Journal of Nursing Education

Educational Innovations 

Preparing Nurse Leaders to Innovate: Iowa's Innovation Seminar

M. Lindell Joseph, PhD, RN; Ann Rhodes, MSN, JD, RN, FAAN; Carol A. Watson, PhD, RN, CENP, FAAN



Currently, no doctoral guidelines to teach innovation exist. Using Christensen's theory of disruptive innovation, the five discovery skills used by disruptive innovators provide the framework for designing a leadership development approach to enable and support a mindset to innovate.


Executive leadership students were provided with didactic content on innovation, were assigned to nonhealth care settings for an anthropological dig to uncover innovative activities, and were provided with reflective prompts to enable a new context for innovation. Faculty collaborated with other flelds and took risks to provide new contexts to innovate.


Students identified and proposed innovations for current health care issues. Some of the innovations included processes, evaluation methods, data analytics for care design, and patient engagement solutions.


Faculty crossed borders for fleld experiences, as well as disciplinary borders. This collaborative seminar demonstrated that it is possible to develop executive nurse leaders to innovate. [J Nurs Educ. 2016;55(2):113–117.]



Currently, no doctoral guidelines to teach innovation exist. Using Christensen's theory of disruptive innovation, the five discovery skills used by disruptive innovators provide the framework for designing a leadership development approach to enable and support a mindset to innovate.


Executive leadership students were provided with didactic content on innovation, were assigned to nonhealth care settings for an anthropological dig to uncover innovative activities, and were provided with reflective prompts to enable a new context for innovation. Faculty collaborated with other flelds and took risks to provide new contexts to innovate.


Students identified and proposed innovations for current health care issues. Some of the innovations included processes, evaluation methods, data analytics for care design, and patient engagement solutions.


Faculty crossed borders for fleld experiences, as well as disciplinary borders. This collaborative seminar demonstrated that it is possible to develop executive nurse leaders to innovate. [J Nurs Educ. 2016;55(2):113–117.]

The Health Systems Doctor of Nursing Practice (DNP) Program at The University of Iowa College of Nursing prepares future executive leaders to serve as innovators (The University of Iowa, n.d.). A unique seminar course in the curriculum, called Seminar on Innovations, has been offered two times. The course design is based on the theory of disruptive innovation (Christensen, Anthony, & Roth, 2004) and requires that faculty take risks (Crenshaw & Yoder-Wise, 2013) to provide students with a new context and mindset to inquire, discover, and innovate to solve current and future nursing or health care challenges (Christensen et al., 2004; Joseph & Huber, 2015). Although other books and resources address how to innovate, the course faculty chose two books co-written by Dr. Clayton Christensen. Those two books are Seeing What's Next: Using the Theories of Innovation to Predict Industry Change (Christensen et al., 2004) and The Innovator's DNA: Mastering the Five Skills of Disruptive Innovators (Dyer, Gregersen, & Christensen, 2011). Dr. Christensen is a professor of business administration at the Harvard University Business School. He is regarded as one of the top experts in the world on innovation, and while at Harvard, he focused his research and publications on disruptive innovation. His first book, published in 1997, The Innovator's Dilemma: When New Technologies Cause Great Firms to Fail (Christensen, 1997), was recognized by The Economist in 2011 as one of the six most important business books ever written (Harvard Business School, n.d.). Because of Dr. Christensen's significant contribution to the body of evidence about how disruption occurs within different industries, it was decided that his framework for disruptive innovation was the best fit for a course to educate nurse leaders about leading transformational change at a time when health care is facing enormous pressure to make dramatic changes in how care and services are delivered. The purpose of this article is to describe how the five discovery skills used by disruptive innovators were the basis of a course design, enabling current and future executive leaders to innovate (Dyer et al., 2011).

Future Nurse Leaders

In 2010, the Institute of Medicine (IOM) stated that effective leaders need foundational competencies to better address leadership opportunities and called for knowledge related to theories on innovation (IOM, 2010, p. 228). In addition, Cronenwett and Tanner suggested the need for strategies to promote innovation and evaluate novel ideas (IOM, 2010, p. 481). The preparation of nurse leaders commonly focuses on skills related to management of operations in health care organizations. These include human resources, budgeting, strategic planning, and working within the typical hierarchical model of health care delivery. Disruptive innovation aligns well with expectations of the IOM report and the new era of rapidly transforming health care delivery. It is essential that nurse leaders of the future are prepared as innovators to identify or facilitate innovations for the challenges facing health care, as well as the transitions across the continuum of care, including population health management.

In the book, Seeing What's Next by Christensen et al. (2004), the authors compared and contrasted sustaining innovation and disruptive innovation. Sustaining innovation represents customary improvements that businesses, including health care, use to enhance current processes and products (p. xvi). Disruptive innovation bridges current processes and products with radically novel approaches to care delivery (p. xvii). Nurse leaders learn about sustaining innovation through education and experiences by quality improvement and safety initiatives that are prevalent in health care today. Learning about disruptive innovation is not routinely incorporated in leadership education. In some instances, innovation is recommended, but the approach or strategy for teaching is not well integrated or articulated (Joseph, 2015).

Discovery Skills for Disrupting Existing Systems

The IOM (2010) called for the discipline of nursing to know theories of innovation and ways to evaluate novel ideas. This validates that preparation as an innovator is an important role in the future of nursing. According to Dyer et al. (2011), innovation and creativity are learned and are not genetic. Those authors provided insight into the skills that distinguish innovative leaders from other leaders. Innovative leaders excel at five discovery skills:

  • Associating: Making connections across seemingly unrelated questions, problems, or ideas.
  • Questioning: Asking questions to understand how things are today, why they are that way, and how they might be changed or disrupted.
  • Observing: Watching the world around them, including customers, products, services, technologies, and other companies, to gain insights into and ideas for new ways of doing things.
  • Networking: Finding and testing ideas through a diverse network of individuals who vary widely in their backgrounds and perspectives.
  • Experimenting: Constantly trying out new experiences and piloting new ideas.

Health systems faculty believed aspiring executives and current leaders of health systems can learn these discovery skills required for disruptive innovation. To do this, learners must be coached to have an:

active bias against the status quo, an unflinching willingness to take smart risks to transform ideas. In addition, learners will require didactic content on discovery skills, support for risk taking, and an experiential activity to apply Christensen's et al. five discovery skills.

Seminar on Innovations

A primary goal of the Seminar on Innovations course is to synthesize course content and experiential activities to identify and propose implementation of an innovation that has utility for and transferability to health care or nursing. The course consists of the following four modules: (a) seeing what's next, (b) management systems and the innovation process, (c) evaluation of innovations, and (d) execution of innovations. To prepare health care leaders to more fully develop their knowledge, skills, and abilities to identify an innovation, students were assigned to a 45-hour immersion field experience. In the field experience, faculty locate and assign a preceptor and site to each student to introduce students to a new context that will facilitate a mindset for using discovery skills (Dyer et al., 2011). This approach is consistent with recent developments in health care innovation. The Institute for Healthcare Improvement adopted a 90-day innovation process that is based, in part, on an innovation system developed by Procter & Gamble (Huston & Sakkab, 2006; Institute for Healthcare Improvement, 2015).

The anthropological dig experience provides the opportunity to identify, analyze, and engage in synthesis. The learner discovers the full nature of innovation and documents experiential narratives for analysis. Finally, learners complete a climate survey on the field experience site and compare themes from the field experience with quantitative results. The Seminar on Innovations course fills a gap in executive nursing education because there is no preexisting curriculum guide for planning this seminar. Further, no guidance could be found in the nursing literature. Thus, having a strong theoretical framework from the business literature was imperative and formed the foundation from which course content and experiences grew. The five discovery skills of associating, questioning, observing, networking, and experimenting were integrated into course experiential activities and assignments. Subsequent discussions demonstrate how the five discovery skills were executed.

Crossing Borders to Innovate

To ensure the transferability of discovery skills to health care, nonhealth care, for-profit settings were selected for opportunities to learn new ways of doing (Neuman, 2009). This allows for the extrapolation of knowledge by learners as they assume the role of an anthropologist and project new context into challenging areas in health care. Sites are evaluated and selected primarily on the basis of:

  • A history of success in the market.
  • A history of innovation.
  • A history of strong leadership.
  • A demonstrated ability to adapt to changes in the relevant market or environment.
  • A history of good citizenship or community contribution.
  • A history of resiliency during difficult economic or social times.

After the sites were identified, leadership in each organization was approached and the field experience was explained. Sites were assured of confidentiality and that learners were oriented about how to assume the role of an anthropologist. Each student was matched to a site. The sites were supportive and welcomed the learners into their organizations. At the end of the field experience, the sites expressed interest in understanding what the learners observed and concluded. This openness and support for nontraditional learners within organizations validated openness to innovation and the required support needed for students to innovate (Joseph, 2015; Joseph & Huber, 2015).

The Field Experience

The authors predicted that the way for learners to innovate is to expose them to the theory of disruptive innovation in tandem with a field experience with a well-functioning, for-profit organization or business outside of health care. This plan would provide learners with a new context and allow them to use the five discovery skills. The goal is to expand the sites that learners encounter for experiential learning in the DNP program from only health care organizations to nonhealth care organizations, which would provide a new context and enhance the likelihood of acquiring discovery skills. Each student was assigned to a novel setting and was asked to assume the role of an anthropologist by engaging in the skills of observing, tracking, listening to understand, and asking questions while engaged in the field experience. When the students were in the anthropologist role, they had to suspend their health care and nursing frame of reference to see and fully appreciate the richness of information available and the opportunity to learn new ways of doing (Neuman, 2009).

While in the field, students made seven separate visits to the field site, which allowed them time to observe and gain a first-hand sense of the local knowledge of innovation, the culture of innovation at the site, how innovation is put to work to achieve organizational objectives, and how it provides a solution for a specific targeted customer or group. Upon exiting each field experience, learners were to write detailed descriptions of their times at assigned sites, including how people appear, what they say, what they do, and whether they have any noticeable imperfections. This allowed them to understand behaviors and interactions for a culture of innovation (Joseph, 2015; Neuman, 2009).

Examples of Students' Field Experiences

The Seminar on Innovations course has now been offered during two different semesters. Examples of field experiences and what was learned provide more specific information about settings, experiences, and skills developed. The following are innovations identified for utility in nursing and health care. These include a triad model for public communication in health care, an evaluation method, an employee engagement strategy, a clinic follow-up process, a patient engagement strategy, multilevel communication methods, and a predictive analytical model. The following innovations are presented in broad, general terms to ensure confidentiality for proprietary reasons.

Student one was placed in a broadcast and communications company. This company includes a newspaper, a television station, a business publication, and several social network sites. It is family owned and has a history of more than 100 years of service to the region. The learner created associations across a broadcasting industry to health care and then questioned current public communications from the perspective of health care issues and patient education. Transferable innovation includes learning to construct communication to ensure accurate and meaningful messages about health care issues for the public, using key stakeholders. The innovation for student one is a triad model for public communication in health care.

Student two was assigned to a manufacturing plant with an international presence, where the focus was on employee wellness and safety. This specific site was perceived by company corporate headquarters as providing leadership in this area. The learner made associations across a manufacturing company to health care and questioned methods of evaluating the effectiveness of employee wellness and safety programs. The learner generated an idea on an evaluation method to justify the viability of an employee health and wellness program. The innovation for student two is an evaluation method for employee wellness and safety.

Student three was assigned to a bank. The bank, founded in 1904, was the only bank in the area that did not fail during the Great Depression of the 1930s and has continued to be locally owned and managed. The learner made associations across the banking industry with the learner's health care military experience and examined practices for employee engagement during orientation. The learner shared observations about the military's employee orientation process, which focuses solely on team-work. The student saw an opportunity to engage health care military employees based on their individuality. Student three defined an orientation innovation to ensure future engagement of health care military employees.

Student four worked with an entrepreneur who owned a chain of local coffee shops. The owner wrote the business plan for the first coffee shop as an undergraduate student at a Big 10 university and opened it shortly after graduation. The owner now has six locations. Student four made associations across coffee shops toward health care by studying client experiences, engagement, and satisfaction and then developed innovative solutions for patient engagement processes in health care.

Student five was assigned to a software sales and marketing company. The software developed by the company allowed electronic follow-up with customers by asking specific questions regarding their encounters with a business. The responses triggered whether additional follow-up is needed before a subsequent customer encounter. Student five made associations across a marketing company toward health care and identified an innovation for timely patient follow-up processes after clinic visits.

Student six was assigned in a direct sales company and evaluated technological methods to standardize communication across multiple sites and stakeholders. The learner made associations across a direct sales company to health care, considering the current inconsistent, ineffective, and variable communication in health care. Through this experience, the learner discovered the importance of effective communication and identified an innovative method of multilevel communication.

Student seven was assigned a global financial company that offers financial products and services, including retirement solutions, insurance, and investment products, to businesses, individuals, and institutional clients. The learner made associations about using data analytics for decision making, then evaluated its use for health in terms of maximizing decision making about the health and wellness of individuals and populations. Student seven designed a predictive analytical model to design a system of care.


The approach of using nonhealth care organizations to facilitate the acquisition of an innovation by applying the discovery skills of associating, questioning, observing, networking, and experimenting was an effective learning strategy based on the theory of disruptive innovation. Students initially voiced fear of failure and reluctance in the ability to use the discovery skill of associating, especially during the first two visits of the field experience. However, they stated that the flexibility of faculty and support and openness from the sites made the field experience intriguing, stretching (i.e., defined by students as “seeing a big picture, larger than just health care and larger than acute care”), and motivating. These statements sustain other studies indicating that organizational antecedents such as support are necessary to inquire for innovation (Joseph, 2015).

In navigating the entire experience with learners, faculty need to use creativity to guide learners in the field experience, the anthropological role, and with the vision of identifying a solution in a nontraditional setting to address a specific health care challenge. In addition, expanding learning beyond typical learning sites for health care was a risk. Although some of the organizations who participated as sites for field experiences had provided nonhealth care students with learning opportunities, none had experience with health care students, and some had not worked with students at all. Asking students to assume the role as anthropologists instead of as clinicians in traditional preceptorship roles was a new framework for learning and called for creative courage from students. Creative courage is the struggle of identifying the solution of a health care issue in a new context and having the courage to see opportunity within a completely new context (Benech, 2013). It is also about engaging in a process of discourse, whereby learners entered the experience with assigned questions and left with new frameworks for understanding issues within health care and experiences of innovation (Lindh, Barbosa da Silva, Berg, & Severinsson, 2010). Finally, sharing observations about whether the participating organizations were engaged in innovation based on learned theory and a diagnostic innovation climate survey was initially perceived as risky by the students. However, that feeling dissipated by conclusion of the experience.

Implications for Leadership, Practice, and Research

The Seminar course has demonstrated a growing need for new contexts and methods to bridge novel approaches for health care delivery. Collaborations between nursing and nonnursing entities will be the impetus to enable disruptions in health care delivery. In the book The Innovators by Walter Isaacson (2014), the author demonstrated how creation of the computer and Internet did not occur in isolation but rather because many people collaborated to use their knowledge and creativity to develop the world as it exists today. The Web was built based on recognizing that there is an art and a science to imagination, understanding electronics, knowledge of transistors, knowledge of programming, and development of computers. The current Web is an amalgam of all these elements. Executive leadership coaches, nurse executives, and faculty must support creative courage in students to persevere by crossing borders (Benech, 2013; Dyer et al., 2011). This will enable seeing new opportunities and approaches for disruptions—specifically, by ensuring learner agility (Kouzes & Posner, 2012). Finally, engaging in research to understand creative courage and collaboration in nonhealth care industries to enable innovation is imperative for the future of nursing.


Nurse leaders must constantly remind themselves that considered risk taking is a precursor to innovation (Crenshaw & Yoder-Wise, 2013). As nurse educators, faculty not only cross borders for field experiences but also cross borders within the business literature by using the theory of disruptive innovation and applying it to health care and nursing practice. The collaborative seminar described in this article enabled learners to identify an innovation with utility in health care and then propose its implementation and evaluation in health care (Mind Tools, Ltd., 2015). Although content was developed as a graduate course within a DNP program, the approach, incorporating both didactic content and a field experience outside of health care, is worth consideration for preparing current leaders not enrolled in graduate programs for disruptive innovation.


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Dr. Joseph is Clinical Assistant Professor and MSN/CNL Program Coordinator, Ms. Rhodes is Clinical Professor, and Dr. Watson is Adjunct Clinical Professor, College of Nursing, The University of Iowa, Iowa City, Iowa.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to M. Lindell Joseph, PhD, RN, Clinical Assistant Professor and MSN/CNL Program Coordinator, The University of Iowa, College of Nursing, 50 Newton Road, Rm. 466 CNB, Iowa City, IA 52252; e-mail:

Received: July 28, 2015

Accepted: November 18, 2015


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