This research explores how registered nurses constructed their leadership role during the provision of health care services in acute care, adult hospitals in Brisbane, Queensland, Australia. As health care organizations change to meet the demands of the twenty first century, nurses in Australia are coming to realize there is a dissonance between what they perceive to be the relevance of their work and the perception of the relevance of nurses’ work by others in the health care system. Consequently, nurses’ contributions to health care services are not recognized. The literature highlights that one way to address this problem is to articulate the various leadership roles contemporary nurses are asked to undertake. This is the aim of this thesis. This research seeks to illuminate the role of the nurse within changing health care systems by making clear the nature of their work through the perspectives of leadership. Consequently, the purpose of this study is to explore how nurses have undertaken leadership initiatives in their role as health care providers within contemporary health care organisations. The literature review generated following research questions: 1. How do nurses describe leadership within their health care organisations? 2. How do nurses experience leadership within their health care team? 3. How do nurses construct their leadership role whilst providing health careservices? In order to legitimate its findings this study aimed to provide a clear theoretical framework. In order to gain a clear understanding of the personal experiences and meanings of the participants, the theoretical framework for this study was underpinned by the interpretive philosophies the epistemological framework of constructionism and the theoretical perspective of symbolic interactionism. The methodology of case study enabled an empirical investigation of a contemporary nursing phenomenon, leadership wherein the researcher was able to pose questions to those nurses from whom most could be learned. Data were collected through two stages. In stage one, the exploratory stage data was collected through three focus group interviews. Stage two aided deeper exploration of the nurses’ leadership constructs with data obtained through one-to-one interviews. Analysis of the data enabled the development of a model of nurse leadership. Participants identified that their leadership was constructed through three perspectives of Self as Leader, Self and Others and Self in Action. The findings contrast the nurses’ unique leadership constructs to those of health care organisations, highlight the lack of acknowledgment for nurse leadership within health care teams, and demonstrate how the nurses’ leadership constructs influence their decision to act in the provision of patient care. This study concludes that as the nurses come to realise traditional leadership models are incompatible with their goal of achieving patient centred care, they have developed a different style of leadership to achieve their vision of patient centred care. Finally this study offers recommendations in the areas of nursing practice, nursing education and research.

Masters in Public Administration - MPA / The nurse qualified in the area of administration occupies a position with immense scope and potential in the profession and in society. The task of senior nursing management is a matter of balancing and reconciling the values and aims of the organisation with the values, aims and professional aspirations of the nursing staff, and of related and interdependent groups of health professionals, while creating and gaining commitment to a wider concept of the service and of the nurses role in it. The balancing and reconciling of organisational, occupational, service and educational demands with individual aspirations and expectations are delicate but essential if all available resources are to be optimally deployed. Success in the latter marks out an effective manager though it is difficult to measure this success. I believe this many sided accomplishment is vital, for surely all philosophy, education and research within nursing is valid ultimately only in its actual application to clinical practice. Professional nurses, fulfilling various degrees of administrative functions, are to be found in all areas and levels of nursing. It is upon the role of the upper echelons of Nurse Administrators (Matrons) in large, general teaching hospitals that this thesis will be focused. Acceptance of nurse leadership and thus of nurses occupying the most senior administrative posts (in nursing) generally has been the norm in South Africa. Unfortunately, this approach is not universal. In some countries such posts are held by physicians or other non-nurses. In others, nurses hold the title but do not wield the power. According to Searle this has arisen because •••• role change to meet contemporary political, socio-economic and health care strategies has not kept pace with the changing demands and activities of the Health Care system2 ••••thus leaving nurses in such cases in historically limited rather than contemporary relevant roles. The discussion and appraisal of nurse leadership has resulted in various national and international bodies affirming the importance of the development of such leadership in ·order to ensure the continuing role of nurses in administration. The World Health Organisation has, in numerous documents, emphasised the need for nurse leadership3, and, together with the International labour Organisation (1977) and the International Council of Nurses, published a statement on conditions of work and life of nursing personnel. Recommendation 1Q states •••• There should be programmes of higher nursing education to prepare nursing personnel for the highest responsibilities in direct and supportive nursing care, in the administration of nursing services, in nursing education and in research and development of the field of nursing 4

Healthcare organizations are responding to changes in reimbursements by redesigning and re-evaluating existing programs to improve patient outcomes. .One such intervention at the project setting was the re-evaluation of the treatment of patients with low risk for chest pain and implementing a cardiology nurse practitioner (NP) service focusing on the reduction of length of stay (LOS) with the goal of improving patient outcomes. The purpose of this doctor of nursing practice project was to evaluate the effectiveness of a nurse practitioner-led service on the reduction of LOS of patients with low risk for chest pain. An established evidenced-based guideline developed by the American Heart Association for the treatment of patients with low risk for chest pain was adopted by the NP service. The project was guided by both the Donabedian model of quality care and the Aday and Anderson theory of access to medical care. The project design proposal is a comparative study using retrospective data obtained from the medical records of LOS pre- and post-implementation of the project. Implications for social change include improvement in patient care on a national level, not only for patients with low risk for chest pain, but also for patients with other chronic diseases. Streamlining care will improve the financial standing of hospitals as well as provide care that is equal and equitable regardless of race or financial status. The findings of this project have strengthened the role of the APN globally as a social advocate for change, actively participating in designing and implementing programs to improve patients' outcomes.

The nursing shortage and high turnover rates are a problem in Canada and the world over. The purpose of this single case study was to explore leadership strategies that nurse leaders in specialty care clinics in Canada use to reduce nurse turnover. The participants were 7 nurse leaders from a single organization with specialty care clinics across Canada who all had above average nurse retention rates when compared to the case organization's average nurse retention rate. The authentic leadership theory was the conceptual framework. Data sources for this study were company documents, participants' semistructured interview responses, member checking of the interviews, and reflexive journal notes. Methodological triangulation was used to enhance validity. Data were analyzed using Yin's 5-step approach to qualitative data analysis. Data analysis yielded 4 categories of strategy themes for reducing nurse turnover: moral perspective, self-awareness, relational transparency, and balanced processing. The results of this study have the potential for positive social change in specialty care by providing senior leadership and nurse leaders of specialty care clinics with strategies that can contribute to nurse-retention initiatives. The availability of more nurses might improve the outcomes of patients who depend on these clinics for their regular infusion of specialty medicines to treat their critical illnesses, such as cancer or rare genetic diseases, where delay in treatment due to the unavailability of nurses can result in adverse consequences for patient care.

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.

Clinical trials involving digital health technologies are complex and challenging deployments. The SMArTVIEW trial (n=800), underway, combines remote automated patient monitoring (RAM) in hospital and virtual hospital-to-home nursing support, up to 30-days post-discharge, for patients who have undergone cardiac and major vascular surgery. Cardiac and vascular surgery patients are at risk for postoperative complications, as well as hospital readmission; SMArTVIEW aims to reduce hospital readmissions and emergency department visits. The purpose of this work was to conduct a process monitoring evaluation of the first 100 patients enrolled in order to examine the implementation, mechanisms, context, and specialized nursing role of the SMArTVIEW intervention. Six data sources were used to examine patient recruitment, daily nursing intervention workflows, RAM technology compliance, technical troubleshooting, patient education, and virtual nursing care. A content analysis was used to identify nursing advice, recommendations, and corrective actions for patients requiring intervention recovering at home. Fifty patients were allocated to the SMArTVIEW intervention; of these, 34 engaged in all intervention components, both in-hospital and at home. In-hospital RAM technology generated 194 notifications, drawing nurses to the beside for patient reassessment. Forty-two daily nurse reports and 926 virtual nursing care records were audited to determine technology implementation issues and nursing actions to support patient recovery at home. Process monitoring uncovered strengths and limitations in the initial days of intervention deployment. Strengths included the functionality of RAM technology, facilitating nurse compliance with required workflows, as well as a high degree of patient engagement in the program. SMArTVIEW nurses addressed multiple health concerns for patients, resulting in 1,865 nursing actions over the 30-day intervention course. Patient withdrawals and lack of standardized communication practices were areas requiring improvement. Results were used to refine and standardize intervention workflows in order to scale the intervention for deployment at a second site (United Kingdom). / Thesis / Master of Science (MSc)

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