Thesis advisor: Dorothy A. Jones / Understanding Chief Nurse Executive (CNE) influence is essential for the discipline of nursing. There are approximately 5000 CNEs in the United States, all are tasked with being the primary identifiable leader representing organizations in which they are employed and the nursing profession of which they are a part. In this capacity, the CNE is the gatekeeper for the advancement of the majority of the 2.4 million nurses practicing in the U.S. Literature suggests that early CNEs lacked influence and often were not recognized members of organizational executive teams. Today, after two decades of struggle, CNEs are identified as essential executive team members. However, they still self identify as being less influential than their C-suite counterparts, leaving us to question, "Having gotten to the table, now what?" This study was designed as an initial step toward answering this question through Validation of the Adams Influence Model (AIM). The AIM is a framework that can be used to understand the influence of the CNE in the acute care setting. The study exposed the AIM to a qualitative data set collected as part of an academic medical center's Survey of the Professional Practice Environment. Directed content analysis was used to categorize survey responses and identify influence content toward validation and refinement of the AIM's operational definitions. Study results validated AIM influence factors and influence attributes with some refinement. In addition to development of a refined AIM, study findings also helped identify continued research opportunities. These research potentials included the exploration of; influence instrument development, the influence process, differences between influence and power, and the relationship between CNE influence, practice/ work environments and patient outcomes. As a discipline, nursing must continue to understand the influence of the CNE. These individuals are leading the profession, at what pace and in what direction cannot be left to chance. / Thesis (PhD) — Boston College, 2008. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

This research presents a critical analysis and original theoretical approach to a complex phenomenon that addresses current gaps in our understanding of the experiences of nurse executives and their organizational positioning in homecare organizations. It reveals how nurse executives experience paradoxical identities of executive and nurse. The competitiveness of homecare as a business and the status of homecare among other healthcare sectors is problematic and exacerbates the tension between those two identities. This qualitative research aims to explore NEs' epistemic and discursive organizational positioning in HCOs. This research also explores how nurse executives enact their moral, socio-professional, political and epistemic agency in homecare organizations in Ontario. The research questions guiding this study were: 1) How do nurse executives enact their agency, identity, values, and means in their organization? 2) What are the daily transactions and negotiations with organizational and systemic entities with which nurse executives engage in their organization? 3) How do nurse executives navigate such complexities to fulfil their organizational responsibilities and enact influence in their organizations? This research emphasized the importance of dominant discourses and practices in homecare organizations, shaping distinct epistemic landscapes that foster specific ways of thinking, speaking, and acting across those organizations and within the healthcare system. Fairclough's Critical Discourse Analysis was used to analyze interviews with nurse executives and selected policy and guidance documents. A theoretical framework combining Critical Management Studies, as informed by Foucault, and the Sociology of Ignorance was used to highlight the complexity of nurse executive power within the context of social structures. This study exposed the relationships and the circulation of knowledge and non-knowledge (i.e., ignorance) and the ability to exercise power within homecare organizations. Findings can contribute to scholarly knowledge about practice, education, policy, theory, and future research perspectives. This research has implications for scholarship about nursing leadership across healthcare and management disciplines by better understanding the power, knowledge, and ignorance dynamics within homecare organizations and the healthcare system.

Transformational leadership has been linked to improved organizational performance and has been recognized as a possible solution to the challenges in Health Care. The role of Nurse Executives (NE) has become an influential leadership position in Health Care Organizations (HCO) and a factor in improving HCO. The purpose of this research was to explore self-reported leadership practices of Veterans Health Administration (VHA) Medical Center NEs, examine leadership strengths of the NEs, and report professional development needs of the NEs. The study population consisted of NEs employed in the Veterans Affairs Medical Centers (VAMC’s) throughout the United States. The Leadership Practices Inventory (LPI) Self-assessment by Kouzes and Posner (2001) was the survey instrument. A letter eliciting participation and a web page address containing the LPI was emailed to the NEs. The survey was completed via the web and submitted electronically. Seventy-seven (55%) of the NEs participated in the study. The results indicate the VHA NEs in this study are using transformational leadership practices regularly. Self-reported leadership practices of this population of NEs indicate that they are engaged in the five leadership practices of challenging the process, inspiring a shared vision, enabling others to act, modeling the way, and encouraging the heart. The NE strengths are enabling others to act, modeling the way, and encouraging the heart. They scored slightly lower in challenging the process and inspiring a shared vision. The self-reported LPI scores of the NE in this study were statistically significantly higher than the leaders in Kouzes and Posner’s research (2002b). The NEs were asked to identify the five most essential leadership skills of exemplary NE. The results indicate professional development for NE should include: transformational leadership skills, financial skills, organization skills, and personnel management skills. Incorporating these skills into a professional development program for NE could be a starting point to improving organizational performance of HCOs. The results of this research provide insight into current NE leadership practices and the professional development needs of NEs, which may lead to the development of a model for professional leadership training for NEs.