Intrapreneurship amongst unit nurse managers at public hospitals

AIM: To improve conceptual clarity of the term commonly used in business intrapreneurship”, as it has potential for application in the public health care facility. Background: Intrapreurship is a term commonly used in the business world. However, the term is poorly understood within the nursing fraternity, yet there is potential for application in health care facilities. The daunting challenges facing public care organizations call for incorporation of innovative initiatives embodied within intrapreneurial principles. Therefore, the intrapreneurial unit nurse managers as frontline runners in the delivery of health care services are well positioned to influence the accomplishment of positive health outcomes. Design: A concept analysis. Data sources: The meaning of intrapreneurship was searched from different sources inclusive of dictionaries and thesauri. Literature from a range of disciplines was explored to better understand the concept, this included; business economics, psychology, and public management. Similarities and differences with other similar concepts such as ‘entrepreneurship’ were also established. Other surrogate terms that are usually confused with intrapreneurship, were also isolated and defined so that more clarity on the concept of interest can surface. Review method: Walker and Avant’s methodology guided the concept analysis Discussion of findings: Attributes which best define intrapreneurship include; innovation, creativity and risk taking. Created model, borderline and contrary cases brought clarity on the expected intrapreneurial behavior by a unit nurse manager. The antecedents of intrapreneurship were categorized into three aspects namely; the external environment, intra-organizational and the individual factors. Consequences of intrapreneurship include; new business venture, innovative initiatives leading to selfrenewal. The empirical referents of an intrapreneurial organization include aspects such as; effective cost management strategies, positive response to change, application of new skills and client/employee satisfaction.


Introduction
Within the last decade, a number of research studies and publications focusing on intrapreneurship have emerged. Seshadri and Tripathy (2006:17) affirm the pivotal role played by intrapreneurship process which determines organization's success. Intrapreneurship approach remains one of the key pathways organizations need to adopt to match the endless global challengesmainly through unleashing the entrepreneurial spirit within its employees. Seshadri and Tripathy (2006:17) believe that intrapreneurship is the major drive for organizational renewal or reinvention. The intrapreneurial path at any organization enables the employees to carve new paths, initiate new ventures, defy the status quo, and break fresh ground (Molina and Callahan 2009:389).
However, understanding of the concept intrapreneurship remains a challenge in disciplines such as nursing. A concept analysis framework of Walker and Avant was applied in this paper. The concept of intrapreneurship originates from economic and management research (Hoge 2011:5). Since its inception, intrapreneurship has focused on how to increase the organizational effectiveness and innovation. According to Hoge (2011:5) intrapreneurship is "one of the post-tayloristic organizational strategies which foster the development of the new type of employee". Gifford Pinchot (1985), one of the founders of the term intrapreneurship, observed intrapreneurs as people who dream of something unusual beyond their job jurisdiction (Teltumbde, 2006:129). Molina and Callahan (2009:389) agree that, despite intrapreneurship being a relatively new concept in different organizational spheres, it has been credited for improving organizational performance by increasing opportunities for success. Therefore, the relevance of intrapreneurship in nursing is least understood as a result, it is important to have conceptual clarity of the term commonly used in business as it has potential for application in the public health care facility.

Background
This paper seeks to understand 'intrapreneurship' by using concept analysis process by Walker and Avant. Burns and Grove, (2009:127) define concept analysis as "a strategy that identifies a set of characteristics essential to the connotative meaning of the concept". In essence, within the concept analysis process, a concept is broken down into the elements that constitute the concept, thus making it easier to see the similarities and differences of this concept as compared to other concepts of similar or close proximity (Walker and Avant, 2011:158). The process of concept analysis investigates a concept in a systematic and logical manner in order to create more clarity on the constructed definition (Walker and Avant 1995). Nursing, as a discipline that is striving towards evidenced-based practice, has to establish a foundation for clear concepts and theories to positively impact on clinical practice through extensive interrogation of foreign concepts such as intrapreneurship which are commonly used in the business world (Wang, 2004: Online). Therefore, this paper seeks to better understand the concept intrapreneurship through an extensive literature search from different disciples. The steps of Walker and Avant's concept analysis framework are followed in this paper:  Selecting a concept.  Determining the aims or purposes of analysis.  Identifying all uses of the concept that can be discovered.  Determining the defining attributes.  Identifying and describing cases such as a model, borderline, contrary, cases.  Identifying antecedents and consequences and defining empirical referents (Walker and Avant, 2011:160).

Data sources
A comprehensive literature search on the concept is quite pivotal in comparing different views on the concept, thereby reducing any bias (Walker and Avant, 2011). Google Free Dictionary (2012:Online) defines an intrapreneur (noun) as "a person within a large corporation who takes direct responsibility for turning the idea into a profitable finished product through assertive risk taking and innovation". The novel way of thinking that is considered inherent to an intrapreneur, is confirmed by the Collins Discovery Encyclopedia (2005: Online) in which intrapreneur is perceived as "a person who, while remaining within a larger organization, uses entrepreneurial skills to develop a new product". In business context, an intrapreneur is perceived as a person who invents new initiatives aimed at improving work performance and profit gaining. Risk-taking, assertiveness, innovation and creation of a new product are some of the universal characteristics of an intrapreneur according to different dictionaries that are congruent in its perception of this concept. The inherent reward and motivation of employees by the intrapreneur, as highlighted by the Google Free Dictionary (2012: Online) reflects the presence of good management practices that are part and parcel of an intrapreneurial organization.

Data selection and analysis
The literature search in this paper covered dictionary definitions and the work of several authors from different scientific backgrounds. A careful analysis of the literature assists the analyst in defining cases -a later step in the process of concept analysis (Wang, 2004: Online). Rhyles (1999:601) affirms the benefit of engaging in such an extensive exercise of concept analysis mainly to enable the researcher to see if there is a sufficient level of agreement and conceptual maturity between the different disciplines. Teltumbde (2006:129) defines intrapreneurs as "entrepreneurs within established organization". Teltumbde (2006:129) further suggests that intrapreneurs are "intra-organizational revolutionaries" as they tend to challenge the current practices and seek to change the systems from within. Their role could potentially be a source of friction in the organization. The on-going urge to unleash the imbedded creativity within the intrapreneur is evident in the definition of intrapreneurship which refers to "employees' initiatives in organizations to undertake something new, without being asked to do so" (De Jong and Wennekers, 2008:4). According to Hoge (2011:5) the word "intrapreneurship" joins the two words "intracorporate" and "entrepreneurship" as a concept which has been derived from entrepreneurship literature. It is very influential in current economic science and practice. Hoge (2011:5) defines intrapreneurship as "a spirit of entrepreneurship within the existing organizations affecting employees' possibilities, competencies, intentions, and behaviors with respect to the creation of new business ventures, products and services. Menzel and Ulijin and Aaltio (2007:734) use a broad but simple definition of intrapreneurship as "entrepreneurship within existing organizations". They also consider intrapreneurship as the process to innovatively find and build an opportunity and resources that would add value to the organization. They purport that the intrapreneurship process operates at the heart of intrapreneurship construct and is executed through the on-going interaction of two main process layers which include the organizational and individual levels. Antoncic and Hisrich (2003:14) also define intrapreneurship as "entrepreneurship within an existing organization". According to these authors, intrapreneurship refers not only to the creation of new business ventures, but it also relates to other innovative activities and orientations such as development of new products, services, technologies, administrative techniques, strategies and competitive postures. Gapp and Fisher (2007:331) also relate intrapreneurship to entrepreneurial action within an organization -"which involves individuals in the driving process.
Intrapreneurship is primarily an individual activity, while corporate entrepreneurship is conducted at the organizational level." Intrapreneurship is also emphasized by Shukla (2009: Online) with shared convictions to other authors that this concept relates to the practice of "entrepreneurship by employees within an organization". In an attempt to better understand this concept the author creates some distinctions and similarities between the often confused concepts of entrepreneur and intrapreneur.

Identifying uses of the concept "intrapreneurship" and surrogate terms
Zulkosky (2009:93) defines surrogate terms to be "words that are often used interchangeably with intrapreneurship". Some authors use the concepts entrepreneurship, corporate entrepreneurship and intrapreneurship in a similar ways. There are however, subtle distinctions to aid differentiation, although literature consistency is still lacking: Entrepreneurship -The notion of intrapreneurship is derived from entrepreneurship. De Jong and Wennekers (2008:8) define entrepreneurship as "the process of creating something new with value by devoting the necessary time and effort, assuming the accompanying financial, psychic and social risks and receiving essential rewards of monetary and personal satisfaction and independence." Entrepreneurship is often related to the business environment being, for example, an innovative owner, partner or employee that will benefit financially from the venture. Corporate entrapreneurship is usually defined at the level of organizations and refers to a top-down process, a strategy that management can utilize to foster more initiatives, and/or efforts to achieve improvement from their workforce and organization (Bosma et Sadlers (2000:27) perceives an intrapreneur as "a corporate employee who introduces and manages an innovative project within the corporate environment as if he/she were an independent entrepreneur."

Defining attributes
Defining attributes is the fourth step in which attributes which are mostly associated with the concept are presented to shed more insight (Walker and Avant 2011). Table 1 below reflects the findings of a systematic analysis of the concept intrapreneurship. The three most agreed-upon intrapreneurial attributes according to twenty authors, from a range of scientific disciplines, inclusive of business management, public management, nursing and human resources management are; innovation, risk taking and creativity. The defining attributes of an intrapreneur are congruent with the notion of Hill, (2003:19) who states he/she is perceived "as a person within a large corporation who takes responsibility of turning an idea into a profitable finished product through assertive risktaking and innovation." Vision, pro-activeness and championing were second most cited with commitment and being a change agent, graded as the third most cited attribute. This makes it safe to accept that innovation, risk taking and creativity are the most critical attributes being mentioned repeatedly (Antonic and Hisrich, 2003:459).

Innovation
Innovation as one of the key defining attributes of intrapreneurship, involves finding a better way of doing things within an organization. Innovation could be reflected in several ways within an organization which include products and services and is associated with development of research and measures aimed at meeting the clients' needs (Arslan and Cevher 2008: Online). Process innovation relates to such aspects involving technological changes in the equipment or those improving performance of employees hence increasing productivity within the organization. Innovation based on improvement of management systems is geared at responding to new environmental challenges and has influence on the improvement of human resource management skills and the better work organization techniques (Arslan and Cevher 2008: Online).

Creativity
Woodman, Sawyer and Griffin, (1993:293) define organizational creativity as 'the creation of valuable, useful new product, service, idea, procedure'. The authors warn that pure mental activity without a resulting product does not constitute creativity. True creativity is inventory in nature.

Risk-taking
Risk-taking is one of the key elements of intrapreneurship that allows employees to experiment in order to have a successful product (Antoncic and Hisrich, 2003:19). Through risk-taking behavior the organization is likely to incur losses related to quickness in taking bold actions and committing resources in the pursuit of new opportunities.

A model case to illustrate the intrapreneurship
According to Walker and Avant (2011:163), "a model case is an example of the use of a concept that demonstrates all the defining attributes of a concept". Therefore, a model case represents an ideal situation which depicts the best applied situation of a concept at organizational level. The critical attributes embedded within intrapreneurship are threefold: innovation; risk taking and creativity. The attributes reflected by the model case below, relate to a professional nurse who is considered intrapreneurial by identifying the need in her area of work and developing creative solutions without necessarily always following bureaucratic channels for permission.

Example of a model case of intrapreneurship
50 year old Sister Matthew (as she is endearingly called by her clients) has been working in a diabetic clinic at a local academic hospital for the past 15 years. She has taken the trouble to qualify as a diabetic expert and applies her knowledge and skills in educating patients, colleagues and students about the condition. She also acts as a consultant for a private organization in the field of diabetes care. She is passionate about her work and she is loved dearly by her clients, whom she sees at least monthly. Sister Matthew kept good records of the clients she saw. She now noticed an increase in the number of patients being diagnosed with diabetesthe last six months a >20% increase in the number of new cases of diabetes type 2. In reviewing literature, she also saw that diabetic care has become an international concern. Her vision then became to lower or prevent such an increase by a range of interventions that include prevention and better diabetes management practices. She decided to employ a turn-around strategy by developing a five year plan together with her team of professional nurses.
Sister Matthew decided to, for the moment, by-pass the senior management of the institution as she anticipated some resistance from them. She agreed with her team that they would involve the management when the idea is more well-developed and functional to some extent. Sister Matthew and her colleagues developed the following simply formulated objectives: To  seek funding to run their program;  influence the hospital senior management to buy into her idea when the time is ripe;  reduce the on-set of diabetes type 2 by 25% in the next five years  using aggressive health education programs;  reduce the complications of diabetes by 80%;  establish both on-site and out-reach programs;  establish a wellness center which has an on-site gymnasium;  Obtain community buy-in and to create a communitypartnership. Sister Matthew and her team did not take any no for an answer, obtained the support of the International Diabetes Federation local representative and private companies willing to participate. Within one year, Sister Matthew and her colleagues obtained expert help and funding from local and international organizations. This enabled her to start her program with immediate effect. In three years the following positive results were seen:  She obtained full support from the senior management of the institution after on-going engagement with them.  Type 2 diabetes was reduced by 10%.  Diabetes complications were reduced to 40% -thus, reducing the budget cost of chronic ailments with >30%.  Obtained the buy-in of the local nursing college and department of Nursing at the university who provided senior students to help with community outreach and mental health programsacknowledging the emotional burden of diabetes to the patient and significant others.
 Health education programs were running and they became so popular that she was requested to host a health education slot at a local radio station to educate the community on diabetes.  The Healthy Lifestyle and Wellness Centre at the clinic became very popular. Eventually it made available to the public for a reasonable fee. This created a monthly income that helped to sustain the Centre and other initiatives. In the above scenario, Sister Matthew's relentless dedication and hard work is reflected in the critical or defining intrapreneurial attributes of innovation, risk taking, and creativity. Risk taking is considered to be one attribute which makes a leader to stand out among his/her colleagues (Boyett, 1997:87).

Borderline case
Walker and Avant (2011:164-5) portray borderline cases as instances that define most, but not all of the attributes of the concept being examined. Such cases may contain most of the inherent defining attributes of a concept, but may differ substantially in one of them. The difference could be in the length of time or in the intensity of occurrence of a phenomenon. The borderline case of intrapreneurship in the scenario below is not an ideal example which could be emulated by unit nurse managers in public hospitals. Concept attributes such as innovation and creativity, are discussed in the scenario below. However, the scenario below does not reflect any risk taking ability or behavior of the unit nurse manager. The inherent critical attributes of intrapreneurship are thus only innovation and creativity. Sister Kent is apparently not ready to deal with senior management in her institution. As a result, she displays mediocre performance. However, she enjoys her current recognition and prefers to stay in a comfort zone by not breaking any rules that my result in her being unpopular with the senior management of the hospital.

Example of a borderline case
Sister Kent is a hard-working and passionate unit nurse manager in a medical care unit. She is punctual. Her unit is reputable for absolute cleanliness as revealed by recent infection control audits. Through her competitive nature, she encourages her staff to think "out of the box" and present new initiatives that will improve the performance in their unit. A suggestion from one of her staff members was to hold patient support groups in the unit, especially for patients with diabetes. This initiative would entail the significant others of patients spending some time, and even stay overnight with the patient in the unit. Sister Kent liked the idea, but was not willing to request permission for such an organized support group. She knew that management was against "outsiders" being in the unit outside of visiting hours and thus did not pursue the idea. She was also not willing to break any rules and to be reprimanded. Despite her lack of assertiveness, she has gained popularity among her peers and management, probably because she is easy to relate to and not inclined to "make waves". She is regarded by the senior management of the hospital as a very loyal employee who follows the organizational rules and regulations carefully and contributes to the well-being of the organization.

A contrary case to illustrate intrapreneurship
Contrary cases according to Walker and Avant (2011:166) are clear examples of what the concept is not. The authors emphasize the significance of contrary cases to the researcher in that they portray a clear picture of the opposite of an ideal situation. The scenario below portrays a contrary case that is considered opposite the intrapreneurial model case seen in the first example. The contrary case below does not reflect any of the critical attributes of innovation, risk-taking and creativity identified earlier.
Sister Lola is the complete opposite of what an intraprenurial professional nurse should be. She is considered to be lazy, arrogant and an ill disciplined nurse who wants to do as she pleases in her work environment without adding any form of real value.

Example of a contrary case
Sister Lola recently requested to be transferred from the maternity ward to the diabetic clinic at the out-patient department of the local academic hospital. The reason was that she wanted to work better hours. She has never liked working with patients requiring medical care and was hoping the management would transfer her to the diabetic clinic. From the beginning, she was grumpy in her new workplace. She felt that the senior nursing manager does not "like her". She however, refrained from arranging a meeting with the manager to discuss her discontent as she was worried they might send her back to the inconvenient shift work she had before. Sister Lola has no interest in the work of the diabetes clinic and does not "like" the large number of older patients coming to the clinic. She finds the patients to be "boring" and does not bring any new ways of doing the difficult work in the clinic and does not even listen to any new idea a staff member might have. She consistently says to her staff: "Why fix anything if it is not broken?" Sister Lola also decides that she will "get back" at the nursing manager by taking sick leave at regular intervals, at least 3 days monthly. It was clear that Sister Lola felt no commitment to and passion for her work.

Antecedents
Walker and Avant (2011:167) define antecedents as "events or incidents that must occur or be in place prior to the occurrence of the concept". Thus, antecedents cannot also be a defining attribute for the same concept. Antecedents are useful to theorists in identifying the underlying assumptions about a concept being studied. Antoncic (2007:311) identifies two main sets of antecedents to intrapreneurship. One is concerned with the external environment of the organization while the second one looks at the organizational characteristics. Antoncic (2007:311) identifies the first group of predictors, viewed as favorable for intrapreneurship, which includes environmental characteristics such as dynamism, technological opportunities, industrial growth and the demand for new products. The second group of predictors of intrapreneurship within the organization include; communication openness, control mechanisms, environmental scanning intensity, organizational management, support and organizational values (Antoncic (2007:311 Looking on the relevant antecedents in the context of a health care setting, MCcleary, Rivers, and Schneller (2006:552) identify seven drivers that promote continued intrapreneurial activity and transformation. These include: growth in new knowledge; changes in customer perceptions, mood and meaning; changes in industry and market structures; aging populations; process improvement; system incongruities and finally, the influence of the so-called "unexpected". Sadlers (2000:30) highlights the following intra-organizational and external environmental factors that are perceived as relevant to stimulating or hindering intrapreneurship. These factors include, for example, the macro-external environment; the structure, size, culture and degree of specialization; central decision-making; clarity of performance objectives; system of rewards or sanctions and the degree of autonomy.
In the private sector the performance objectives are usually developed from shared participation and managers are not penalized if the projects fail, thereby encouraging risk-taking behavior (Sadlers, 2000:32). Contrary to the private sector which is more reputable for fostering intrapreneurship, a different picture is painted by Sadlers (2000:32) about the factors which inhibit intrapreneurship in the public sector. These factors include: inherent bureaucratic processes of public sector departments and institutions, sharp exposure to the media on projects that fail, lack of competition among employees, poor resource control, massive regulation and accountability requirements through red tape and the measuring of in-puts rather than out-puts, multiplicity and ambiguity of goals over time, ongoing or relatively secure government financial back-up. Within the organization itself, there are certain antecedents which determine the success of intrapreneurship initiatives. Therefore, Sadlers (2000:32) identifies individual or person-centered intrapreneurial characteristics such as leadership, creativity, innovation, opportunism, risk-taking, facilitation and synthesizing.

Consequences
The next step, according to the Walker and Avant (2011) concept analysis model, discusses the consequences. Walker and Avant (2011:168) define consequences as "those events or incidents that would occur as a result occurrence of the concept, in other words the outcomes of the concept". Consequences are useful in determining the often neglected ideas, variables or relationships that may yield fruitful new or further research (Walker and Avant, 2011:168). The intrapreneurship initiatives within an organization culminate in consequences resulting in; new business ventures and innovative initiatives that will lead to self-renewal through the pro-active identification of opportunities (Antonicic and Hisrich, 2001:505). The consequence of increased performance is extrapolated further by Sadlers (2000:32) who highlights some possible positive achievements which an intrapreneurial organization is likely to have. These include the identification and exploitation of new value enhancement opportunities; the development of new products; and the development of new markets or the development of new methods for production.

Empirical referents
Determining empirical referents for the defining concept is the final step of concept analysis (Walker and Avant, 2011:168). At the end of a complex concept analysis initiative, the following questions normally crop up: "if we are to measure this concept or determine its existence in the real world, how do we do so?" (Walker and Avant 2011:168). Within the framework of concept analysis, a link between the outcome criteria for total quality management and the empirical referents, as described by Walker and Avant (2011), can be made. Therefore, the following outcome criteria that would evidently be seen in an intrapreneurial public hospital, could be a decreased absenteeism and staff turnover; less mal-practice case hearings at the South African Nursing Council; improved personnel management outcomes; staff embracing evidenced-based practice by engaging in scientific research in their units; increased national and international benchmarking initiatives on clinical issues; increased innovative and creative competition at unit level and improved quality of care as evidenced by low mortality rate, low infection rate, and good outcomes from patient exit questionnaires (Faugier, 2005:51;Casida and Pinto-Zipp, 2008:8).

Discussions
Literature affirms the indispensable contribution of adopting intrapreneurship approach on the forward-thinking organizations.
Mack, Green and Vedlitz (2008:234) concur that "no innovation of significant magnitude can be introduced into a stable policy domain without champions who advocate its introduction and use". Such champions must have the ability to directly and indirectly motivate others to accept innovation. Shukla (2009: Online) strongly believes that the novel way of performance within an organization should be engrained within intrapreneurship principles. Leong: (2004:2) asserts that strong position of unit nurse managers as intrapreneurs could "facilitate transfer of research findings, internal evidence and evidence-based product, evaluation of practice at the same time ensuring that organization achieves cost-avoidance, cost-reduction, and revenue generation from intrapreneurial activities they engage in". When taking into consideration the current complex and seemingly disconcerting world of nursing leadership and management, intrapreneurial approaches are critical to truly address the complex realities of modern-day clinical practice (

Implications
Concept analysis as a process has numerous advantages. Walker and Avant (2011:169) are of the opinion that a concept analysis clarifies the symbols (words or terms) used in communication and renders very precise theoretical, as well as operational, definitions that can be used in theory and research. Concept analysis can assist in the clarification of nursing terminology -that have become catchphrases -which then tend to lose their meaning. Furthermore, this initiative is also advantageous in tool and nursing language development. Finally, the rigor of this intellectual exercise helps the improvement of cognitive abilities through focused analytical thinking. The relevance of intrapreneurship cuts across different spheres of nursing namely education, practice and research. Understanding of intrapreneurship by nurses and incorporation of its principles is pivotal in expanding the body of knowledge of the profession. Despite a strong appreciation of the value of concept analysis, some critics such as Morse (1995:2), Paley (1996:598), Hupcey and Penrod (2005:205) as well as Rogers (1989:331) (as cited by Risjord 2008: Online), put forward a different perspective. They are concerned that it may be an arbitrary and hollow exercise with the initiative failing to produce a useful theoretical base. Its potential contribution to the evolution of nursing science has been constrained and it is not fully clear how the concept analysis process, advocated by Walker and Avant, contributed to further intellectual progression.

Conclusion
Improvement of performance remains a major concern for every organization inclusive of public health care sector. To understand the concept better, this paper interrogated literature from a variety of disciplines. The analysis of the concept brought to the fore, three main defining attributes of an intrapreneur namely: Innovator, creator, and risk-taker. These attributes were used in creation of the model, borderline and contrary cases. Antecedents of intrapreneurship were observed through different lenses such as external and internal organizational environments, and on individuals themselves. For instance, the supportive exter-nal environment included aspects like dynamic environment that offers endless technological opportunities. Within the organization, positive aspects that influence the successful implementation of intrapreneurship include; communication openness, participative decision-making, organizational and management support. Defining attributes of the intrapreneur include innovator, leader, team builder, innate qualities like risk-taking, demographic attributes such as gender and level of education. Situational attributes were also highlighted. Aspects such as professional organization membership, community organization membership were also considered crucial in defining an intrapreneur. The numerous challenges which the public hospital are confronted with include increasing health care costs, staff shortages, staff burnout to mention but a few. Therefore, embracing of intrapreneurship approach in such public hospitals is important in order to realize positive results evidenced through empirical referents such as decreased absenteeism and staff turnover, less malpractice case hearings at the South African Nursing Council. Embracing the foreign concept 'intrapreneurship' by unit nurse managers who are crucially positioned in spearheading delivery of health care services is a positive move that could contribute in the mitigation the endless challenges which seemingly have become a norm especially in public health care hospitals. Therefore, understanding of intrapreneurship through concept analysis initiative is crucial to develop the caliber of nurse managers who embrace innovative initiatives which include embracing new technology and applying measures that curtail escalating health care costs. Such innovative initiatives elevate the nurse managers to becoming true champions on teams which they lead.