based on current evidence.


The team develops a possible new solution, including in their toolkit the following items to help prevent hospital readmissions related to falls: environmental home assessments that include the use of technology and a checklist for home fall risk assessment before discharge. Environmental assessments may include virtually walking through the home and identifying nonstationary rugs, steps, and elevated floor transitions when going from carpet to tile or hardwood floors; assessing the patient's cognitive awareness and physical compromises; and identifying risky patient behavior tendencies, such as walking at home without a cane or assist device when ambulating short distances. The possibility of a customized discharge plan based on patient needs is then developed into new policies and procedures.




1. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2011. [Context Link]


2. Quigley PA, White SV. Hospital-based fall program measurement and improvement in high reliability organizations. [Context Link]


3. Ganz DA, Huang C, Saliba D, Shier V. Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care. AHRQ Publication No. 13-0015-EF. Rockville, MD: Agency for Healthcare Research and Quality; 2013. [Context Link]


4. Collins J. Good to Great: Why Some Companies Make the Leap...and Others Don't. New York, NY: Harper Collins; 2001. [Context Link]


5. Porter-O'Grady T, Malloch K. Leadership in Nursing Practice. Burlington, MA: Jones and Bartlett Learning; 2013. [Context Link]