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Table of contents

Introduction. 2

Discussion. 2

Transformational leadership. 3

Innovation in healthcare. 5

Change and Change management 6

Use of evidence to support change. 9

Conclusion. 10

Reference list 12

Appendix 1. 15


Modernization and advancements in medical science making healthcare care systems to face a large number of challenges in order to deliver cost-effective health care services. Patient’s disease acuity and rise in health care costs are some of the problems identified to be addressed.  However, it is important to improve the quality of nursing healthcare services that might result in alteration of the existing theories and models. Therefore, leadership and innovation in the healthcare system are necessary to resolve the existing health care problems with critical evaluation and design a new role for nursing professionals.  This project highlights the key decisions that affect the consequences of a patient’s lives by providing navigating nursing services.



Leadership is explained as a series of process that includes direction, motivation, collaboration and motivation in order to aim optimum care outcomes.  A nurse should be capable of supervising the particular field through leading patient acuity, complex environment. According to the Institute of medicine, a nurse should be eligible to lead the interprofessional team of the concerned healthcare system (Vito-Thomas et al. 2018). The nursing leadership has been proved to be effective in patient safety with directly participating in clinical care. Nursing leadership creates a vision of motivating and empowering staffs. A nursing leader is an agent who has the self-confidence of leading own team through valuing patients (Regan et al. 2016). They play a significant role in improving the health of patients and care users. The leadership phenomenon of nursing leadership reflects the general leadership style. The leadership is described as an interactive process that encourages the followers in order to accomplish nursing goals. However, leadership is not confined to higher management levels, instead, this serves as a discipline that every nurse need to follow.

The nurse leadership skills concentrate on the patient and the entire nursing team who advocates patient through effective communication and formal leadership position (McGilton, et al. 2016). The profession is autonomous which requires the nurses to make decisions of taking responsibility for their tasks. The nurses make and grant the decisions that help them forming the foundations of leadership. The availability of multiple resources increased the interest at the level of clinical settings. A nurse playing the role of a good leader participates in effective communication among different healthcare disciplines ensuring the continuous patient pace. Nursing leadership concentrates on patient and healthcare team rather putting effort on a formal position of leadership. The identified characteristics of leadership that a registered nurse should possess are

  • Clinical expertise
  • Collaboration
  • Interpersonal understanding
  • Effective communication
  • Coordination

These traits are desired in a clinical leader in order to gain expertise in healthcare so that the leader can empower making, make a clear vision and provide knowledgeable guidance to patient and families (Saugel et al. 2017).

The two leadership theories identified for nurses and applicable in the healthcare industry are as follows

Transformational leadership

Transformational leadership theory is identified as a relation between a follower and his leader where they motivate and encourage each other resulting in the formation of system congruence between the two (Harris & Mayo, 2018). The two traits that are common among the transformational leader are personality and strong vision. Transformational leaders encourage the followers in adjusting their expectations, inspiration and opinion to achieve common objectives. There are four factors that frame the transformational leadership style.

  • Ideal impact
  • Strong motivation
  • Intellectual stimulation
  • Participative leadership

The transformational leadership theory aims to bring a change in the healthcare system. For example, there are many practices that might result in an adverse effect on the patient. Intensive care unit nurses change catheter of the patients that make acquiring urinary tract infection (Gorski, 2017). Therefore, the function of a transformational leader is to modify the catheter changing practice so that there is least chance for the patient to acquire any hospital infection.


The transformational leadership theory focuses to introduce a new change by utilizing the style as changing agents who utilize the qualities to encourage the followers achieving the goals by empowering other staffs and sharing the common vision with them. The followers are influenced and motivated by their transformational leader to reach their goals. This can only be achieved if there is the bonding of trust between the two and there is an effective communication skill to lead other members.

In transformational leadership, the registered nurse schedules time and place to participate in the private conversation. The conversation comprises of one to one talk to ensure respect and trust of the leader. The registered nurse the speaker and is imperative to identify nurse needs. The director of the organization presents the expectation of the nurse that encourage her for further development (Gray et al. 2016).


As per Harris & Mayo, P. (2018) there are concerns that raise the ethical values of this leadership theory as a result of their focus on the behavior of their leader in order to encourage individualism, risk factor and ruthless dictatorship. The nursing profession is lacking behind to acknowledge its limitations of transformational leadership theories.

Engaging leadership

This kind of leadership defines a behavioural range, values and approaches. When a leader adopts the leadership style, it amplifies the performance potential. The engaging leadership was discovered as a model after conducting for 3 years. It reports a longitudinal knowledge that has been undertaken by the NHS environment that tests the effectiveness of the model (Harris & Mayo, 2018).

The findings are theorized in a construct of engaging leadership style is embodied by the model that can correlate with staff well being, work performance and productivity. They described a hierarchy where the managers and staffs are treated as partners and leadership is generated along.


However, the entire team holds the responsibility for the whole performance despite of certain contextual issues that impact a negative effect on the team. Ensuring positive relationship with external and nearby agencies might help some of these issues to be resolved. There are some organizational determinants recognized that is influential to the ward culture that even include the leadership style of the senior managers (Melnyk et al.2018). In such a situation the registered or the staff nurse is not held responsible for the failure of leadership actions since the reformation of the entire organization is essential in order to enable the ethical partnership to drive leadership approach as demonstrated in the model.

Innovation in healthcare

The NHS Institute for innovation has provided in the Leader’s guide in order to support the change effect in the healthcare sector. As per (Kerridge, 2012) All the available resources represent that the leading changes should be on par with the management factor. In such a scenario, a large fraction of workers to opt for a difference in patient care by delivering the changing practice.

The leadership framework of NHS identifies the employee with potential contributions to the development of service. However, a maximum number of people have the potential to judge a specific scenario but lack the confidence to perform since they are unaware of the theory that will help them out in a difficult environment.

There is a big challenge of acquiring hospital-acquired infection serving as a threat to healthcare practitioners. However, with the implication of best practices, the challenges can be mitigated. Catheter-associated urinary tract infection is described as a clinical that most patients admitted to ICU experience. Innovations in healthcare practice have taken initiatives where a multidisciplinary team consisting of EBP mentor applied several steps of EBP approach to reducing catheterization time in patients suffering from multiple co morbidities and immune-compromised (Masters, 2018).

EBP occurs only in the environment that motivates the clinician to investigate the evidence in order to support the particular clinical practice (Kerridge, 2012). Multiple strategies have been identified that reduce the cause of urinary tract infection which is designed by clinical practitioners. The core strategies are identified that supports short term use of catheters. The evidence-based practices that reduce acquiring of urinary tract infection from catheterization are discussed

  • Practicing washing of hands with disinfectant
  • Taking standard precautions such as wearing of sterilized gloves while making adjustments during catheter handling and collecting system.
  • Adjustment with a catheter will be performed by an efficiently trained person who is well trained about the aseptic handling of the collection system
  • Using advanced quality sterilized equipment
  • Maintenance of close-ended drainage system
  • Monitoring unobstructed urine flow
  • It is very necessary to check that the drainage pouch is placed below bladder level.

There are many clinical symptoms reported where indwelling the catheter inserts are improperly justified or improper causing potential distress to the intensive care unit patients (Hickman et al. 2018). Therefore there are innovations of multifaceted intervention have proved to be most effective in introducing a change of practice that combines the effective practice guidelines along with management of nursing personnel. This systemic approach of implementation of evidence is far productive than focusing on a single intervention.


Patients developing faith in the healthcare system seeing the positive outcome


Most of the approaches are under clinical trial


More number of evidence is helping the nurses to investigate an advanced scientific approach that would completely get rid of UTI in catheterized patients


In case no positive data obtained from the clinical trial it will become a great challenge for healthcare practitioner to check the issue of concern

Change and Change management

Change is an important component of health care professionals. A leading change or a transformation is a challenge among the nursing leaders amidst complications and big challenges that deal with direct patient care (Rosenkranz & Preston, 2015). The nurse leaders are introduced to different theories and outlines that support the changing process to give a shape to a healthy working environment. There are a number of factors or forces that bring the change, the concerned forces include increasing treatment costs, technical innovation, and workforce shortage and so on. The initiatives for a change are implemented within the context of organizational goals.

Theories and models in change theories

The achievement of all staffs of a healthcare organization contributing to service development irrespective of its role and discipline as outlined in NHS leadership framework of 2011. The guideline provides the improving skills of the entire health care organization in order to create an environment of the service environment (Kerridge, 2012). Once the cause for change implementation is identified there are three steps that guide the change to bring success.

  • Pilot the change
  • Monitoring the success
  • Sustainability

Lewin's change theory

This change theory is in the nursing profession and involves 3 stages which are the unfreezing stage, moving stage and refreezing stage. The mentioned stages depend upon the presence of driving and restraining forces. The forces are illustrated with the help of models that would provide evidence to show the effectiveness of driving force over resistant force. Here the resistance force refers to the nurses or employees of the healthcare organization who are not likely to accept any change. As per (Kerridge, 2012) the type of resistance might originate from lack of knowledge and understanding of information or any discord occurred with the provided information

Force field model

The perception of change theory and models plays critical in modifying an organizational structure. Acquaintance with different changing theories supports a framework for managing, evaluating and implementing human behavior. Lewin theorized three-stage change model to examine the factors influencing a situation. This theory requires the leaders to refuse preexisting knowledge and substitute with the latest one. The model is based on the fact that a leader can determine and understand the force potency. Lewin illustrates any behavior to be a dynamic force balance acting on the opposite directions. The force field model is applicable to support a stabilized environment and enlisting two types of forces (Rosenkranz & Preston, 2015).

Driving force: It is unidirectional force that pushes a person in the desired direction.

Restraining force: reverse to the direction of force so that the person can counter the driving force to hinder the change. In this condition, change occurs if the driving force is more powerful than the restraining force.

Unfreezing change refreezing model

Kurt lewin theorised a 3 stage model that includes unfreezing, change and refreezing. The forces and factors that influence the situation are identified. The model describes unfreezing as the initial stage that involves a searching method assisting individuals in demolishing the previous pattern of practice in order to overcome the resistance. However, this particular stage is assisted by disequilibrium that disrupts a system where the driving forces are identified. A introduced change eventually includes strengthen the driving force followed by weakening the restraining forces which are achieved by

Increasing the driving forces which direct behavior opposite to the existing equilibrium, decreasing the restraining force negatively affects the action away from equilibrium.

Roger’s change theory

Lewin theory was modified by Everette Roger who created the five-stage theory. The five stages of Roger change theory include awareness, evaluation, interest, adaptation and implementation (Saugel et al. 2017). This theory is applicable to prolonged changed projects and the theory is successful when the nurses adopt the introduced changes who refused it earlier because they heard from the nurses who adopted initially.

The five stages of Roger theory is illustrated below.

Building a relationship: the first stage analyze the importance of introducing a change

Identifying the problem:

The changing agent decides the necessity to bring the change; the nature of change will be decided as per the problem requirement.

Gather resources

Evident resources are gathered to support the cause for the change

Choose the appropriate pathway: selecting the appropriate path to introduce the change is selected

Establish change

 The change is introduced which can give effective results from the previous practice

Maintenance: The outcome of the change is monitored and analyzed to compare the effectiveness with respect to initial practice.

PDSA cycle

PDSA cycle enables to understand the effectiveness of the introduced change. The cycle also helps to analyze risk factors if involved (Gray et al. 2016). The clinicians also monitor the parameters so that any further adjustments can be made. PDSA cycle also helps to enhance the success rate after implementing any change as the difficult areas are already identified.

The steps of the PDSA cycle are illustrated as follows (Kerridge, 2012)

Act: In case there is a new change implemented for a different purpose, the same cycle will be repeated.

Plan: Planning involves the analysis of objectives which is involved to initiate the change. It also includes the location and time of introduction of change.

Study: Study helps to analyze the obtained data against desired targets. The study also helps to understand the changes and learning its effective outcome.

Do: The last step of the PDSA cycle sets the plan into action followed by the recording of data after noting down observations.

Once it has been established that the change introduced has proved to be efficient, consecutive new ideas for improving the service will come into action from then onwards and it becomes easier to accept more projects immediately after implementation of the initial change. However, at the end of a productive change, it should be noted that the change which is sustained today might become resistant tomorrow. Therefore any change should be sustained as long as the new improved idea is introduced in order to start all over again.

Use of evidence to support change

Centres for disease control prevention CDC have laid down specific steps that serve as evidence to support the change. PICOT questions help the healthcare practitioner to identify the health issue and find an effective solution through evidence-based practice (Skaggs et al. 2016).

Asking clinical question

The clinical questions can be forwarded to UTI suffering patients as well as clinicians

The questions will investigate the cause of UTI and practices that are followed as prevention steps. The gathered data can be utilized to draw statistics in order to compare the success rate of prevention. The PICOT prepared in this particular scenario is

Adult care user hospitalized for prolonged duration in intensive care Unit (P), how does the nurse-driven guideline evaluates the accuracy of short term catheter handling (I), compared to guidelines set by WHO, affect the total number of CAUTI rates (O) over a post intervention period (T)?

Searching for best evidence

Based on the PICOT feedback a systematic literature search will be conducted such as CINAHIL, CDSR and DARE. The databases searching with the help of keywords provided with the last updated evidence related to catheter-related urinary tract infection (Fleming-Dutra et al. 2018).

Critically appraise the evidence

The critical appraisal helps to determine whether the identified literature is reliable and applicable to the clinical feedback.   The appraisal also identifies a number of studies and different systemic review for the systemic organization (Ponce-de-Leon et al.2018). The critical appraisal helps to form the evaluation table to make a comparative study.

Integrating the evidence

The gathered evidence helps to select a practice for clinical implementation, for instance, the supplemental strategy of CDC advices to use bladder scanners in order to evaluate urinary retention that might cause the formation of infection (Fleming-Dutra et al. 2018).

Evaluating the outcome

After collecting the available evidence the nurses realized the fact that a urethral catheter outweighed its importance on removal (Finkelstein et al. 2019). This highlighted the requirement of more training and education on protocol revision so that its impact on the patients can be improved.


A registered nurse acts as a clinical leader who is likely to influence the patient and his families in order to integrate the utmost care that generates a positive outcome of the patient. A nursing leader is involved in delivering a quality care service that influences other members of the team. Nurse as a clinical leader possesses medical expertise in a specialty practice area using interpersonal skills enabling nurses and care providers to provide productive patient care.  A nursing leader’s activity at the bedside is illustrated in participated leadership through utilization of their medical skills and demonstrating the therapeutic relationship between the patient and the concerned nurse. Nurses are responsible for the outcome of their patients, therefore, it is very important for every nurse to offer persistent observation and monitor to the patient. A registered nurse holds the potential to work effectively in critical circumstances that necessitate a nurse to examine a patient closely. A participative leader can make effective clinical decisions on a needed intervention and communicate with the rest of the team member in order to receive assistance, support and guidance.

Reference list

Finkelstein, J. A., Raebel, M. A., Nordin, J. D., Lakoma, M., & Young, J. G. (2019). Trends in Outpatient Antibiotic Use in 3 Health Plans. Pediatrics143(1), e20181259. Retrieved on: 12 March 2019 from:

Fleming-Dutra, K. E., Linder, J. A., Hyun, D., Iskander, J. K., Thorpe, P., & Laird, S. (2018). Be antibiotics aware: smart use, best care. Retrieved on: 12 March 2019 from:

Gorski, L. A. (2017). The 2016 infusion therapy standards of practice. Home healthcare now35(1), 10-18. Retrieved on: 12 March 2019 from :

Gray, M., Skinner, C., & Kaler, W. (2016). External collection devices as an alternative to the indwelling urinary catheter: evidence-based review and expert clinical panel deliberations. Journal of Wound, Ostomy, and Continence Nursing43(3), 301. Retrieved on: 12 March 2019 from :

Harris, J., & Mayo, P. (2018). Taking a case study approach to assessing alternative leadership models in health care. British Journal of Nursing27(11), 608-613.

Hickman, L. D., DiGiacomo, M., Phillips, J., Rao, A., Newton, P. J., Jackson, D., & Ferguson, C. (2018). Improving evidence based practice in postgraduate nursing programs: A systematic review: Bridging the evidence practice gap (BRIDGE project). Nurse education today63, 69-75. Retrieved on: 12 March 2019 from :

Kerridge, J. (2012). Leading change: 1--identifying the issue. Nursing times108(4), 12-15.

Kerridge, J. (2012). Leading change: 2--planning. Nursing times108(5), 23-25.

Kerridge, J. (2012). Leading change: 3--implementation. Nursing times108(6), 23-25.

Masters, K. (2018). Role development in professional nursing practice. Jones & Bartlett Learning. Retrieved on: 12 March 2019 from :

McGilton, K. S., Bowers, B. J., Heath, H., Shannon, K., Dellefield, M. E., Prentice, D., ... & Boscart, V. M. (2016). Recommendations from the international consortium on professional nursing practice in long-term care homes. Journal of the American Medical Directors Association17(2), 99-103. Retrieved on: 12 March 2019 from :

Melnyk, B. M., Gallagher‐Ford, L., Zellefrow, C., Tucker, S., Van Dromme, L., & Thomas, B. K. (2018). Outcomes From the First Helene Fuld Health Trust National Institute for Evidence‐Based Practice in Nursing and Healthcare Invitational Expert Forum. Worldviews on EvidenceBased Nursing15(1), 5-15.

Ponce-de-Leon, A., Rodríguez-Noriega, E., Morfín-Otero, R., Cornejo-Juárez, D. P., Tinoco, J. C., Martínez-Gamboa, A., ... & Sifuentes-Osornio, J. (2018). Antimicrobial susceptibility of gram-negative bacilli isolated from intra-abdominal and urinary-tract infections in Mexico from 2009 to 2015: Results from the Study for Monitoring Antimicrobial Resistance Trends (SMART). PloS one13(6), e0198621. Retrieved on: 12 March 2019 from:

Regan, S., Laschinger, H. K., & Wong, C. A. (2016). The influence of empowerment, authentic leadership, and professional practice environments on nurses’ perceived interprofessional collaboration. Journal of nursing management24(1), E54-E61. Retrieved on: 12 March 2019 from :

Rosenkranz, S., & Preston, I. R. (2015). Right heart catheterisation: best practice and pitfalls in pulmonary hypertension. European Respiratory Review24(138), 642-652.  Retrieved on: 12 March 2019 from:

Saugel, B., Scheeren, T. W., & Teboul, J. L. (2017). Ultrasound-guided central venous catheter placement: a structured review and recommendations for clinical practice. Critical Care21(1), 225. Retrieved on: 12 March 2019 from :

 Skaggs, M. K. D., Daniels, J. F., Hodge, A. J., & DeCamp, V. L. (2018). Using the evidence-based practice service nursing bundle to increase patient satisfaction. Journal of Emergency Nursing44(1), 37-45.  Retrieved on: 12 March 2019 from:

Vito-Thomas, D., Allyn, P., Wagner, L. B., Hodges, T., & Streitmatter, S. S. (2018). The Evidence-Based Practice Fulcrum: Balancing Leadership and Emotional Intelligence in Nursing and Interprofessional Education. Retrieved on: 12 March 2019 from :

Wang, X., Chen, Y., Yao, L., Zhou, Q., Wu, Q., Estill, J., ... & Norris, S. L. (2018). Reporting of declarations and conflicts of interest in WHO guidelines can be further improved. Journal of clinical epidemiology98, 1-8. Retrieved on: 12 March 2019 from:

World Health Organization. (2018). Improving infection prevention and control at the health facility: interim practical manual supporting implementation of the WHO guidelines on core components of infection prevention and control programmes (No. WHO/HIS/SDS/2018.10). World Health Organization. Retrieved on: 12 March 2019 from:

Appendix 1

SMART Objectives




Urinary tract infection or UTI is a very common hospital-acquired infection where more than half of the infection is attributed due to urethral indwelling.

In order to comply with the emergency case which involves urinary catheter replacement, peer to per education or training session have proved effective. The education intervention included correct handling of the catheter, proper management and timely removal under the initiative of active CAUTI surveillance. This approach has reduced the rated of catheterization to 9.3% which directly reduced CAUTI to 5% per 650 catheter days (Wang et al. 2018).


Reduction in the number of correspondents of UTI risk was analyzed in the catheter days.

Independent tests were conducted using the SPSS software in order to compare the difference between different groups. The catheter days were numbered based on the pre-intervention and post-intervention period. However, after the educating program, it was observed that there was a significant drop in catheter days.

Evidence-based practices have revealed usage of bladder bundle that will decrease CAUTI through using collaborative strategies (, 2019).


Governmental bodies such as WHO has implemented written guidelines that provide instructions for proper catheter use,   and insertation following the quality of evidence. The body also developed criteria following acceptable indications for indwelling catheter use.

3 months


Implemented a   documentation to preserve a patient record that will include clinical advice on placement of catheters and date and time of the insertion. The document will also contain details of the registered nurse who inserted and monitored the catheter (Gray et al. 2019). Along with it, daily maintenance care and nursing documentation and justification of catheter removal record will also be added.


The nurse should set a reminder for everyday use to maintain the progress note to evaluate the necessity.

2 months


There are crucial steps that are trained to the nurses so that the objectives of reduction in urinary infection are achieved. This ensures educating the nurses with the aseptic conditions and monitoring sensitive condition of intensive care unit patient. Other evidence practices are under clinical trial whose applicant will be very much productive when they are approved. This includes the use of advanced technology instruments for catheter replacement so that least manual is involved.

4 months


The measures to reduce infection are realistic to implement on hospital admitted immunocompromised patients. The nurse driving protocol includes the steps that every nurse need to practice on catheterized patients

Securing the indwelling catheters after insertion made in order to prevent urethral movement as per quality evidence 3 (Skaggs, et al. 2019).


In case of examination of urine, a small fresh sample can be collected by needleless sampling port that will use a sterilized syringe followed by disinfecting the adaptor after use as per guidelines of quality evidence.



 Training of the nursing professionals about the sterilization practices will take 3 months of time after which they will be asked to perform individually based upon which their performance will be graded. In case of any difficulty arises, the concerned nurse will be further sent for a training session. After completion of training and hands-on experience, they will be asked to take a test to prove the skills so that patient health is not compromised due to the wrong implementation of practice. The entire process will take a maximum of 6 months.



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