Professional nurse involvement in shaping the electronic health record continues to be minimal in spite of the presence of shared governance models. The redundancies and nurse dissatisfaction with the electronic health record requires a new approach. The advancement of a shared governance model to a professional governance model has resulted in an increase in professional role involvement in four areas:

1. Accountability.
2. Professional obligation.
3. Collateral relationships.
4. Decision-making.

Increased professional nurse involvement results in, nurses more actively engaged in problem solving to improve nurse satisfaction with the electronic health record. Evidence reflects a positive impact on nurse satisfaction when a professional shared governance structure is in place and guides the professional practice of nurses specific to autonomy and accountability. Additionally, evidence also revealed that nurses have a desire to be included in the quality of design, implementation and sustainability of electronic documentation.

Nurses are using health information technology during patient care activities in acute care at an unprecedented rate. Previous literature has presented nurses' response to technology obstacles as a work-around, a negative behavior. Using a narrative inquiry in one hospital unit, this dissertation examines nurses' interactions when they encounter technology obstacles from a complexity science perspective. In this alternative view, outcomes are understood to emerge from tensions in the environment through nonlinear and self-organizing interactions. Innovation is a process of changing interaction patterns to bring about transformation in practices or products that have the potential to contribute to social wellbeing, such as better care. Innovation was found when nurses responded to health information technology obstacles with self-organizing interactions, sensitivity to initial conditions, multidirectionality, and their actions were influenced by a plethora of sets of rules. Nurses self-organized with co-workers to find a better way to deliver care to patients when using technology. Nurses rarely told others outside their work-group of the obstacles that occurred in their everyday interactions, including hospital-wide process improvement committees. Managers were infrequently consulted when nurses encountered technology obstacles, and often nurses did not find solutions to their obstacles when they contacted the Help Desk. Opportunities exist to facilitate interactions among nurses and other members of the organization to realize better use of health information technology that improves quality and safety while decreasing cost in the patient experience.

The healthcare system is plagued with increasing cost and poor quality outcomes. A major contributing factor for these issues is that outdated leadership practices, such as leader-centricity, linear thinking, and poor readiness for innovation, are being used in healthcare organizations. Through a qualitative case study analysis of innovation implementation, a new framework of leadership was uncovered. This framework presented new characteristics of leaders that led to the successful implementation of an innovation. Characteristics uncovered included boundary spanning, risk taking, visioning, leveraging opportunity, adaptation, coordination of information flow, and facilitation. These characteristics describe how leaders throughout the system were able to influence information flow, relationships, connections, and organizational context to implement innovation.