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Seton Hall University Dissertations and Theses
Seton Hall University Dissertations and Theses
(ETDs)

Winter 2011

Connective Leadership: The Chief Nursing

Officers' Relationship with Staff Nurses
Mary Ellen Clyne
Seton Hall University

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Recommended Citation
Clyne, Mary Ellen, "Connective Leadership: The Chief Nursing Officers' Relationship with Staff Nurses" (2011). Seton Hall University
Dissertations and Theses (ETDs). 1775.
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 CONNECTIVE LEADERSHIP: THE CHIEF NURSING OFFICERS'

RELATIONSHIP WITH STAFF NURSES

BY

MARY ELLEN CLYNE

Dissertation Committee

Dr. Judith Lothian, Chair

Dr. Jean Rubino
Dr. Joyce Wright

Approved by the Dissertation Committee:

Date it;- . /. ..J-o I I

Date t;; - t - ~ t (

Date/:;,t- / - ;>0 II

Submitted in partial fulfillment of the

Requirements for the degree of Doctor of Philosophy in Nursing

Seton Hall University

2011
 1

Copyright © Mary Ellen Clyne 2011

 2

ACKNOWLEDGEMENTS

First and foremost, I would like to take this opportunity to thank and acknowledge

the six ChiefNursing Officers who participated in this study. I feel privileged that

they were able to help me better understand the nature of their relationship with their

Staff Nurses. I am indebted to these wonderful nursing leaders who so willingly

shared their very own, personal experiences with me. If it were not for the honesty of

the ChiefNursing Officers' spoken words and thoughts, this research study could not

have come to fruition. Words cannot express the appreciation I have for them and

how much I have learned from them.

I would be remiss if I did not acknowledge Aline Holmes from the New Jersey

Hospital Association and Deanna Sperling, President for the Organization of Nurse

Executives ofNew Jersey. Aline and Deanna were instrumental in facilitating my

access to recruit Chief Nursing Officers from New Jersey. Without their assistance, it

would have been difficult to secure participants for this study.

It is important for me to share a sincere thank you to my colleagues from the 1st

Ph.D. Cohort at Seton Hall. You all hold a special place in my heart. We have been

through so much and our bond will last a lifetime. I would also like to thank Dr.

Wendy Budin for accepting me into the fIrst cohort of Ph.D. students in the College

ofNursing's Ph.D. program at Seton Hall University. Additionally, I would like to

acknowledge Dr. Donna Gaffney who gave me a great sense of support during this

journey. Also, I need to recognize Dr. Mary Ann McDermott for all of her guidance,

mentoring and love during Dissertation Colloquium, Dissertation I and II.

 3

I must acknowledge my work family. First, I have to give thanks to my boss,

Thomas A. Biga, Executive Vice President for Barnabas Health. Tom encouraged

and supported me during my scholarly journey. He had the confidence in my

leadership ability and always allowed me to be me. A special thanks to Nancy

Holecek, Senior Vice President of Patient Care for Barnabas Health. Nancy provided

me the opportunity to expand my nursing research horizons within Barnabas Health.

I am also grateful to Judith Mundie, Vice President of Education for Barnabas Health.

Judy always expressed an interest in my scholarly pursuits and she was my

cheerleader every step along the way. I am totally indebted to my nursing executive

team at Clara Maass Medical Center. I want to give a big thank you to Lea

Rodriguez, Margaret Nielsen, Donna Vega, Shelly Schneider, Michele Witwick,

Keera Ferreira, Linda Dietterich, and Diane Coluzzi. I must thank my two executive

assistants who have been a tremendous help to me during this journey, Debbie

Przystawski and Diane Faiella A special thanks to Dawn Bibbo who has always

been by my side. I have been truly blessed to work with them. They guide me and

enlighten me everyday. To the Nurse Managers, you are the best and I am so proud

of you. I want to thank the StaffNurses at Clara Maass Medical Center who have

kept me grounded each and everyday. Words cannot express my gratitude to my

executive team; Dr. Frank Mazzarella, Lea Rodriguez, and Jim Rolek. You all have

been my rock, thank you. My literature review would not have been possible if it was

not for Clara Maass Medical Center's librarian, Arlene Mangino. Thank you, Arlene.
 4

I am very appreciative and thankful to my dissertation committee members; Dr.

Jean Rubino and Dr. Joyce Wright. They willingly agreed to be part ofmy journey

and my committee. They have been a great support to me. I am so grateful to them.

My utmost thanks and love go to Dr. Judith Lothian. I am honored to have her as

the Chairperson of my dissertation committee. Judy consistently gave me strength

and motivation when I needed it the most. She was always there to pick me up, dust

me off, and guide me in the right direction. Without question, Judy is my beacon.

Her enthusiasm and love for qualitative research is contagious and I have developed a

love of qualitative research from her. She is a true mentor in every sense of the word.

I would not be where I am today without Judy by my side. With every ounce ofmy

being. I thank you.

 5

DEDICATION

With much love, I dedicate this dissertation to Gerard, my husband who played,

"Mr. Mom" so that I could pursue my scholarly journey. He encouraged me to put

myself first to complete this dissertation and he would take care of everything else. I

would also like to dedicate this to my children, Patrick, Jeffrey, and Morgan, who

loved me unconditionally throughout this journey. Also, I would like to dedicate this

to my sister, Ann and her family, as well as my extended family, Ron and Maddy.

Finally, I would also like to dedicate this dissertation to my deceased grandparents,

my mother, and my in laws, who always encouraged me to pursue my education.

 6

Table of Contents

LIST OF TABLES ...................................................................................9

LIST OF FIGURES ................................................................................ 10

ABSTRACT........................................................................................... 11

CHAPTER

I. INTRODUCTION

Personal Recollection..................................................... 12

Aim ofth.e Study............................................................. 13

Perceived Justification for Studying th.e Phenomenon.... 13

Research Question...........................................................14

II. REVIEW OF THE LITERATURE

Introduction..................................................................... 15

Summary......................................................................... 18

III. METHODOLOGY

Introduction......................................................................20

Design and Approach.......................................................20

Assumptions, Biases, and Beliefs .....................................21

Researcher Stance.................................................22

Trustworthiness.................................................................24

Participants........................................................................30

Gaining Access ..................................................................31

Protection of Human Subjects.............................. .32

Formal Acceptance and Initial Contact................ .33

Data Collection.................................................................. 34

Data Analysis ..................................................................... 36

IV. FINDINGS

Participant Profile.............................................................39

Acute Care Hospital Setting Profile ................................. .42

Vignettes............................................................................ 44

V. THEMATIC FINDINGS

Themes.............................................................................53

Developing and Sustaining the Relationship .......56

Creating a Positive Work Environment. ..............75

Brave Leadership.................................................83

Return on Investment...........................................95

VI. FINDING MEANING

Metatheme........................................................................98

Connective Leadership ........................................98

Support for Findings in the Literature............................. l 03

Social Exchange Theory....................................... l03

Relational Leadership Theory............................... 104

Connective Leadership Theory ............................. l05

Nursing Leadership Perspective........................... 108

VII. SUMMARY, CONCLUSIONS, AND IMPLICATIONS

Summary........................................................................109

Conclusions.................................................................... 109

Strengths and Weaknesses of the Study......................... lll

Personal Reflection......................................................... 112

Implications for Nursing Practice................................... 114

Recommendations for Future Research .......................... 116

A Final Thought. ............................................................. 117

VIII. REFERENCES ........................................................................ 118

IX. APPENDICES

A. Methodological Outline for Doing Phenomenology... 123

B. Letter to Organization for Permission to Access

Membership................................................................. 125

C. Permission Letter of Support from Organization......... 129

D. Invitational Script. ........................................................ 130

E. Letter of Invitation to Participants................................ 131

F. Consent Form................................................................ 133

G. Introductory Cover Letter to Potential Participants ......136

H. Interview Guidelines/Outline........................................ 138

LIST OF TABLES

1. Participant Profiles Demographics .................................... .40

I 2. Participant Profiles by Experience..................................... .41

I 3. Acute Care Hospital Setting Profile....................................43

4. Themes, Subthemes & Categories ...................................... 55

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LIST OF FIGURES

1. CONCEPTUAL MODEL OF THEMES ......................................... .54

2. CONCEPTUAL MODEL OF THEME # 1 & SUBTHEMES ........ .57

3. CONCEPTUAL MODEL OF THEME # 2, SUBTHEME,

& CATEGORIES ............................................................................. 76

4. CONCEPTUAL MODEL OF THEME # 3 & SUBTHEMES ......... 84

5. CONCEPTUAL MODEL OF THEME # 4 & SUBTHEMES ......... 96

 11

ABSTRACT

"CONNECTIVE LEADERSHIP: THE CHIEF NURSING OFFICERS' RELATIONSHIP

WITH STAFF NURSES"

Mary Ellen Clyne, MSN, RN, NEA-BC

Seton Hall University

2011

Background: According to the Health Care Advisory Board (2006), forty six percent of staff
nurses (SNs) from the acute care hospital setting are not satisfied with their ChiefNursing
Officer (CNO). Additionally, SNs were found to have the lowest employee satisfaction
scores compared to all health care workers from an acute care hospital. The study findings
indicated that SNs felt the CNO was removed from the reality ofthe SNs work day; in
addition, the CNO did not care about things that were of concern to the SNs; and the CNO
was not a visible advocate for nursing in the organization. The SNs also reported that hospital
administration does not respect the contributions of nursing in their Health Care
Organizations. There is no research regarding the nature ofthe CNOs relationship with SNs
from an acute care hospital setting.

Objectives: The aim ofthis study was to describe and understand the nature ofthe CNOs
relationship with SNs from an acute care hospital setting.

Method: The method of inquiry utilized for this study was phenomenology. Six CNOs
participated in the study. Interviews with each participant were conducted and each interview
was recorded, transcribed, and analyzed by utilizing qualitative techniques as described by
Ely (1991). Patterns and themes emerged from the lived experience of each participant.
Each theme was identified and described.

Results: Four main themes were identified: developing and sustaining the relationship,
creating a positive work environment, brave leadership, and return on the investment in the
relationship. One metatheme was discovered: connective leadership. Connectivity leadership
captured the essence ofthe relationship between the CNO and SNs.

Conclusions: Seven research-based recommendations are presented for the practice of

nursing administration.

Key Words: ChiefNursing Officer, Staff Nurses, relationship, connective leadership,

phenomenology, nursing leadership, qualitative.
 12

Chapter I

INTRODUCTION

Personal Recollection

An interesting experience transpired as I mentored graduate students whose course

work required observing and interviewing a CNO. In our time together, the graduate

nursing students recalled that their experience with me was not typical of their own

personal experiences of nursing leadership from their acute care hospital setting.

I have experienced the joy and good fortune of being able to establish positive

working relationships with the SNs in my hospital setting, where I am a CNO. I have

made it a point to be a visible and accessible leader who demonstrates caring

behaviors toward the SNs. I value the SNs' thoughts, feelings, and the concerns

about their patients, their work environment, and them as individuals. I ensure that I

"close the loop" on any commitments I make with them and I follow up as

appropriate.

In my role as a CNO, I take great pride in connecting with SNs. I believe it is

important to be truly present in my face to face interactions with the SNs. It has

always been my goal to understand, from the SNs perspective, how the organization

was in the past, how the work environment is situated for them currently, and how we

can work together to provide the best possible care to those we serve as we move

forward in the future together. Ultimately, my goal is to continue to further enhance

their professional growth and development, as well as assuring that their work

environment will support existing goals.

 13

Soon after listening to the students' remarks, I realized that while I knew many of

the CNOs throughout the state, I had assumed the relationships they had with their

SNs were similar to mine. It was then that I realized that I needed to know more

about these relationships.

Aim of Study

The aim of this study was to describe and understand the nature of the Chief

Nursing Officers' (CNOs') relationship with staffnurses (SNs) within an acute care

hospital setting.

Perceived. Justification for Studying the Phenomenon

In 2006, the Health Care Advisory Board (HCAB) announced results of a

qualitative study that examined acute care SNs satisfaction with nursing leadership

and with their work environment. The Health Care Advisory Board (2006) reported

that 46% of acute care staff nurses are dissatisfied with their CNO and compared to

acute care ancillary health care workers, the acute care staffnurses are the most

dissatisfied group of employees in a hospital setting. The study findings indicated

that SNs felt the CNO was removed from the reality of the SNs' workday, that the

CNO did not care about things that were of concern to the SNs, and that the CNO was

not a visible advocate for nursing in the organization. Additionally, the SNs reported

that hospital administration does not respect the contributions ofnursing in their

Health Care Organizations (Health Care Advisory Board, 2006). Research suggests

that the CNO is a critical conduit for employee engagement and enhancement of

relationships (Covey, 1991; Kane-Urrabazo, 2006; Abbasi, Hollman, and Hayes,

2008; and Taulbert, 2008); however, there is little research that describes the CNOs'
 14

relationship with acute care SNs. Understanding this relationship may potentially

provide the necessary insight that may serve as the basis for interventions in nursing

administrative practices.

Research Question

What is the nature of the ChiefNursing Officers' (CNOs') relationship with Staff

Nurses (SNs) within an acute care hospital setting?

 15

Chapter II

REVIEW OF THE LITERATURE

Introduction

The current work environment for nursing and nursing leaders presents unique

challenges related to the nursing shortage (Cox, 2002; HRSA, 2005; Flynn, 2007).

Research demonstrates the nursing shortage will be exacerbated by several factors

including; aging of the United States (US) population coupled with the large nwnber

of aging Registered Nurses (RNs) who are expected to reach retirement age within

the next 15-20 years (Buerhaus and Straiger, 1999; HRSA, 2005). It is estimated by

the Bureau of Labor Statistics that the United States will require more than one

million nurses to meet the needs of its people by 2020 (Cox, 2002; HRSA, 2005).

Although recruitment efforts are important and underway to assist in solving the

nursing shortage, efforts must be made to retain those RNs currently in the workforce

(Cox, 2002). It is important that nursing leaders understand and address the issues

facing the nursing staff so that the CNOs can ameliorate the factors other than aging

and retirement which are driving RNs away from the bedside and retain the current

workforce (Cox, 2002).

Cummings, et al. (2008), Deeter and Villeneuve (2001) posit that an occupational

reality facing RNs is that they are among the most overworked, stressed, and absent

(sick) workers in the United States (US) workforce. RNs have endured an increase in

their workload related to the nursing shortage which has added to the ongoing work

related stress. Other stressors also negatively impact the SNs such as negative aspects
 16

of their work setting, lack of autonomous practice when not warranted and a

perception of being treated unfairly and not in charge of the delivery of the care they

provide to patients (Cummings, et. aI., 2008). Focus on problems in the current work

environment is essential in acute care settings since hospitals are the largest

employers of RNs in the US and will be most directly and negatively affected by a

decline in working nurses (HRSA, 2005).

CNOs must ensure that SNs will have a forum to enhance communication, provide

opportunities for future growth, encourage various levels of participation so that the

SNs can be part of the decision making process, and seek ways to improve the work

environment (Jehn, 1997; Aiken, Clarke, Sloane, Sochalski, Busse, and Clarke, 2001;

Laschinger, Finegan, Shamian, and Wilk, 2003; Kane-Urrabazo, 2006; Leiter and

Laschinger, 2006). Through these opportunities, the SNs may feel a stronger sense of

organizational commitment and trust (D'Amour, Ferrada-Videla, San Martin

Rodriguez, and Beaulieu, 2005; Kane-Urrabazo, 2006). There is some evidence that

successful CNOs engage their staff in a meaningful way and stay connected to them

(Lundrigan, 1992).

We have a limited understanding of the complexity of relationships between

and among SNs and other health care professionals, including CNOs (Klakovich,

1994; Schofield and Amodeo, 1999; Drinka and Clark, 2000; D'Amour, et al., 2005;

Duddle and Boughton, 2007). According to D'Amour, et al. (2005), the working

lives of health care professionals in the acute care hospital setting occur in collective

environments where everyone is constantly interacting. For health care workers,

these group interactions, when they occur in the spirit of harmony and trust, can take
 17

on various forms and can generate positive outcomes such as sharing of ideas and the

creation of a common goal (D'Amour, et al., 2005). Adding to the complexity of this

phenomenon is that health care leaders and health care professionals must flnd better

and more effective ways to work together (D'Amour, et al., 2005; Kane-Urrabazo,

2006; Duddle and Boughton, 2007).

A review ofthe literature suggests that workplace relationships ofSNs with other

health care professionals are problematic, in general (Duffy, 1995; Jehn, 1995;

Farrell, 2001; Taylor, 2001; Duddle and Boughton, 2007). Studies suggest that

several things happen when there are poor working relationships, including escalating

conflict, employee dissatisfaction, decline in morale, increased patient errors, and a

lack of cohesiveness with others (Jehn, 1995; Rayner, 1997; Farrell, 1999; Quine,

1999; Duddle and Broughton, 2007). Ultimately, SNs are choosing to leave the

Health Care Organization (HCO) (Jehn, 1995; Rayner, 1997; Farrell, 1999; Quine,

1999; Duddle and Broughton, 2007). During times ofthe nursing shortage, poor

working relationships are even more damaging to SNs and the organization as a

whole (Aiken, et al., 2001; Aiken, Clarke, Sloane, Sochalski, and Silber, 2002; Kane­

Urrabazo, 2006; Duddle and Boughton, 2007).

The combination of poor relationships and conflict in the workplace can interfere

with the SNs' work performance, productivity, diligent workplace presence, and

patient outcomes (Jehn, 1995; Farrell, 1997 and 2001; Aiken, et al., 2002; Bowles and

Candela, 2005). Additionally, SNs also experience an inability to concentrate and

focus on the direct patient care when there is conflict and poor relationships in their
 18

work environment (Jehn, 1995; Farrell, 1997 and 2001; Aiken, et al., 2002; Bowles

and Candela, 2005).

The literature suggests that when a positive work environment exists, patients are

more satisfied with the care provided by the SNs, and enhanced quality patient

outcomes are evident (Kangas, Kee, and McKee-Waddle, 1999; Aiken, 2002; Duddle

and Boughton, 2007). While the literature suggests that positive interactions are

important, there is a lack of knowledge as to how to achieve this.

Klakovich (1994) suggests that both nursing leaders and SNs experience stress

because of ongoing political and fmancial turmoil in the current health care

environment. Stress promotes a mutual lack of support and can negatively influence

the behaviors of the CNO and SNs (Klakovich, 1994). CNOs are perceived as being

elite, by not being visible to the SNs, and not appreciating the value of SN

involvement (Simms, 1991; Klakovich, 1994). Klakovich (1994) posits that there is a

need for a new paradigm to improve the synergy between nurse leaders and SNs, one

that she calls connective leadership. Connective leadership could successfully

diminish the SNs' perception of being abandoned by their CNO (Klakovich, 1994;

Mauksch, 1990). Klakovich (1994) suggests that the connective leadership ''will

allow nursing leaders to function effectively within the organizations culture while

empowering nursing staff through the provision of a caring professional practice

environment" (Klakovich, 1994, p. 50).

Summary

The literature focuses on the work environment ofSNs (Kangas, Kee, and McKee­

Waddle, 1999; Aiken, 2002; Duddle and Boughton, 2007), working relationships of
 19

SNs with other health care team members (Jehn, 1995; Farrell, 1997 and 2001; Aiken,

et aI., 2002; Bowles and Candela, 2005), leadership studies regarding the mase

managers behaviors/styles and effects on the SNs (Klakovich, 1994), but it fails to

describe in any depth the nature ofthe specific relationship that exists between the

CNO and the SNs. Therefore, in order to understand and describe this relationship, it

is important to evaluate what transpires between the CNO and the SNs from the

perspective ofthe CNO having the experience.

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Chapter III

METHODOLOGY

Introduction

Phenomenology is a philosophical approach to enhance our understanding of

human experiences (Husserl, 1964; Parse, 1985; van Manen, 2002). It does not make

assumptions as to what is real or not real (van Manen, 2002). According to

Spiegelberg (1972), phenomenology is an attempt to expand the wodd view of our

experience by raising to the surface previously neglected components ofthe specific

experience being studied.

In phenomenology, the true essence of the phenomenon that we strive to

comprehend is uncovered (Merleau-Ponty, 1962; Parse, 1985; van Manen, 2002).

The focus of phenomenology is to describe our human experiences as they are lived

or experienced (Hussed, 1965; van Manen, 1984). Phenomenology rejects

quantitative methods of natural science (Hussed, 1964) because it excludes the

human experience (Colaizzi, 1978).

Design and Approach

Phenomenology, specifically, van Manen's approach was used to answer the

research question, "What is the nature ofthe CNOs' relationship with acute care

SNs?" Van Manen's method is hermeneutic in nature and thus combines both

descriptive and interpretive styles. Van Manen (2002) developed and utilized this

method in the study of professional practice. A comprehensive description of van

Manen's approach is outlined in Appendix A.

 21

Because the literature is silent on the nature of the CNOs' relationship with SNs

from an acute care hospital setting, and little is known about this experience, the

method of phenomenology was an appropriate approach to answer the research

question (Colaizzi, 1978; van Manen, 2002). Using van Manen's (1984; 1990; 2002)

approach, I turned to the nature of the lived experience (van Manen, 1997, p. 5); I

investigated the experience of the CNO's relationship with their acute care SNs by

utilizing their stories and words; I uncovered themes from the CNOs' lifeworld

descriptions. Additionally, I utilized specific guidelines for analyzing and "writing

up" the data as provided by Ely, Vinz, Dowing, and Anzul (1997; 2006).

Assumptions, Biases, and Beliefs

In phenomenology, it is imperative for the researcher to be aware of their personal

biases and how that could potentially influence the research process. The researcher

must be cognizant ofhislher worldview and preconceived notions regarding the

phenomenon of interest. According to van Manen (1984), the identification of such

assumptions, biases, experiences, intuitions, and perceptions must be noted. In doing

so, the researcher then has the ability to think about those beliefs and break free from

or understand the ways in which they may be influencing the research process.

Van Manen (1990; 2002) and Ely (1991) recommend that the researcher use the

technique known as bracketing. Bracketing allows the researcher to concede and

identify their predetennined beliefs and assumptions before data collection.

According to Munhall (2007), the identification by the researcher of assumptions,

biases, experiences, intuitions, and perceptions prior to data collection is called

decentering. Decentering is a way for the researcher to keep an open mind about
 22

what is being revealed by the participants or in this case, the CNOs. It allows the

researcher to actually hear what the participants are saying without bringing in their

own notions about the experience. In this study, I used both bracketing and

decentering. Additionally, my predetermined assumptions and notions were

examined against the results of the study in accordance with the audit process by my

dissertation chair (Lincoln and Guba, 1985).

Researcher stance.

There were several assumptions about the nature of the CNOs' relationship with

SNs that had the potential to influence the research process. These assumptions

evolved over time based on my life experiences and were the lens through which I

viewed professional interactions. Some of my life experiences provided for the

development of my personal and professional values that were refmed over years of

being a SN and later as a nurse leader. In a parallel way, my assumptions and beliefs

were also influenced by my ongoing academic journey.

Growing up, I was usually attentive to the needs of other people. I felt an inner

desire to lend a helping hand to those I believed were in need. I felt connected to the

people with whom I surrounded myself and for whom I had concern. While engaged

in such caring interactions, my sense of being connected seemed reciprocal and, thus,

provided personal rewards for being actively involved in such a relationship. Later,

the choice to become a nurse was a natural fit for me. I have consistently maintained

a sense of value for demonstrating caring and concern from my early years as a SN

and now as a nursing leader.

 23

Over the past 25 years, I have sought to broaden my perspective on how to best

activate my ideas about nursing. Through education, I have gained a theoretical

perspective of nursing and most especially, an area ofongoing interest to me, nursing

leadership. I am aware that in my professional role as a CNO, I was deliberately and

perhaps even unconsciously, profoundly influenced by my worldview ofleadership

behaviors that has been developing over the course of my life.

Generally, I believe, that a CNO needs to recognize the importance of creating an

environment that fosters a positive, caring, and compassionate work setting for SNs.

I believe that when a CNO listens very carefully to what the SNs are saying, they are

able to keep their finger on the pulse ofthe organization, based on the evidence

provided by the SNs. The CNO has to be brave enough to act in the best interest of

the SNs and thus, generate and maintain the much sought after positive, caring, and

compassionate work setting where both the CNO and SNs will thrive.

When I began this study, I did not know if other CNOs believe as I do about

interactions with SNs. While my worldview has guided me to formulate meaningful

and professional productive relationships with my SNs, there is little in the literature

that describes the relationship.

As a qualitative researcher, I was cognizant of my worldview and worked to make

sure that it did not cause a bias for me when entering the field. It was imperative for

me to acknowledge where I came from as a nursing leader but more importantly that

as a nurse researcher my goal was to capture the essence of my participants'

experience, not my own. In an effort to prevent any kind of bias, I took the
 24

opportunity to bracket and write how my beliefs were potentially influencing what I

saw and what I was interpreting.

Trustworthiness

I established and maintained trustworthiness by adhering to the criteria for rigor in

qualitative inquiry as outlined by Lincoln and Guba (1985), Guba (1981), and

Sandelowski (1986). The four criteria are credibility, transferability, auditabi/ity, and

conjirmability.

Credibility. According to Lincoln and Guba (1985), credibility is one ofthe

most important elements in establishing trustworthiness. Specifically, credibility

allows the researcher to demonstrate that the fmdings are based in reality and when

reality is upheld, it demonstrates internal validity which is similar to the criteria set by

quantitative researchers (Guba. 1981). Additionally, a qualitative study is deemed

credible when the study presents rich descriptions and or interpretations of the

phenomenon under study whereby those who are having the experience would

recognize the experience as their own as well as others who can identify with the

study just by reading it (Lincoln and Guba. 1985; Sandelowski, 1986; Beck, 1993).

Truth is subject oriented and not researcher oriented (Lincoln and Guba. 1985;

Sandelowski, 1986). The researcher must ensure a separation from the experience to

allow for truth to come forth as they describe or interpret the experience under study

to enhance credibility (Lincoln and Guba. 1985; Sandelowski, 1986). Therefore,

credibility is the truth value of study data (Lincoln and Guba. 1985).

Lincoln and Guba (1985) describe three elements to enhance the credibility of

a study: prolonged engagement, persistent observation, and triangulation of the data.

 25

Prolonged engagement. Prolonged engagement is not to be confused with

the actual time spent in the field, but rather it is the time spent by the researcher to

establish trust, understand the culture, and clarify information (Lincoln and Guba,

1985). Prolonged engagement between the participant and the researcher is to gain

deeper understanding and to build a sense of trust between the researcher and

participant (Lincoln and Guba, 1985).

I focused on establishing trust with each participant in the study by taking time to

allow them to feel comfortable with me, by assuring them that confidentiality ofthe

interview data would be maintained, and how that would be accomplished. Each

interview session took approximately 1-2 hours. Two interviews were conducted

with each CNO and I continued to interview CNOs until the data were saturated. The

multiple sessions enhanced truth value and credibility of data. Of note, the CNOs

were very enthusiastic about sharing their experience with rich descriptions.

Michele, Shelly, and Donna share their sentiments about participating in this study

which captured the general essence of all the participants.

Michele: I am so thrilled to be a part of this.

Shelly: It is my pleasure...this is great, I'm energized, I'm

going to go upstairs and tell them (the SNs) how great

they are, because they are!

Donna: I am happy to assist you.

Upon each encounter with the eNOs, I was cognizant to thank them for

participating in this study. I told them that I appreciated their willingness to assist me

in my research endeavor, as they would be assisting me in a phenomenon which has

 26

not yet been explored. This was done in an effort to ensure a trusting relationship

with one another.

Persistent observation. Lincoln and Guba (1985) encourage the researcher to

identify and code meaningful observations. I made persistent observations and

documented both typical and atypical events which were captured as field notes.

There was a comparison between the observations made and the spoken words by the

eNO.

Triangulation. Triangulation refers to the combination of two or more data

sources such as observations, focus groups, and individual interviews, which when

put together, form the essential data elements of qualitative research (Lincoln and

Guba, 1985). It is through the process of triangulation that the researcher can in fact

verify the experiences and viewpoints against others who share similar backgrounds

or experiences (Lincoln and Guba, 1985). Therefore, triangulation confmns the truth

of the research findings (Lincoln and Guba, 1985).

To enhance credibility, this study assessed congruence of data across all data

sources including all data recorded in the form of field notes, memos, and

transcriptions from all interviews and returning to the literature as themes emerge.

Transferability. Transferability is sometimes compared to external validity

or generalizability in quantitative research which suggests results can be applied to

another situation (Guba, 1981; Lincoln and Guba, 1985). In qualitative research,

generalizability is not the goal and there is little threat to external validity because

qualitative research is done in the natural setting (Lincoln and Guba, 1985). Guba

(1981) posits that qualitative research is focused on the degree of similarity between
 27

two contexts and does not attempt to develop generalizations. According to Lincoln

and Guba (1985), and Sandelowski (1986), the researcher is to provide the reader

with a broad, rich descriptive data about the experience, and it is the judgment of the

reader to determine if the description is transferable to other situations, and if the

findings are meaningful and applicable to their own experiences. The descriptions

are formulated by exploration, clarifying, and analyzing the data (Lincoln and Guba,

1985).

I collected and provided rich descriptions of data as described by the spoken words

of the eNOs. These rich descriptions of their experience allow the reader to

determine if the findings are transferable. Although the number of participants was

relatively small, the intensive and prolonged contacts with the participants supported

transferability in this study (Lincoln and Guba, 1985). Six eNOs were interviewed,

two times each, and until there was saturation of the data. The CNOs were

encouraged to speak freely about their experiences in order to capture the true essence

of the nature of the relationship they had with their acute care SNs.

From this study, the findings demonstrated rich descriptions of the nature of the

eNOs' relationship with their acute care SNs. These descriptions are represented by

way of the themes which emerged and the metatheme which was revealed as

illustrated by the spoken words (quotes) from the eNOs. The actual spoken words by

the eNOs demonstrate fittingness of the findings (Sandelowski, 1986). Fittingness

allows the reader to determine whether or not the fmdings are transferable (Lincoln

and Guba, 1985).

 28

Auditability. Auditability in qualitative research relates to consistency of

qualitative findings and is sometimes described as the qualitative equivalent of

reliability in quantitative research (Lincoln and Guba, 1985; Sandelowski, 1986). In

quantitative research, an instrument/tool is utilized to gather data but in qualitative

research, the researcher is considered the instrument (Guba, 1981; Lincoln and Guba,

1985). Auditability is achieved when another researcher can draw the same or similar

but not contradictory conclusions from the findings (Lincoln and Guba, 1985;

Sandelowski, 1986). When another researcher can follow the audit trail used by the

investigator from its beginning to its end, follow the progression of events in the

study, and has comprehension of the logic by the researcher, then according to

Lincoln and Guba (1985) and Sandelowski (1986), auditability is achieved. The audit

trail is deemed as the most significant technique that provides for trustworthiness

(Lincoln and Guba, 1985).

In this study, auditability was achieved by meticulously developing an audit trail,

i.e., securing all memos, audio tapes, data and transcriptions, coding process, and

process for category development so that other researchers can follow the decision

trail. The decision trail related to ongoing data collection and analysis remains

completely transparent, including bracketing where I consider how my research

stance was influencing what I saw and how I interpreted it.

Confirmability. Confirrnability is sometimes compared to neutrality in

quantitative research (Guba, 1981; Lincoln and Guba, 1985). According to

Sandelowski (1986, p. 33), "neutrality refers to maintaining freedom from bias in the

research process and product." According to Lincoln and Guba (1985),

 29

confinnabililty is achieved when the fmdings of the study accurately describe the

experience and ideas of the participants and not the objective or subjective stance of

the researcher. Specifically, when truth value, plus auditability, and transferability

are established, then confinnability is achieved (Lincoln and Guba, 1985;

Sandelowski, 1986).

For this study, I ensured that ongoing member checks were conducted to provide

clarification and validation so that the participants can "see" themselves in the

transcribed data collected. Additionally, I would circle back to the eNOs for further

clarification for example, I would ask them, "Did I understand you correctly when

you said... ?" The eNOs were able to agree, disagree, or clarify my understanding

and correct my interpretation of their spoken words. Ensuring the validation of the

data through member checks, the data are more credible. An audit trail was provided

and I was aware ofmy stance as a researcher; bracketing and writing about how my

beliefs may be influencing how I saw and interpreted the voice and expressions of the

interviewees were given careful scrutiny. I was very careful to ensure that I kept my

own personal beliefs and biases bracketed.

In an effort to ensure the trustworthiness ofthe data as it relates to the validity of

the fmdings, I also utilized the technique known as decentering (Munhall, 2007).

Decentering allowed me truly listen and hear what the eNOs were saying during their

interview. This specifically fostered my ability to remain as objective as I could so

that I would not bring my own thoughts, beliefs, and worldview into the findings of

this study.
 30

I reviewed my data collection and analysis with my dissertation chair who

reviewed the audit trail. Triangulation ofthe data also provided for confJlIllability.

Participants

When conducting a phenomenological research study, it is imperative that the

participants have knowledge and expertise of the phenomenon under investigation

(Field & Morse, 1985). Since this was a study of the nature of the CNO-SNs

interaction in the acute care hospital setting, the participants were recruited from a

purposeful sample. The participants were to have responsibility for SNs in acute care

hospitals, with at least three consecutive years of experience prior to this study.

CNOs from the Organization of Nurse ExecutiveslNJ (ONEINJ) and the New Jersey

Hospital Association, Chief Nursing Officers Constituency Group (NJHA-CNOCG)

were invited to participate based on their experience and expertise as nurse

executives, and because they were willing to describe the nature oftheir relationship

with SNs working in the CNO's hospital. CNOs who meet the inclusion criteria were

asked to volunteer for this study without limitations for age, gender, race, education,

or type of acute hospital setting. I excluded any CNO with whom I had a friendship

and or social relationship over and above my professional relationships.

Six CNOs from the state ofNew Jersey participated in this study. From the six

CNOs who responded to this study, it was their perspective that they felt positive

about their relationship with their SNs. Additionally, the six CNOs valued the

relationship they had with their SNs. Foundational to understanding the CNOs'

relationships with the acute care SNs, it ~as helpful to become acquainted with the

CNOs career background, education, and their personal stories related to becoming a
 31

nurse and becoming a CNO, as well as, knowing the characteristics of the acute care

hospital setting in which they worked.

Data saturation was achieved after interviewing six CNOs. This was achieved

when consistent patterns and themes emerged from the data and no new information

could be gleaned from the data collected (polit & Beck, 2004, p. 57).

Gaining Access

Because I have worked as a CNO in acute care hospitals for the past 13 years, I

have had the opportunity to develop relationships with other CNOs through my

professional nursing associations. These professional working relationships enhanced

my credibility and were a valuable asset for gaining access to CNO participants for

this study. Specifically, being a member of two professional organizations facilitated

my networking with other CNOs from ONEINJ and NJHA-CNOCG. The

professional relationships I maintained through these organizations provided access to

CNOs locally.

The purpose ofthe research was explained to CNO professional organizations

including, the ONEINJ and the NJHA-CNOCG, in order to gain access to potential

volunteers for this study. Specifically, I interacted with the Executive Director of

ONEINJ and the Vice President of the NJHA-CNOCG whereby I reviewed all

materials that would be sent to their membership. I obtained permission from the

professional organizations to invite potential participants for this study. I submitted a

letter, to each organization, requesting permission to invite CNO volunteers from the

professional organization's membership through the organization's emaiVlist serve

(see Appendix B). In gaining access, I asked each organization to provide me with a
 32

letter of support for this research study with access to their members through the

organization's list serve (see Appendix C). Although, I did not have direct access to

. the email/list serve for the CNO members, each organization emailed all materials to

CNO members via their list serve, including an Introductory Cover Letter (see

Appendix G), Letter ofInvitation (see Appendix E), and the Consent Form (see

Appendix F).

I scheduled a time to speak: with each potential participant who responded with

an interest in participating in the study. The invitational script (see Appendix D) was

read to potential participants. I also reviewed the Letter of Invitation, described the

inclusion and exclusion criteria, the approximate amount of time for each interview,

the number of anticipated interview sessions, information related to data collection,

and confidentiality. Additionally, I answered any questions the potential participants

had about the study and participation. I closed the conversation by arranging a time

to conduct the first interview. Individuals who participated in the study returned the

Consent Form to me.

Protection of Human Subjects.

This study did not commence until Institutional Review Board (JRB) approval

from Seton Hall University was granted. Each CNO in this study received a letter of

invitation, outlining the study and a request for their participation (see Appendix F).

Each CNO who participated was asked to sign an Informed Consent that included,

consent for audio taping of conversations and interviews (see Appendix G). The

CNOs had the right to withdraw from the study at any time, for any reason, without

reprisal. There were no known physical risks to the CNOs and there were no direct
 33

benefits but, there may be a benefit to CNOs for the potential of fostering further

research in the future. Additionally, there were no supervisory or collegial

relationships between the researcher and the CNOs.

The identities of the CNOs in this study were never revealed (Munhall & Chenail,

2008). The CNOs were anonymous to all but me and their names were changed

(Munhall & Chenail, 2008). Audiotapes were coded for each CNO to maintain

anonymity, and I transcribed the audiotapes verbatim. Each CNO was infonned and

reassured that the field notes, transcripts and other notes would be stored and secured

on a thumb drive which would be placed in a locked desk drawer whereby only the

researcher will have access to the key. No data was stored on a hard drive. The data

will be stored for at least three years. The CNOs were infonned that the findings

would be reported in the aggregate and their true identity would never be revealed.

Formal Acceptance and Initial Contact.

Once the CNO agreed to participate in the study by returning the signed Consent

Fonn, I made an initial telephone contact with each participant at a convenient time,

to answer any final questions regarding the study, review participant responsibilities,

and to arrange for an appointment with the individual to conduct the first interview.

Specifically, I asked the CNO to select a setting or location that would be conducive

for a private, one on one interview with no interruptions. At the end of each

interview session, I made arrangements with each participant to schedule a follow up

meeting, as appropriate. This process was continued until there was saturation ofdata

and member checks were completed.

 34

Data Collection

Data were collected through interviews with each participant. A semi formal

interview was conducted with the eNOs. An interview outline (see Appendix H),

was used initially. Specifically, the outline contained general questions that were

utilized as a guide.

I spoke with each eNO twice, over a one to three week period of time. The eNOs

provided me with their perception regarding the nature of their relationship with their

acute care SN's. Initially, I asked eNOs to tell me about their acute care hospital and

the story about how they became a eNO. This allowed the participant to become

more comfortable, provide background information, and assisted in the facilitation of

developing trust. Additionally, other open-ended questions were posed to each

participant including, "Tell me what it is like for you to be a eNO," "Share with me

how you interact with your staff nurses," "Describe your relationship with your staff

nurses," and " Describe a specific example that illustrates your

interaction/relationship with your staff nurses." At the end of each interview session,

participants were asked if there was anything else they would like to add.

All interviews were conducted in each eNO's office with the door shut for

privacy, with one exception; one interview was conducted in a public place but it was

conducive to the interview process. The interviews took place on weekdays and

during normal business hours.

I audio recorded each participant during our interview via a digital recorder. The

digital recorder was placed on the table between me and the participant. A letter was

assigned to each participant and each session was noted. To ensure anonymity, the
 35

real names of the participants were changed. The average time for each interview

ranged from 45 minutes to 75 minutes. Field notes, memos, audio tapes, and

verbatim transcriptions of interviews with each participant provided rich data for

analysis. Observations were described in written field notes. I simultaneously

reviewed the audio tape and the transcription for accuracy. Any discrepancies were

noted on the transcription. Additionally, I read and re-read each transcription before

initial analysis of data began. Based on the preliminary analysis, additional questions

were identified prior to the next interview, including any questions related to content

needing further clarification.

At the time of the final interview session, I thanked the eNO for her participation

and asked permission to contact her if further clarification of data was necessary,

during the analysis phase of this study. The data collection phase took approximately

6 months. At that time data saturation had occurred.

During the interview process, I was aware of my biases and constantly worked to

insure that my beliefs were not leading the participants. Bracketing was an effective

tool which I utilized to keep me grounded (Ely, 1991). Following each interview, I

wrote many comments about what I was hearing from each participant and I

questioned myself constantly to make sure I was hearing their words and not inserting

my own thoughts and beliefs into what the participants said. Additionally, bracketing

ensured that my research stance was not unduly influencing what I was hearing and

interpreting from the participants. It was imperative for me to acknowledge my own

experiences as a nursing leader but more importantly that I stayed in the role of nurse

researcher capturing the essence of my participant's experience, not my own.

 36

Data Analysis

I read and reread the transcribed interviews, developing codes, categories, sub

themes, themes, and a metatheme. The codes were grouped and put into analytical

categories. Van Manen's (1997, p. 5) methodological outline was utilized for data

analysis and can be found in Appendix A.

The mechanics of data analysis as outlined by Ely et al. (1991) provided a guide as

the detailed work of the data analysis took place. Logs were my data repository and

they were put in chronological order. "The log is the place where each qualitative

researcher faces the self as instrument through a personal dialogue about moments of

victory and disheartenment, hunches, feelings, insights, assumptions, biases, and

ongoing ideas about method" (Ely et al., 1991, p. 70). Specifically, the "log is the

data" (Ely et al., 1991, p. 70). The logs commenced with my initial feelings about the

journey upon which I am embarking. All my interactions with each participant were

recorded, including any telephone calls, visits, conversations regarding gaining

entree, and any responses. In writing the logs, my margins were wide enough for me

to write comments, make categories, note my hunches, and determine what needed to

be clarified. The log was established to accommodate sequential pagination so that I

could easily refer to the log when I developed my analytic memos as part of the

process. Specifically, the analytic memos were my personal reflections on the logs as

well as an incorporation of my observer comments.

In an effort to establish categories, I followed the guidelines provided by Ely et aL

(1991), which are as follows,

 37

1. I reacquainted myself with what I was about to categorize. Specifically, I selected

one entry from my log, read and pondered it several times until I felt I have captured

the essence of it.

2. I wrote comments in the margins of the log about my thoughts related to the entry.

This allowed me to capture why the remarks were interesting to me, what my insights

were relative to the entry, and any topics that came to mind as a result of my thoughts

about the topic.

3. I created "meaning units" by reading the narrative and divided it in a way that

made sense to me. That transpired as I found meaning throughout the log. For

example, I noted, "There is something going on here."

4. Once the meaning unit was identified, I designated a label for it, in the margin of

the log. The label was descriptive, with only one, or a few words to describe it and a

code was assigned.

5. A list was made of all labels. Then, I assessed the list for any similarity between

labels and put similar labels into groups that seemed to fit together. If the labels did

not seem to fit into a group, the label was maintained as a single item. Groups of

labels were compared and contrasted to assess for links across label groups. I

continued this process until I could find a descriptive meaning, as opposed to looking

for reoccurrence.

6. I continued to analyze the data and applied the labeling, grouping, and across

group comparisons process while reflecting upon the previous labels as I worked

through the next log entries. I was cautious and aware, so as to not to force fit labels
 38

into these new meaning units. Once the labels fit, they were considered as a

temporary title for categories.

7. I wrote the analytic memos as I went along to prepare for the final analysis.

8. The final analysis was focused on the search for themes.

According to Ely et al. (1991), a theme is defined as meaning which consistently

runs through the pertinent data. Additionally, a theme can also be a meaning that

carries a heavy emotional or factual impact (Ely et aI., 1991). The data analysis

resulted in the identification of four themes specific to the phenomenon with eight

subthemes, and one metatheme which emerged; I went back to review the literature

following the emergence of each theme and the one metatheme.

 39

Chapter IV

FINDINGS

Participant Prome

As shown in Table 1, all six participants were female and the CNOs ranged in age

from forty eight to sixty seven years with an average age of fifty seven years. Three

of the CNOs' held a doctorate degree (one CNO had a Ph.D. and two CNOs' had a

DNP) and the remaining three CNOs' held a master's degree (two CNOs' had a MSN

and one had a MA). One CNO who held a MSN degree was enrolled for her

doctorate degree. All six CNOs obtained national board certification in their area of

specialty, Nurse Executive, Advanced (NEA-BC). All the CNOs in this study

belonged to ONEINJ, their professional organization. Four of the six CNOs are

Johnson & Johnson Wharton Fellows from the Nursing Executive Program.
 40

Table 1

Participant Profile by Gender, Age, Race, Education, National Certification Held,

Professional Associations, & Other Education

Participant Gender Age Ethnicity Educational National Professional Other

(n=6) F= Race Level Certheld Associations Education
Female
M=
Male

Judy F 61 Caucasian MA NEA-BC ONEINJ J&J

FELLOW
Donna F 55 Caucasian DNP NEA-BC ONEINJ

Michele F 67 Caucasian DNP NEA-BC ONEINJ J&1

FELLOW
Lea F 48 Caucasian MSN NEA-BC ONEINJ J&1
FELLOW
Margaret F 57 Caucasian MSN NEA-BC ONEINJ J&1
FELLOW
Shelly F 55 Caucasian Ph.D. NEA-BC ONEINJ

The CNOs had been Registered Nurses (RNs), from twenty-eight to forty-six

years, with an average of thirty-five and a half years as a RN. The CNOs possessed

on average twenty-nine years of experience in Nursing Administration. The average

length of time the participants held the position ofCNO was thirteen and half years.

The average numbers of years experience as a CNO in their current acute care

hospital was eight years. This information is depicted in Table 2.

I
~
I
iI 41
I

Table 2

Participant Profile by RN Experience, Nursing Administration Experience, CNO

Experience, and Length of Time as CNO in Current Acute Care Hospital Setting,
Prior CNO Experience

Participant Total Total Total years Length of Time Prior

(n=6) Years Years experience asCNO in CNO
As An Experience in asaCNO Current Acute Experience
RN Nursing Care Hospital
Administration Setting

Judy 40 38 25 3 Yes

Donna 33 25 13 13 No

Michele 46 32 14 14 No

Lea 28 26 13 3 Yes

Margaret 35 32 25 10 Yes

Shelly 32 25 7 7 No

All participants began their career as staff nurses. The six participants held

various administrative positions along their career path such as a nurse manager,

director, and eventually progressed to the CNO role. Three of the participants also

had previous experience in nursing education. There were three participants who

shared that their current position as a CNO was their first. The remaining three

participants had prior CNO experience.

 42

The CNOs were well read and current with both leadership and nursing

administrative literature. Comments from Judy, Donna, and Michele illustrate this

commitment to staying current.

Judy: It is a very short article, yes, the article was written by

Dana Blexo and Catherine Robinson-Walker and it is
called, "Investing in Leadership; an unwavering priority."
What she talks about in order for a nurse exec to be
successful, you have to be a coach, a mentor, you have to
lead by example, you have to share your vision, support
the teamwork, teach, inspire, and motivate, all at the same
time. I look at this and I say, this is what I live and breath.
This is from Nurse Leader, this just came out, I think I got
it this week.

Donna: Let's help them (the RN's) to get where they need to be.
So, we've really engendered that kind of thinking in the
organization and there's also a book, I don't know if
you've ever read it, From Good to Great by Jim Collins.
So, urn, I really think that has helped us with our journey.

Michele: We were able to work with the staff (RN's) and help them
understand where we were going all going and giving them
opportunities to meet with the staff and see what their needs
were, type of model, and I kept hearing about Magnet, Tim
Porter-O'Grady, Shared Governance, and I was thinking,
why couldn't we do that here ... So, we brought Tim
Porter-O'Grady here, which was such a big deal for the
hospital, I'll never forget that day. We were so nervous, we
had about thirty nurses in the room. That's when we started
our Shared Governance journey.

Acute Care Hospital Setting Proide

All six acute care hospitals were community based and one hospital was a

designated trauma center. Five of the acute care hospitals were not for profit and one

acute care hospital was a for profit hospital. Only one of the acute care hospitals had

their SNs represented by a nurses union. Two hospitals achieved Magnet status and
 43

the remaining four hospitals were on the Magnet Journey. Table 3 depicts the acute

care hospital setting profile by each participant.

Table 3

Acute Care Hospital Setting Profile by Participants- Type of Hospital Setting, Profit
vs. Not for Profit, SN's represented by Union vs. Non Union, and Magnet vs. Non
Magne~agnetJourney

Type of Profit SN's Magnet

Participant Hospital Setting VS. Represented by Vs.
(n=6) Non Profit Union Non Magnet/
Vs. Magnet Journey
Non Union

Judy Community For Profit SN's Non Magnet-

Hospital Non On the
Unionized Journey
Donna Community Not SN's Magnet
Hospital & For Non
Trauma Center Profit Unionized
I

1
I
Michele Community
Hospital
Not
For
SN's
Non
Non Magnet
On the
Profit Unionized Journey
Lea Community Not SN's Non Magnet

II

Margaret
Hospital

Community
For
Profit
Not
Unionized

SN's
On the
Journey
Magnet
Hospital For Non
Profit Unionized
I
Shelly Community Not SN's Non Magnet
I
Hospital For
Profit
Non
Unionized
On the
Journey
!I

 44

Vignettes

I created a vignette of each CNO in this study. The purpose of creating the

vignette was to assist the reader in gaining a better understanding ofeach CNO who

participated in this study. The goal was to bring to life the CNO and demonstrate that

although they have different relationships with their SNs, they have a commonality

relative to their lived experience regarding this phenomenon of interest.

Lea.

Hello, I'm Lea. I did not always want to be a nurse but the career I wanted to go

into was not an option. So, I spoke with my mother and she encouraged me to go into

nursing. My mom was a ChiefNursing Officer. I knew that someday I would be a

nursing administrator. My mom always offered me so many wonderful insights from

her experience as a nursing leader. She was very well respected in the nursing

profession. I came up through the ranks quickly from a staff nurse, to a charge nurse,

to a head nurse, to director, then a CNO. I continued on in my education over the

years. I am currently enrolled in school for my doctoral degree (ph.D.). I previously

worked at several different hospitals in the Philadelphia area. Before I came here, I

thought I worked in "Mecca", and then I came here. I have to tell you, I love it here,

and I love the staff. Coming from such a big academic hospital setting, I really didn't

get as much time with the staff that I would have liked. Here, I can take time to be

with the staff nurses. The best part of my job is interacting with the staff nurses. I

am out on the floors and I watch what is going on and I have to tell you, I am so

proud of the staffnurses here. The staff nurses here just amaze me. I created a

professional practice council and I will tell you, this meeting is the best meeting I
 45

have. I look so forward to working with the staff through the professional practice

council. I want the staff nurses here to be able to make the decisions about patient

care and their practice. They are on the front lines of patient care and they have the

answers. You know, when you invest in the staff nurses you get it back in patient

care and patient outcomes. I have so many incredible stories about how my staff

nurses have made such a wonderful impact with the patients here. I think it is so

important to recognize the staff nurses. I want to make sure the staff nurses have

access to me. As a matter of fact, I was asked to move my office to the executive

suites but I told my boss that I didn't want to move. I want to stay right here in the

thick of it all. I want to know what is going on. Even though my staff nurses are

unionized, I have been able to decrease the grievances by 80% and I am proud of that.

I feel it shows the staff nurses that I care about them, I want to understand their

concerns and I will be responsive to them. I take great pride and satisfaction in

mentoring and coaching the staff nurses and nurse externs. I will never forget what it

was like to be a new nurse and I never want to leave the staff nurses with the negative

experience I had with my Chief Nursing Officer. Therefore, I have learned from

those past experiences and know what type of leader I want to be. I appreciate the

staff nurses and they appreciate being appreciated. Most of all, I want the staff nurses

to know that I am human.

Michele.

Hi, I'm Michele. I have been around for a long time. I have been in this hospital

for my entire professional nursing career. You could say that I grew up here. I

actually grew up in this community. My nursing background was that of an OR

 46

nurse. I worked for a wonderful eNO who was so wann and compassionate. She

encouraged me to go back to school to advance my education. I started out as a

diploma RN. I went back for my BSN, my masters, and I just recently completed my

DNP. As I went back to school, I was provided the opportunity to assume various

nursing leadership positions at this hospital. I went from being the director to the

eNO. The eNO position became vacant when my eNO retired. I really admired her.

She also encouraged me to get involved in our Professional Organization for Nurse

Executives and I joined the Organization for Nurse Executives ofNew Jersey. I was

very active on many of ONEINJ committees. I would go there to learn and see what

was going on outside the four walls of this hospital. I was so impressed by what

others were doing, I would think, why can't we do that here? So, when I would come

back from those meetings, I spoke to my team and I said, "Let's try this." I kept

hearing about Tim Porter O'Grady and shared governance, and you know what? I got

Tim to come here and he told us what shared governance was all about. Although we

are in a rural setting, there is no reason we couldn't do innovative things with our

nursing staff. I was so excited. We created a shared governance model and a

professional practice council. I wanted the staff nurses to be empowered to drive

change in their pmctice. I have the nursing staff run the professional practice council

meetings. We work together to identify problems and issues. I help to facilitate the

resolution of the issues. I have an open door policy and the staff nurses know they

can come to me for anything they need. I have all kinds of forums to communicate

with the nursing staff. What I love to do most is to go up on the floors and make

rounds with the staffnurses. I like to talk to them about what is going on with their
 47

patients and most ofall what is going on with them. I really take a personal interest

in them. I know everyone by name. I will do anything for them and I will always

help them. I even push patients on stretchers from the Emergency Department (ED)

to the floor if the ED is too busy. We are always celebrating something around here.

The staff nurses really do a great job with the quality of care they provide to the

patients. I am so proud ofthem. You know, we were number one in the state for our

core measures. It is about making sure the staffnurses are happy. If they are happy

then the patients will be happy. It is that simple. I think I have the best staffnurses in

the state. I think the staff nurses know that I care about them. I do love my staff and

they love me back.

Margaret.

Hi, I'm Margaret. I have been at this hospital for several years now. I came here

with previous CNO experience from out of state. I had a passion for wanting to be a

nursing administrator. I held several leadership positions but I went into education

before I assumed the CNO role. I have a master's degree and I am currently enrolling

in school for my doctorate degree. My previous role in education has really helped

me in this role as CNO. I offer many educational sessions to the nursing staff and

nursing management team here. I believe in transformational leadership and that

guides me in what I do here. It is all about the nurses. I believe that they are the key

and drivers to making positive changes for patient care and in the organization.

When an issue arises, I form a task force and have the nurses at the bedside work on

the problem because they know best. They can tell me what needs to change, so we

can make things better-they are the experts. We just built a new ICU and I had the
 48

staff nurses work on the design, the work flow, and they detennined the aesthetic

interior design for the unit via evidence-based practice and a literature review. I was

really so proud of them. We were pioneers for a new electronic medical record and I

had the staff nurses involved in this as well. Our hospital has achieved Magnet status

and I am so proud of the nursing staff here. I take the time to be visible and

accessible with the staff nurses. I am here for them. I appreciate all that they do. I

know it isn't easy on the floor but I am here to make things better for them. I care

about the nursing staff. I am also involved in my professional association, the

Organization of Nurse ExecutiveslNew Jersey.

Donna.

Hi, I'm Donna. I always knew that I wanted to be a nurse. I have been at this

hospital for many years. I previously worked as a nurse in the New England area and

then came out to New Jersey. I have been here at this hospital ever since I moved to

New Jersey. My clinical nursing background was in Maternity. When I started out in

this hospital, I was a nursing supervisor and then went into a nurse educator role. I

was able to work my way up to the position as the CNO for this hospital because the

previous CNO just didn't fit here. Her leadership was very authoritative and that

didn't sit well with the staff nurses. I was given the opportunity to be the acting

CNO. I was eventually given the CNO and it was nice because the stafIknew me.

The staff nurses knew what kind of a leader I was, down to earth, calm, and I had a

deep understanding of what the nurses day to day challenges were from working with

them as a nursing supervisor. The former Chief Executive Officer of the hospital was

a great mentor to me. He believed in my ability to further pursue my career

 49
!1
I

advancement as well as my education. I had my BSN but he encouraged me to get

J
j
my Master's degree. I recently completed by DNP. I am active in the Organization
I
~

of Nurse Executives of New Jersey. We are a Magnet hospital. I like to make rounds
1
I and see the staff nurses. I created a professional practice council and I really enjoy
~
I networking with the staff nurses on the committee. The management team here has

Ij adopted the philosophy of servant leadership. It has really helped me to connect with

j
I
the staff nurses here. I want to truly understand their needs. I like to recognize the

t nursing staff for a job well done. A regret I have is that, I wish I could be out on the
i
floors more with the staff but the staff know that I am available to them for whatever

they need. My secretary knows that if a staff nurse calls me, she gets me right away

so I can speak to him or her. The staff nurses have my email so if they want to ask

me a question, they can reach me by email and I will follow up. I am an advocate for

the nursing staff. I also advocate for the nurses when I am in my senior management

meetings and at the board meetings. I feel it is so important to recognize the staff

nurses.

Shelly.

Hi, I'm Shelly. I knew I wanted to be a nurse when I was young. It was because

of my best mend. She had cancer and unfortunately she died, but I was always there

for her. I watched her in a lot of pain and I was there to comfort her. I will never

forget her. I went to school for nursing and eventually ended up with my Ph.D. in

nursing. I have worked for this hospital for quite some time now. I previously

worked as a director in another health care facility and I came here in the late 1980's.

I really enjoy working here. I was hired as a director of nursing and then worked my
 50

way up to the CNO position. I did not have any aspirations to become a CNO but the

previous CNO had left and my Chief Executive Officer asked me to think about it. I

did and the next thing I knew, I was given the position. I had a great rapport with the

staff nurses and when it was announced, during nurse's week, that I got the CNO

position, the staffnurses cheered and clapped for me. I will never forget that day. I

have been involved in the Organization ofNurse Executives in New Jersey for many

years. We are on the Magnet Journey. The staff nurses here really deserve that

recognition. They work hard. I really try to understand from the staff nurses point of

view, what is happening on the patient care units. I am frequently in the ED. We

have a very busy ED and I want to do what I can to help them. Very often, I get them

pizza because they are so busy, they never have time to eat and I tell them, "You have

to eat, you can't keep working like this without food." The ED staff nurses call me

the "Pizza Lady." The bottom line is the staff nurses know that I care about them. I

do come in on the weekends and make rounds. I treasure that time because it is my

time with the staff nurses. I take my time doing the rounds and I am not rushed. I

really feel it is the best time of the whole week. I want the staff to know they can

come to me with anything. I will not tolerate any bad mouthing from the doctors

about the nurses. I will stand up for the nursing staff, whether it is with a physician or

even a family member. I am their advocate. I am the voice of reason. The staffhas

access to me. We have a great professional practice council. The staff nurses at the

hospital are involved in making decisions here and they are empowered. I try to be

very down to earth with the staff nurses. I want them to be comfortable with me. I

hold round the clock meetings with the staff nurses on each shift. I show them that I
I 51

1
j

I I
am human and I have a sense of humor. You have to be able to laugh at yourself and

not take yourself too seriously. It is important to have that connection with the staff

II nurses. You have to get to know them. I would do anything for them and I they

if
would do anything for me.

Judy.

l
{

1
!
Hi, I'm Judy. I have been a CNO and Chief Operating Officer before this hospital

position. I have worked in the Mid West before coming to work in New Jersey and I
~!
held various nursing administrative position along the way. I did want to be a Chief
~
i Nursing Officer and I had a wonderful mentor who I am still in touch with today. I
i
I am an active member ofthe Organization of Nurse Executives in New Jersey. I have
l
i obtained my Master's degree. I always wanted to be a nurse as far back as I can
I
i

I
\
r
remember. My expertise was in Maternal Child Nursing. At this facility, I am

working hard to regain trust between the staff nurses and administration. The hospital
~
!
!
has been through a lot and I want to support them through this new leadership
! transition. The staff nurses here have my cell phone number and they know they can
!
!
I! call me anytime. I do get calls from them in the middle of the night and that is fme. I
i
i come in early on the night shift to make rounds. In the beginning the staff nurses
r

were so surprised to see me, but now, they are used to me. I keep every Friday open

with no meetings scheduled because that is my day to round on all the patient care

units and see the staff nurses. I am encouraging the staff nurses to obtain their

national certification as well as getting them to go back to school to further their

education. I try to reward and recognize the staff as much as possible. I write

personal thank you notes to them on a job well done. I will say I was very touched by
 52

the outpouring of support I got from the staffnurses when my father died. I didn't

expect anything and so many of the staff nurses came to see me and sent me cards to

express their sympathy. I was truly touched.

 53

Chapter V

THEMATIC FINDINGS

Themes

Four themes and eight subthemes (see Table 4) emerged as the data were

analyzed. The four themes (see Figure 1) were:

• Developing and Sustaining the Relationship

• Creating a Positive Work Environment

• Brave Leadership

• Return on the Investment-Investing in the Relationship with SN s

 54

Figure 1

Themes- Developing and Sustaining the Relationship, Creating a Positive Work

Environment, Brave Leadership, and Return ofthe Investment ofthe Relationship

with the SNs.

Investment
in the
Relationship
withSNs
 55

Table 4

Themes, Subthemes, and Categories

Theme SubTheme Category

Theme # I-Developing Sub Theme # I A-Getting to Being Human

and Sustaining the know each other Caring & Compassion
Relationship Presence by
RoundinglManagement by
Walking Around

Sub Theme # I B-Trust Transparency

Integrity
Fairness
Autonomy
Respect
Non-Threatening
Protection

Sub Theme # 1 C- Reciprocal Support

Support Appreciation
Thankful
Recognition

Theme # 2- Creating a Sub Theme- Shared SN Satisfaction

Positive Work Governance SN Voice/SN Decision
Environment Maker
Teamwork
Inclusiveness

Theme # 3-Brave Sub Theme # 3 A- Advocates Pride In Nursing

Leadership for Nursing Visionary
Promotes Nursing

Sub Theme # 3B- Agility Adaptable & Flexible

Takes Action
Change Agent

Sub Theme# 3 C- Coach and Shares Knowledge

Mentor
Theme # 4-Return on Sub Theme- Positive Patient Patient Centered
Investment in the Outcomes
Relationship with SNs
 56

Developing & Sustaining the Relationship

Developing and sustaining the relationship was the first theme to emerge from the

data analysis. The eNOs participating in this study described the evolution of and the

importance of their relationship with their SNs. Developing and sustaining the

relationship was the strongest and most common theme discovered in the analysis of

the data, and was comprised of several subthemes: Getting to know each other, trust,

and reciprocal support (see Figure 2).

 57

Figure 2

Theme # 1- Developing and Sustaining the Relationship and Subthemes: Getting to

Know Each Other, Trust, and Reciprocal Support

 58

Getting to know each other.

The CNOs expressed throughout the interviews how important it was for them to

get to know the SNs and for the SNs to get to know them. They felt this was the first

step in the fonnulation of the relationship. When asked what would be their advice to

a new CNO coming into this position, all the CNOs made the statement that the new

CNO had to take the time to get to know the SNs. It was also interesting to note that

the majority of the CNOs made the statement that when they were SNs, they did not

know their own CNO. Every CNO verbalized that they made a concerted effort to

ensure that they knew their SNs.

Donna sums up what all the CNOs stated about getting to know each other.

Donna: You need to really get to know them (SNs) and have them
get to know you.

Three categories describe the process of getting to know each other: being human,

caring and compassion; and presence by rounding/management by walking around.

They are discussed below.

Being human.

The CNOs felt it was very important for the SNs to see them as human beings. All

ofthe CNOs wanted to relate to the SNs on a human level. They were proud to be

able to say that they knew the staff by name. Consistently, the CNOs felt that by

getting to know the SNs by name, it made a difference in the sense of allowing for

ease in developing the relationship.

Lea: I do think it is incredibly important to call everyone by name.

Judy: It is my goal.. J have 450 nurses to eventually know all them

by name, to get to know them personally, uh, I think that

 59

personal relationship, fmding out who they are ... So, you
know, I try to have a personal relationship with all my
staff but that takes a lot of time.

Donna: I had a couple ofBSN students... they are actually our

employees but they did their clinical time here
and they said to me, "Oh my god, we can't believe you know
everybody's name."

The eNOs wanted the SNs to call them by their fIrSt name. If the SNs called them by

their last name, the eNOs would show their sense of humor by saying, "Mrs. Smith is

my mother in law."

Margaret: Everybody knows me as Margaret.

Judy: We are on a first name basis ... Some of the staff even have a hard
time calling me Judy, but you know when they say, "Mrs. Jones,"
I say, ''that is my mother in law," but I think I have developed a
very strong relationship with them and I think I am very approachable.

All the eNOs verbalized how important it was for the SNs to view them as human

beings. They were passionate in sharing stories about how much it means to them as

being perceived as human and that eNOs are not perfect. Being human was

significant for the eNOs in developing and sustaining the relationship with the SNs.

Lea: They get to see you are a human being, you make mistakes, um,
you are not going to bite their head off because they made an error
or something like that.

Margaret: I am on the bio ethics and so, I am out there doing the bio

ethics consults and stuff. I think they see the human side

of me.

Shelly: Well, they know I'm human. I mean, at yesterday's meeting,

first meeting, well, I unfortunately, the slide, we were using
a proxima and it set to then ten second flip time, so my slides kept
flipping and they were watching me .. .it was comedy of errors. It
makes you look human and I usually laugh if I make a mistake...
let them know you're a real person, don't be haughty, don't be
haughty...let them see you as a person.
 60

Caring and compassion.

As part of the development of the personal relationships with the SNs, the CNOs

were interested in understanding the SNs on both a professional and social level. The

CNOs conveyed caring and compassion to the SNs.

Lea: Before they (SNs) start, all the directors send them a little
packet, and in the packet it is a free meal ticket, free lunch, for the
fIrst day they are here we allow them to valet park so they don't
have to worry or be confused on where to park. .. So, they don't
even have to worry about the car on the fIrst day. They get a welcome
card before they start...it's really, you know as a new employee, what
flusters you the fIrst day you were there, so it's trying to take all those
concerns away when they start.

Michele: 1 think that knowing them (SNs) as people, you know, if a staff
member comes down, 1just had one this morning whose husband
has urn a brain tumor and he's been two years clear and she came
in this morning to tell me that it's not, urn, it's come back. It's like
grapes, it's not really that big but just to sit there, 1 mean, my heart
just went out to her. I'm like, ok, now, what can we do for you?
Do you need time off? Do the manager and I need to sit down so that
you're free to be able to support your husband, because your family
comes fIrst now. Urn, those types ofthings.. .1 had a nurse who was
going through a real bad divorce, if my husband ever knew, he would
kill me... but he took the car, he took so much, she didn't even
have transportation to work. She went to look for a car in one
ofthe those second hand lots that she thought she could afford but
she didn't have the down payment. So, 1 said to her, "I will help
you with the down payment but you gotta promise me that you'll
pay me back." It is that type of stuff because people don't have other
resources and yet what do we get from when we had these snow
storms, they didn't even, it wasn't a matter of how to get them
in, they know the snow was coming, so they packed their bags and
they were ready to stay overnight. You can't pay people enough for
that. ..you can't and I am looking and the place is so small, I know
them all on that type of personal leveL

Donna: 1 love them (referring to the SNs), 1 really do.

 61

Presence by rounding/management by walking around.

All of the CNO engaged in management by walking around. Each CNO expressed

a high level of satisfaction when being out and about on the nursing units, interacting

with their SNs. It was obvious that this brought them a strong sense ofjoy and

happiness in their day. The CNOs absolutely wanted to be visible and by making

rounds the CNOs were able to increase their visibility, accessibility, and presence.

Lea: So, I do think it is really, really, important for me to be present

and I say that to the staff.

Margaret: I was present with them, right there with them, to

hear, listen, take it in, respond and make things

happen.

Judy: I think people see that I care, it is that presence, and it's that

front line presence, and it's valuing what we are asking

them to do, being in the front lines, being available.

Rounding was conducted by the CNOs on both a formal and informal basis.

Several of the CNO maintained a consistent time they rounded and others chose to

round on an unscheduled basis. If there was free time, the CNOs would opt to run up

to the nursing units to conduct spontaneous rounds.

Michele: If you asked my boss, the CEO, he would say, "She hasn't
evolved enough because she is still up there on the units and
she's late for meetings because she gets involved in talking to
the staff (giggles)," you know, if I have to be here
until seven at night so I can see the staff, it's just those litt1e­
how's it going, what's the best thing that happened today...that
has always been my style.

The CNOs demonstrated their presence not only during the rounding process but

also by the way in which they engaged the SNs while making rounds. Ofutmost

importance to the CNOs was the fact that they wanted to relate to the SNs in the
 62

moment of their interaction. Specifically, they wanted to take the time to listen and

understand what the nurses were facing at the bedside, how they could be of

assistance and to come across as being genuine towards them during the interaction.

Lea: The first week I was here, um, I was

rounding and no one really knew who I was, I was walking
around in my lab coat, looking through charts, trying to get a
sense of the issues and what systems they used, and things like
that and I was standing at one of the nurses station and the
nurse was on the phone and she was talking to a patient who
had just been discharged, he was elderly and his wife had come
to pick him up but it was a struggle to get him home, the two
ofthem were needy, the patient got home and realized that he left
his glasses ...so he called and he was talking to the nurse
and again, I am standing in the background listening to her, and
she was talking as sweet as a pumpkin, and then she goes, look,
you live in ***name of a nearby town and I live in the town
right past * **name ofthe nearby town, I get off work at 7 pm
I will drop them off for you and I just stopped dead in my
tracks, and I'm like, I don't think I have ever hear
a story like that even in Philadelphia, 1...1 was so overwhelmed,
I came down here and we give cards and gift cards, things like
that and I wrote a little thank you to her, she didn't know me,
and I walked up to her about 2 hours later to meet her and I said,
Hi, my name is Lea, she said Hi, I'm Amy, and I said, Amy,
you just validated for me that I made the right decision in
coming here. I was just blown away.

Michele: I think, first and foremost, you have to be a good listener and
you have to be really present. I don't think it's the amount of
time, it's the, it's the touch on the shoulder, it's looking them
right in the eye when they are trying to tell you something about
a patient care issue, a physician issue, or just about how their
day is going. You can't be too harried and you've got to be
very centered and focused on them and I think that says it all.
You gotta get out of your office, and that's hard for us, right?

Donna: We get a scouting report. First of all, we have a very formal

process for a senior leader has to visit every area including the
nursing units, once a month; at least once a month... We have
a formal schedule, they know we're coming. We get a scouting
report... and it basically goes over some ofthe personal things that
manager might want you to know. For example, a staff member
 63

recently returned after a long leave that was public ...and she's
back, her husband had cardiac surgery, and that was disclosed, I
mean anything you wouldn't want to be disclosed wouldn't be
on the form, one of the radiologist has a fIrst grandchild. So, it's
the little things that are on there as well as, urn, anything hot,
there having an American College of Surgeons visit to the
Cancer Center in May ... So, any little tidbit you need to know
and any issue, any hot issue as well as any congratulations ... So,
the manager is responsible for giving us that, the week or a couple
of days before and then I basically go and make rounds .. jt is kind
of open ended but it gives you some things to talk about and then
you can follow up.

Trust.

Establishing trust is the second phase of the CNO relationship with the SNs. Each

CNO expressed how important it was for them to establish a trusting relationship with

the SNs. The CNO ensured a level of trust with the SNs by being transparent with the

SNs during their interactions and various types of communication. Without such

trust, the relationship would be strained and a lack of support would be evident. Trust

developed over time and captured the essence of seven categories. There were seven

categories that describe the beliefs and behaviors of the CNOs that contributed to the

development of trust, they were as follows: transparency, integrity, fairness,

autonomy, respect, non-threatening, andprotection.

Transparency.

The CNOs expressed the need to be transparent when interacting with the SNs.

They felt transparency would have a positive impact upon furthering the development

of their relationship with the SNs. All the CNOs described ways in which they

demonstrated transparency to their SNs as well as the importance of being

transparent.
 64

Lea: I say what I mean and mean what I say, I am a stickler... but being
consistent for staff, it is incredibly important, that urn, once you say
something it's not going to change somewhere else, urn and if you
say it, then you're going to do it and you get back to them or
do whatever you say, that is crucial.

Shelly: I think you just have to be very, very, transparent. I think

you have to tell them the good, the bad, and the ugly .. .1 don't
think there is any other way to talk to a professional
nurse, except to be straight with them. I think it gets
you more ground then trying to spin...I'm not a spinner.

Donna: It's about honest conversations ...they understand the realities.

Integrity.

Also important to the CNOs was integrity. They expressed how significant

integrity was for establishing a relationship. Many of the CNOs described examples

of how they demonstrated their sense of integrity to the SNs.

Margaret: It takes time, you have to prove yourself...trust has to be

earned. It's that we believe in ...and one of them is trust

and integrity ... So, we live it.

Shelly: I don't share anything confidential, because I can't. I have to

maintain all that stuff but, I'll answer any question, with, you
know, complete candor and truth. I think the truth will set you
free.

Judy: I think overall they, over time, you know, they've trusted me.

They see that my commitment to them is strong.

Fairness.

Hands down, the CNOs were all in agreement; they had to be fair in their decision

making, when it comes to the SNs. The CNOs understand that things are not always

black and white but at the end of the day, they had to be fair. They felt fairness was

one way the SNs would judge them and they did not want the SNs to perceive that

they were unfair in their approach. Ultimately, if the CNO was perceived as being
 65

fair to the SNs, this fostered positive relationships with the SNs. Margaret shared

how important it was for her SNs to perceive her as fair. The other eNOs described

examples of how they demonstrated their sense of fairness to the SNs.

Lea: I have a nurse who came through our extern program, who we
hired as a RN and she really thought she wanted surgical services
and we put her in surgical services, which was rare. We don't
usually put GNs (graduate nurses) in the OR (operating room) but
she really thought that was what she wanted to do and I was like, let's
give it a shot. We worked with her all summer. She was great, gave
her a shot and I think the flrst week she was there she was like, oh
my god, what a huge mistake but she was afraid to tell me and urn, the
nurse who precepted her for her externship, I was doing rounds
one day and she goes, have you talked to Dawn, she was going to come
to talk to you and I said, no, what's wrong and she said, she doesn't like
it, can we do anything for her and I'm like let me fInd her. So, I came
and talked to her and I tried to tell her and get in her head there are so
many other opportunities for her, let me try to help you. So, it took me
a little while because we had no vacancies but urn, we piecemealed a
position for up in med-surg and I just saw her preceptor yesterday and
she said, have you seen her? She flipped to nights so I don't see her as
much and she said, oh my god, she is so happy ... so, I think, I think the
reason they appreciate, you know...

Michele: It goes back to being a good listener and you have to tell the story
straight, it isn't always good news. I don't think you can,
sometimes, it's just killing you, you know, youjust have to say
"No I can't do that, no we can't do that for this reason but I've
come ofthe years to understand it's not really so much the
message, but that you have been open and honest with me, and
that's just the way it is. I think they deserve that from us.

Shelly: We're making things a little more stringent (regarding their

(clinical ladder program-to be fair to everyone participating) ...
what I hope they tell you is that I am fair.

These eNOs believed that honesty was the best policy. They acknowledge the

intelligence of their SNs and fully understand that you cannot pull the wool over their

eyes. Therefore, the eNO's philosophy was to be honest when communicating with
 66

the SNs. Even if the CNO has a difficult message to deliver, it cannot be sugar

coated; it has to be honest and sincere.

Lea: I am a very honest person and I don't beat around the bush, here is the
deal...

Michele: So, even when there were times when we couldn't

give raises and corporate wanted us to wait and

he said, "If they want to know in January and they

ask the question, then I feel I need to share that in

an easy a way I can because not everybody's is

making the big bucks. So, I think they deserve an

open honest answer.

Donna: It think it's openness, I think it's honesty ... So, I try to

be very, urn, honest but not pessimistic.

Autonomy.

All these CNOs echoed how important autonomy was for the SNs. The CNOs

elaborated on several examples on how autonomy is actualized in their acute care

setting.

Michele: We began the TCAB (Transforming Care At the Bedside) journey

and staff shines when they are able to express their own autonomy
and ideas about their units and so I think that all put that whole
package together and you are supported by your team and hospital
administration helps for staff to feel like this is a place they really
want to work.

Shelly: You have clinical power (referring to the SNs) ... and then let's keep our
eye on why we are here and all the things that you do, that is so
important, and why you are so important.

Judy: I have involved them in a lot of decision making and autonomy which
I don't think they had prior which I think they really value.

Respect.

Judy, Margaret, and the other CNOs share how important it is to be respectful to

one another. According to the CNOs, being respectful does make a difference to the
 67

SNs. Acknowledgement of respect further enhances the relationship between the

CNO and the SNs.

Michele: I think above all, if we don't respect each other, we're going
to have a hard time to work together.. .1 think they need to be
respected for what they do in their position.

Shelly: I hate criticism like anybody else but I do listen.. .1 may not like it
but I listen, but they think it is real cause I will go back to them
and tell them, "you're right," and they like thaL.! always treat
people very respectfully.

Donna: I think I show them a lot of respect for what they are doing

and I know they are doing hard work. Believe me, I know

its hard ...

Non- Threatening.

Judy and Shelly make it a point to share that they want to make sure that the staff

feel comfortable interacting with them. To put the SNs at ease, Shelly takes the

approach of being warm and smiling when interacting with them and she will even

tell them a joke. In doing so, Judy and Shelly, believe this will lead to a positive

relationship with the SNs. They take pride in the fact that they are not an intimidating

force. The other CNOs also agree with this type ofapproach and the benefits of

fostering the sustainability ofthe relationship. The ultimate goal for the CNOs is to

have the SNs feel safe in speaking up about any issues they have so they can work

collaboratively to improve a situation.

Michele: Lunch with Linda was for the staff to come down and share
the good things that were happening on the unit and how the
physician-nurse collaboration was. It was just to talk. We
never went with an agenda, and it was not, was not to be
a setting where you came to complain about a physician
or a staff member. This was to talk about our professional
practice, what kinds of things would they like to see or
educational, what types ofthings would they like for us
 68

to bring in, what do you think we should feature for nurses

day, uh, those types ofthings.

Margaret: Word gets out quickly, people aren't afraid to come to me

with their issues. It's part of our nursing philosophy, and
we developed that with our staff.

Protection.

It was quite interesting, the CNOs were really so protective over their SNs. It

reminded me of a mother bear protecting her cubs. All of the CNOs provided

examples of how they single handedly protected the SNs in their organization from

harms way whether it was from a disciplinary action that was going to be taken or a

termination, the CNO advocated for the SN and was the one who could see the

situation objectively and provide guidance for the final outcome ofthe SN. The

CNOs were very passionate about protecting and saving their nurses from harm. The

CNOs were realistic in considering the circumstances surrounding the incidents that

the SNs were involved in. The protection offered by the CNOs to the SNs augmented

their relationship and trust in their relationship.

Lea: I think what helps build the relationship and I'll give you an
example, this happened here um about three years ago. We had a
g very significant medication error and um with a pregnant mom and
1
i! you know that is our bread and butter and the nurses in the entire
MCH (Maternal Child Health) division were pretty exceptional.
I
!
I have to say, they are amazing; besides st. Pete's in North Jersey ...
We deliver more babies than anybody else. So, this is the baby capital
i
I of South Jersey. So, it's a big, big, thing and we had a really
significant issue, a medication issue and I think based on how we jumped
I
j
on this and how we handled things and stuff like that, it was, is this
i woman going to lose her job? So, I am sitting with the director and I'm

II like, did she do it on purpose? And she is like, no.. .! said then, why
should she lose her job? I said, I bet you 10 to 1 she will never do it again
I
and she goes, oh my god, Lea, she has been crying for two weeks and I'm
like, don't you think she already leamed...do you know what I mean? I
think that kind of philosophy has kind of helped to change the relationship
 69
!
of the staff you know sometimes they don't know how to take me ...do you
I.
j
j
know what I am saying? Well, it's like heck, we are all human, we come,
we make a mistake, it's a whole different thing if it is intentful. But,
that's, that's different ...that wasn't the case. It wasn't egregious. 1

I
i
i
remember my, even my directors were like, wow.

Michele: Now, if 1 hear them, a doc, sometimes the doc's get

I
I going on them (SNs), 1 will step in, "You were just

I talking [Link]'s enough now." "We need to take

the two of you and we'll talk about it." But 1 do defend

II them on that, because they are not here 2417 and they
don't always have the right answers ...the staffnurses say,
"Michele is somebody who always has our back." So, from
that stand point too ...they see that happen.

I Shelly: I represent the nurses, the good, the bad, and the ugly ...
always, even the ugly.. .! have family members that say,
I know that nurse didn't tell the truth and I let her in here

I
I said, "I'm sorry," I said, "I represent that nurse and I
represent the hospital, trust me that things will be done
properly but I'm the person you need to speak to."
1
Similar to being protective, the CNOs shared many stories about how strongly
1
I
1
.~
they felt about their SNs and they clearly defended them to the end. They would not

allow for their SNs to be taken advantage of by anyone. All CNOs were very clear
~~
~
about their position relative to defending the SNs. In one specific case, Shelly had a
j

1~ SN who was not truthful to her regarding a situation that transpired with a physician,

1 but because the physician was wrong in his approach, Shelly continued to defend the
t SN. Michele and Margaret made a point of sharing that they will defend the SNs to
i
I !
~
the point that they can and it all comes down to trust, and according to Shelly, they

know that their leader is fighting for them. Examples of how the CNOs defend their

I staff in the face of adversity is evident. This also helps to develop and sustain the

relationship between the CNO and SNs.

I Lea: The turtle is our little, um, our little mascot and the turtle means not
II

I
 70

that you are slow and consistent but that you stick your neck out
for what is right.

Judy: I think sometimes senior management; you know, has this, uh, uh,
vision and they want to make it happen but you've got to remember
that you've got all levels ofstaff, all generations of staff, learning
levels are different, and you can't make it happen over night and you
need to at least, to take time and you need to get buy in.

Reciprocal Support.

The third phase in developing and sustaining the eNOs relationship with the SNs

was reciprocal support. It became apparent that reciprocal support was the outcome

of building and cementing the eNOs relationship with the acute care SNs for the

present and in the future. Specifically, reciprocal support emerged as a positive and

significant turning point whereby the eNOs gave support to the SNs in various

venues and the SNs gave the eNOs support not only in their role as the leader but

also in their participation on projects and committees they served.

There were four categories which emerged from the data that formed the sub

theme of reciprocal support. The four categories were; supportfor one another,

appreciation for one another, a sense ofthanlifulness, and a need to recognize each

other. The eNOs provided rich descriptions of each category, which are noted

below.

Supportive.

All of the eNOs discussed, in depth, a great sense of reciprocal support they have

encountered between them and their SNs. Specifically, this sense of reciprocal

support gave the eNOs a feeling of validation for being there for their SNs, which in

tum demonstrates that they are human, they have feelings, and they ultimately care
 71

about the SNs. Conversely, the SNs were there to support the CNO. The CNOs

verbalized the fact that reciprocal support added to their relationship with the SNs.

Ultimately, once reciprocal support was achieved a trusting relationship was

solidified. This statement was evidenced by the overwhelming sentiments of genuine

love for each other from the CNO perspective.

Lea: We had someone who was in a car accident and his wife was
in the traurna center at Cooper and we donated PTO (vacation
time) and did everything, trying to help him. He didn't have
enough money to fix the car. So, we got him taxi rides so he could
go back and forth to see his wife .. .it's that kind of stuff and I think
the more you try to demonstrate for your staff and I, my world is
nursing, the more you try to demonstrate for your staff
appreciation and caring, urn, and that they are someone who is
very valuable, urn, the more they will give back to the
organization.. J have always believed that you get more with
honey and urn, again, if your employees feel like they are
appreciated, cared for, and valued they will rise to the
occasion...Many people have said to me, Lea, your people
would do anything for you.

Michele: My relationships at work, it's like who will help me out

when I need it and I'm here if you need me. So, I just

think that's what ties into having a good relationship .. J feel

free to share those things with them about me so that's

how I view it, that's to me loving them and they love me back

Margaret: The staff feels so supported... They are so supportive of me.

We had a nurse who had metastatic cancer. She came to

right down here to tell me, you know ...we're all in this

together... When people are in a crisis, they've got to know

that we care about you.

Judy: When my father died and I had to leave suddenly and then came

back, I just couldn't believe that during the time my family and I

were grieving, the support I received from the front line staff as

well as the managers and physicians, they came to my home

in the time that I was grieving, they brought my family food,

they were, I got letters from the front line staff, uh, the ancillary

support as well as nursing, and I was just overwhelmed with

the response and didn't expect it, didn't even think that, that,

 72

would even happen ... that was above and beyond ...they didn't
need to do that, there were no expectations, there were none
whatsoever, but you know, it feels good to know that you are
in such a caring environment, so supportive.

Appreciation.

A sense of appreciation was noted by all the eNOs. They truly understood the

reality of what their SNs go through on a day to day basis and they sincerely

appreciate all that they do for the patients, the patient's family/significant other, each

other, and the organization as a whole. Because the eNOs in this study conduct

rounds on the patient care units they can see what the frontline SNs endure and they

appreciate them for their hard work. The eNOs also want to ensure that the SNs

know that they do appreciate them. These eNOs do not take their SNs for granted.

Lea: I think they (SNs) appreciate being appreciated .. .! do believe

recognition makes the employees feel appreciated .. .! have worked
very hard very hard to let them (SNs) know how much I appreciate them.

Margaret: I appreciate them.

Shelly: We went through a storm and we came out better.

Thankful.

The eNOs verbalized how thankful they were to have such a great group of

SNs. Donna commented how amazing it was to be part of a team, a winning

team. The eNOs give credit to their SNs for making the organization successful

as well as the positive patient care outcomes. The eNOs did not want to take credit

for organizational achievements, positive patient satisfaction scores, and recognition

for quality outcomes. The thankfulness by the CNOs came directly back to the SNs.
 73

Lea and other eNOs described how the SNs would also thank them in an

unsolicited way. Specifically, Lea had described a scenario regarding union

negotiations with the SNs. As Lea was rounding, the key union leadership came up

to her to say, "Thank you, it went well and we really appreciate everything you did."

Additionally, the eNOs made it a point to share with me how they take the time out

to send hand written thank you notes to the SNs and they mail the thank you notes to

the SNs home. The eNOs felt it was so important to recognize the SNs and let them

know how thankful they are for all that they do and their efforts do not go unnoticed.

These examples illustrate the caring and concern for one another. Thus, the

relationship between the eNO and SNs continues to evolve and strengthen.

Michele: When we did our 1st Nursing Summit and our theme

was daffodils, one ofthe nurses does cross stitch

and she presented that on behalf of all of them in 2005.

I mean that's the kind of stuff you, you, can't buy

that... (Michele walks over to framed crossed stitch

on the wall and reads the following) ...Thank you for

your vision, Michele, one bulb at a time-

Love Your, Hospital Family.

Margaret: I send them thank you notes..J'll get thank you

notes back for doing that.

Shelly: I am going to go upstairs and tell them how great they are,
because they are.. .! get out there and I thank them, you know,
it's one, one of those things that ifthey get in (referring to a
snow storm), I've got to get in, but just these little things to say,
"I appreciate you," "thank you," ''thank you for coming in."

Recognition.

All eNOs have formal recognition programs in place for their SNs. The eNOs

verbalized the importance of establishing and maintaining their programs. They felt

it was a positive morale booster for the SNs. Again, the eNOs were so proud oftheir
 74

SNs and they in turn want to recognize them. Although the recognition is provided to

the SNs directly, the CNOs also share the SNs recognition both internally and

externally. Additionally, the CNOs also have an informal ways of recognizing the

staff. Shelly recalls how she often sends pizza to the Emergency Department when

she recognized that they are holding or the Emergency Department volurne is on the

rise for the day. This type of recognition is done spontaneously. The SNs from the

Emergency Department joke with her that she is the pizza lady. When Margaret

makes rounds on the units and she observes a wow moment with a SN, she will

reward them on the spot and recognize the SN in front of hislher peers. Overall,

recognition has had a profound effect on the relationship between the CNO and the

SNs.

Lea: I have never experienced such amazing, incredible

nursing care, never, never, never...the extent and extreme
of what they do for patients is absolutely overwhelming to
me... We do celebration rounds once a month. We bring around,
I don't want to say treats, but stuff, and we celebrate something,
urn, nights and days, urn, so we can see everybody and say thank
you for or we did great...cause the first thing they say (SNs) is what
are we celebrating this week?

Donna: We recognize and celebrate a [Link], educational

achievements, customer service... So we congratulate and
celebrate.. .! mean most of the recognition, we try, we do it
formally; again, like I said, and informally. We have WA WA
cards ten dollar WA W A cards and if you catch somebody doing
something wonderful, we just give them a little personal
note that goes to their home with the WAWA card. Yes,
we are told that it is a big deal because it gets put on the
refrigerator, people are very proud of that.

Judy: We celebrate nursing .. .! recognize nurses, we have a tea and

we recognize nurses who have published, conducted research,

received their certification, received an advanced degree, they

are invited to meet with me for tea and we share our

 75

accomplishments. I send them personal letters.

Creating A Positive Work Environment

Creating a positive work environment was the second theme identified. The

ability to create a positive work environment for the SNs was very important for the
I
!
CNOs. The CNOs absolutely recognize that it is the SNs who are responsible to
I
I
;
make things happen for the patients and the organization. It was the responsibility of
i
I

j the CNOs to ensure that the SNs have the resources they needed to provide the
~
i highest quality of care to their patients and that they create an environment whereby
l
j the SNs can thrive. From the CNOs perspective, the formation of their relationship

1 with their SNs makes the difference in creating a positive work environment. Shared

I
!
Governance was the subtheme which emerged from the data. There were four

! categories which emerged from the subtheme, they are as follows: SN satisfaction, SN
I voicelSN decision making, teamwork, and inclusiveness (see Figure 3). The rich
Ii
! descriptions are noted below.
I
\
~
 76

Figure 3

Theme # 2-Creating a Positive Work Environment with Subtheme-Shared

Governance and Supporting Categories

 77

Shared Governance.

The eNOs expressed their desire to create a positive work environment for the

SNs whereby they could establish a shared governance model which would take the

SNs professional practice and growth to the next level. Every eNO had established

professional practice councils, including those that were not a designated Magnet

Hospital. The eNOs believed in forces of Magnetism and felt it was very important

to get the staff involved as the expert and allow them to shape the delivery of care.

The eNOs also expressed that they readily give up control and they want the SNs to

drive the future of nursing in their organizations. The eNOs verbalized the positive

impact this model has not only on the SNs but on the organization as a whole.

SN Satisfaction.

Lea and the other eNOs shared their beliefs that if a caring and compassionate

environment could be created for the SNs, they would be satisfied. Michele and the

eNOs all felt that the hospital environment had a family type of atmosphere and the

eNOs can be there for the SNs. Overall, the eNOs wanted to ensure that their SNs

were satisfied with them as leaders and that they were creating a positive work

environment which would satisfy them at various levels such as professional growth

and development, open lines of communication, and a sense of presence, just to name

a few. Donna discussed the importance of employee engagement. She felt that

engagement with the SNs would lead to a positive work environment because the SNs

would be emotionally invested in their jobs and in the organization. Specifically,

Donna shared that the SNs give their hearts and minds to their work; it is not just

thinking about the SNs getting through their twelve hours shift and going home to
 78

forget about everything. Margaret and the other CNOs were very proud to share that

the SNs "love it" at the hospital. The statements below demonstrate the essence of

what the CNOs did to positively impact SN satisfaction.

Lea: The mission of the system has two primary components, focusing
on patients, patients, outstanding patient experience
and also the employee. So, if you have happy employee, you will
have happy patients and vice versa and all around. It is very
refreshing to say the least...So, how do I keep them (SNs) happy?
I think I had mentioned some of this but, urn, we do have a strong,
strong, focus on recognition. We have, I would say, unofficial
recognition and very formal recognition...and we do that in a
variety of ways. I'll just list a couple ofthem: we do "Caught
you at your best." It's a little card that we keep on the units so that
employees or patients or families can fill them out. They get collected,
. urn, once a month. We send a letter home to the employee. So, if
somebody does something really cool at the moment, they could fill it out.
They get a letter with something called ***Hospital Cash and it is a paper
dollar that we've made that's available. They can spend it in the cafeteria
or the coffee bar or something like that. .. We also recognize, urn, the
clinicians through Press Ganey (patient satisfaction tool). We send them
letters, have parties... Formally, the health system also has something
called the Superstar awards ...that's where the employee gets an
invitation in the mail to come and show up at a bus location at one
of our sites and we tell them how to dress. They get on the bus. They
have no idea where they are going and we bring them to a location and
we have a big party; whether it be at a big art museurn or the, you know,
we had it at the Constitution Center. It is a really kind of spanky event,
a nice event. ..We also make sure we, urn, recognize for achievements;
whether it be certifications or what happens in our nursing newsletter...
those types of things and anybody who has graduated from [Link]
recognition than you could possibly imagine.

Michele: Now with the relief projects going on, people will give their time
urn, all you have to do is put a box out there and say what you
need and people are willing to give a hand and we when we
do our community fair, we have, the hospital is featured there. So
we have many volunteers, we have to, they only have to come and
spend a half an hour because it is not only the time they come in and
serve the community, it is being able to be together and work
together.
 79

Shelly: I tell them how important nursing is and why we need nurses.
I tell them, this is all about you, this is about you, because, you
know, you're the best.

SN VoicelSN Decision Making.

The CNOs were all in agreement that it was paramount for the SNs in their

organization to have a voice and more importantly for their voice to be heard. All the

CNOs have established professional practice councils whereby the SNs have a voice

and can make decisions about their own practice. Lea and Judy provide an

illustration of her Professional Practice Council.

Lea: Something that gets me absolutely incredibly excited is that we

have something called the Professional Practice Council and

that is where one nurse from each unit meets with me once a

month, all day, with me. So, I set the agenda. ..So, I have 15-16

nurses that sit on that council and they hear it straight from me.

Whether it be reports, quality issues, what do you guys think,

how about this kind of thing.. .1 will tell you it is my favorite

day of the month. It is exciting...It is fun. I get to know 15

nurses really well and they are on the committee for one year.

I take them on road trips, urn, do all kinds of stuff like that and

it has been, like I said, my favorite day of the month. It's been

pure joy for me.

Judy: You need to get buy in, that means not just getting buy in
with the managers but with the front line staff.

In an effort to make improvements for the bettennent of patient care and the

organization, the CNOs understand the significance of establishing and sustaining

their relationship with their SNs. The CNOs noted that they have to be behind the

SNs. Some CNOs commented that they were the cheerleaders for the SNs because

they wanted them to know how much they cared about them and several made

comments that, "it's all about them." They were sincere in their comments and only

wanted the best for the SNs. This goes a long way in making improvements. There
 80

are several illustrations which depicts the deep descriptions for making

improvements.

Margaret: You know we have unit practice councils

and Shared Governance, and they have done so

many wonderful things with pain management,

changing how they deliver care, renovating the

units, they designed our maternity, they designed

the ICU (Intensive Care Unit). It's all from my

staff. They picked the colors, they picked the

pictures, they did the research, what's the best

evidenced based color, what's the best evidenced

based pictures, you know...

Margaret illuminated the general desire of the all the CNOs to have SNs on

various committees in the acute care hospital. The CNOs are very much aware

that SNs have to be intimately involved in being the decision makers for quality

patient care outcomes. They also recognize the value of the SNs as decision makers.

Over and over, the CNOs shared stories of how they have integrated the SNs into

committees and the power the SNs have gained for the betterment of patient care.

Shelly commented that it was her own staff that developed their Differentiated
1
Practice Model (Clinical Ladder Program). Listed below are several examples of

! how SNs in the acute care hospitals are given the power and control to make both
i
nursing and patient care decisions.

Lea: I also think that we have a process in this health system where
we use a lot of six sigma tools which incorporates a lot ofthe
front line employees into the decision making processes and
transformation is going to change and urn I think it is a huge
focus on the value of the front line care giver and the information
that they have that can help assist in that change.

Michele: Practice council always amazes me; the wonderful stuff

they always come up with and the solutions that they

have made.

 81

Margaret: The system (the computer system) was built by my

nurses, not me, I'm not the expert, they are. So,

whenever we did the nursing docwnentation system

I had a nurse from every single unit specialty area

sit around the table with IT (informatics) and Siemens,

and they built the nursing doc (docwnentation)

system... So, they built it and they love it. We did the

same thing with our care plan modules. A nurse from

every single area, they built it, we cut down the

number of care plans from three hundred to one hundred

fifty six. We have a nursing task force for everything.

All the eNOs clearly expressed the need and desire for their SNs to be empowered.

They did not want to hold them back from this opportunity. The CNOs were very

thoughtful in sharing the benefits of an empowered nursing staff. Donna illustrates

below the impact of SN empowerment.

Donna: I really try to encourage my staffthat, you know, this is really

what you do well (being a nurse), you need to really emphasize
that and play to [Link] yourself with your patients (meaning
that they are empowered to make a difference).

Team Work.

In an effort to enhance the nature ofthe CNOs relationship with the SNs, it was

important to create a strong sense ofteamwork. It was not about shifts in power and

control but it was about the eNOs recognizing the value of the SNs and coming

together to make positive change in the work environment. Specifically, it was about

helping one another through support and caring. Shelly provides two types of

example to illustrate the sense of team work that demonstrate how together the eNO

and the SNs work as team to ensure the best patient care, they are noted below.

Shelly: If I'm giving the nurses what they need, I know the patients

will do great, it always goes back to the patients but it is

through the nurse and then the patient gets, and it's my job

 82

to make sure the nurses have what they need, educationally,

mentorship, support, equipment, whatever, if they have what
they need, they will do right by the patient.

Shelly: We pulled together to get us through (referring to the SNs helping

each other in the ED without being asked) ... they just stepped up.

i Inclusiveness.
1
i
Judy and the other eNOs want the SNs involved and included in projects and
j
.1
I changes that will affect them or their patients. The eNOs ascribe to including one
f
l and all to create a positive work environment. They do not want anyone left out of

the process. Noted below are several comments made by the eNOs about

inclusiveness.

Margaret: I sent out a memo to all nurses and said, if you can get
away at nine o'clock, come down to the lobby and we
are going to take your picture (for Magnet).

Margaret: The nurses give input and feedback as to where we

are progressing quarterly (meaning the strategic plan).
So, by having the plan, everybody is marching to the
same drummer and we know where we want to go
and how we are going to get there.

Donna: You need to include everybody who works there for you, you
know, it's one of those social things that really are very
important...As we integrate technology, particularly our,
our, information systems, and you know, documentation
on line and all, that's been you know, at times, a challenge
and I don't want us to select systems or products that people
are going to be like, "What was she thinking?"
"This was her ultimate decision and she picks this?"
So, I guess that inclusiveness and even making sure that I don't
have the expertise, and believe me, I don't about a lot of things
but I go to the people who do know and who can help me... We
really have some people who are brilliant and who know way
more than I know.
 83

Brave Leadership

The third theme of this study was Brave leadership. The CNOs articulated clearly

that they needed to be brave in their role as the Vice President of Patient Care

Services/CNO. They stated they needed to be brave enough to stand up for what was

right on behalf of their nursing staff, the patients, and the organization as a whole.

There were three subthemes that together constituted the theme of Brave Leadership:

advocates/or nursing, agility, and coach & mentor (see Figure 4). The descriptions

for each subtheme are noted below.

 84

Figure 4

Theme # 3- Brave Leadership and Subthemes-Advocates, Agility, and Coach &

Mentor

Advocate for nursing.

Lea stated it best when she said that she has incredible passion for her SNs. This

statement captures the essence of how the eNOs feel about their SNs. It is through

this passion that the eNOs advocate for their SNs. The eNOs truly care about their
 85

SNs and want to ensure that they do right by the SNs in the sense of meeting their

emotional and professional needs. By advocating for SNs, the CNOs further enhance

their relationship with the SNs because the SNs know that the CNO has their back.

Below are the three categories that lead to the emergence of this subtheme,

advocating for nursing; pride in nursing, visionary, andpromotes nursing.

Pride in nursing.

Michele shares that she feels "blessed" to work with her SNs and Lea feels like

she is Cinderella because she is so fortunate to work with such a great group ofSNs.

She freely shares her sense of pride she has for her SNs. Shelly and Donna echo the

same sentiments that they are proud of their SNs and Shelly commented that she is

always proud of them.

Lea: I have been in 6, as I said to you, other health care institutions and they
have all been like the Mecca kind of thing, at least in Philadelphia and
you think you are in these exceptional places and then I got here
and I have never experienced such amazing, incredible nursing
care, Never, Never, Never. You know, the physicians are
community physicians but the nursing care, and the extent and the
extreme of what they do for patients is absolutely overwhelming,
to me... We had a patient on our floor last fall, and his wife
passed away, ok, and last fall he was the patient and he was very
depressed, and no one could crack the shell and find out what
was going on with this man. Everyone thought it was because
of the loss of his wife. He was upset about his wife but that
was not why he was so depressed. When he lost his wife and
he had to be admitted to hospital, he had to give his dogs away
and he gave it to a pound, he had 3 dogs, and he fmally shared
this with one of the nurses on the floor who's a wonder woman,
she is just a pure joy and she was so taken by his story, that
she went to the phone and called the pound, to find out
about the dogs. All the dogs had been adopted and she got
names of who they were adopted by so that he could call them and
make sure they were all ok. So he finally gets discharged and he
reaches out to these families and he gets to visit the dogs. It
gets better, so this past week he happens to get admitted on
1
I 86

I the same floor and he sees this nurse walk by the floor, he says,
Marty, Marty, and she comes in and says, Oh my gosh, I can't
believe you are back in ...because she wasn't his nurse, and he
1 says, I just want you to know what you did for me, it was so
wonderful, and I will never forget you, on top of it, he was able to
get his oldest dog back. He would have never been able to do that
if it wasn't for Marty and I am like, this is what the nurses do.

Michele: When a patient from a nursing home was dying, that group
of nurses would go in, so that's what they do, they call and
they say, "You know what?" "It doesn't look good here,"
and they will go in and hold the patient's hand. You know
that kind of stuff, you can't dictate it, I guess you don't get
it when it doesn't come from the heart.

Shelly: I am very proud of them, of the nursing department.

I want to say, we are the cream of the crop, we're getting
there and I know it sounds very, urn, whimsical but I believe
that we are, we went through very tough times, we are in
tough times but people are willing to stand up and do what's
right.

Donna: I'm proud of them...I'm really their advocate.

Visionary.

The eNOs expressed both the desire and need to be visionary as a leader.

Specifically, the eNOs set the vision and then shared that vision with the SNs, who in

turn, became active participants in seeing that vision becomes a reality. The eNOs

acknowledged the importance of the SN s involvement. Margaret made the best

comment to illurninate the eNOs perception of being visionary as noted below:

Margaret: If you've a vision, you have to communicate it to the

staff and get them behind it. So, I think the nursing
strategic plan, we identify what goals we want to
pursue for that and everybody works towards it. For
Patient Satisfaction, we want to be in the 90th percentile,
and everything I do, everything, I mean, we talk about is
customer satisfaction.

Donna also made a similar commented to Margaret which is noted below:

 87

Donna: Together, you kind of have to have the vision and then pull

everyone along but I really think: it's about people, people

get it done.

One of the most consistent visions that the eNOs shared was that of either working

on obtaining Magnet status or having achieved Magnet status. Shelly and Judy

commented that they were on the Magnet journey and that was their vision. The

eNOs were passionate about their desire for their SNs to be recognized not only

internally but externally to the nursing community and to the community which they

serve. Below is an example of how Michele's vision came to life regarding the

establishment of a Shared Governance Model as part of the Magnet journey.

Michele: I think: I have been so lucky, the things I learned because at the time
the hospital was just starting with all the new things that were
happening out there for nursing with all the new programs, urn,
and we were fully active, at one time, in VHA, and when you sat
around that table, oh, you came away with a wealth of knowledge
and what kind of programs you could do at your hospital
and how you could lead your nurses and all the wonderful things
about the Shared Governance Model and autonomy. So, I've
been given that opportunity and, and, the slate to say take it where
you want to and that's what we've done and I hope that I am doing
the best for the staff and, but you know, that's only because I get
the administrative support and they say, "Well, I don't quite
understand it but if you think: it would be good for the bottom
line, go ahead."

Promotes nursing.

Judy and Shelly highlight the fact that they promote nursing at every chance they

get. They and the other eNOs have such a sense of pride in the SNs that they want to

let everyone know how special the SNs are. Shelly has always stated that she tells the

SNs, "It's all about you!" Lea made a great point, which was echoed among the other

eNOs as follows:
 88

Lea: What people, I think, understand in this health system

is we are only as good as the nurse at the bedside or the caregiver
at the bedside. So, ifyou can, urn, you know, absolutely
impact the care giver at the bedside, we become that much
ofa stronger organization.

Margaret clearly told her senior administrative team why the SNs at the bedside

are so valuable, so important, and so significant to the clinical care of the patients.

Basically, Margaret's appeal to the senior administrative team allowed for the

continuation of the SNs reimbursement for their participation in their DPM program

at a time when raises were not given to other employees in the organization. It was

this pride that the eNO had in the SNs that made the difference. Additionally, it was

the basis of the relationship between the eNO and the SNs that solidified this sense of

pride and the positive benefits of such.

Some of the eNOs also shared their sense of pride they had about their SNs in

external forums. They wanted everyone to know how great their SNs were. The

CNOs claimed bragging rights in regards to their SNs. One eNO provided an

example of her proudness as noted below.

Donna: I was invited to a quality conference in New Mexico and we bragged

about the nurses and the accomplishments they've made.

Agility.

The eNOs expressed the importance of agility as it emerged from three categories

that saturated the data. The first category was being adaptableljlexible. The second

category was taking action. The third category was change agent. Below are

illustrations for each category as expressed by the various eNOs.

 89

Adaptable/Flexible.

The eNOs described the necessity of being flexible in their role and how they

relate to the SNs. They truly do not see things as black and white. They want to have

a full understanding of situations affecting the SNs before they react. They are very

sensitive to the needs ofthe SNs and want to do the right thing by them. The CNOs

felt it was imperative to be known as being flexible and it was also a positive gesture

to solidify their relationship with their SNs. Michele provides an example of being

flexible.

Michele: I don't know and there again, if! know they

.are having a real busy day, in the ED, I will
help transport, I am putting myself in their
place, they can't get it done, and our transporters
are really busy, I can push a stretcher, I can still
do that and they say, "Oh, no you can't." Yeah
I can. Well, I just think that that's what that
means to me, that I can still step into helping them
out in some way.

Given the turbulent health care environment, the eNOs must be adaptable in their

leadership. Several of the eNOs also expressed that they had to be strong and brave

in their approach. Below are two illustrations from Lea and Shelly which describes

the way in which they have to be strong in the sense of brave leadership which

includes being open to constructive criticism so you can adapt your style if

neccessary and the value of not being perceived as weak.

Lea: You have to be willing to take the criticism and internalize it

to make yourself better. Feedback doesn't have to be negative,
it's really just to help you.

Shelly: You have to be brave (referring to leadership) ... you can't,

you can't be perceived as being weak because if you are
weak, that means you can't advocate, you have to be brave.
 90

Takes action.

The eNOs are known for taking action. They verbalized that they are the "go to

person" to get things done. In addition to this, the CNOs value the fact ofhaving this

reputation. It gives them added credibility with the SNs and it also further enhances

the nature of the eNOs relationship with the SNs because they know the eNO will be

there to take the appropriate action necessary. The eNO has to be brave to take on

the challenges she has been confronted with. There are three examples by Lea,

Margaret, and Judy who shares several insights about how they take action.

Lea: If you are not out and about, if they (SNs) don't feel comfortable coming
to you and saying, "Lea, here's the dirt"...and what is crucially
important is your response. You cannot over react. You have to
thank them, regardless of what they just hit you with ...as you know,
the floor just blew up. Thank you for sharing but I think that the
reaction is absolutely critical.

Margaret: There was a lot of distrust at that point (when Margaret

first came to the hospital). So, I had to be very visible

I had to be a cheerleader, I had to lead them to a better

place. Magnet really helped.

Judy: I'll ask, if I had to fix one thing what is your biggest frustration when
coming to work. ..So, they know I'm open, I am interested and I am
spending time to talk to them (referring to them being able to take action
and correct what is frustrating the SNs).

Change agent.

The CNOs stressed the importance ofbeing a change agent. It demonstrated that

they knew the literature and they wanted to be on the cutting edge of shaping their

nursing division with the SNs by their side. The eNOs are not satisfied with the

status quo and they had to be brave to try new things and bring new experiences to

the SNs and to the organization as a whole. The eNOs had to be brave to introduce
 91

these opportunities but the payoff was priceless. Several of the CNOs discussed the

different types ofjourneys they were on with their SNs. Their journeys are noted

below.

Lea: We applied for the Malcolm Baldridge Award.

Michele: We are on the Magnet journey.

Michele: We are a Plane Tree Affiliate.

Many of the CNOs also introduced new programs for the SNs in an effort to

elevate their own professional development. These new programs also had an added

benefit to the patients and recognized the value of the SNs. The CNOs were

delighted to have been able to make positive changes on behalf of the SNs. The

CNOs felt a great sense of accomplishment by being able to get the support from their

Chief Executive Officer. If it were not for the CNOs advocating for the execution of

such programs and being brave enough to introduce them, the SNs work environment

would not be enhanced. Below are rich descriptions of brave leadership projects

executed by Margaret and Judy.

Margaret: Being an advocate for nursing, I was able to

improve things for the nursing staff, certification pay...
we offered classes here for the staff to get their certification.
They all passed. We paid for the test and then we gave
them three bucks an hour more, once they got their
certification... We gave them preceptor pay, we gave them
charge pay, urn, I got the staffmg up to par, we're 1:6 on
days and nights... When they need something or want something,
I investigate it and I get back to them.
 92

Judy: I just recently closed the Diploma School of Nursing and we are
opening up a BSN program... The nurses are really involved with
making that happen. We also have a big push toward nursing, nurses
getting certification... We take the opportunity to raise the bar of nursing,
changing expectations, giving more autonomy, and the value of nursing
is the key.

Coach and Mentor.

Being a coach and mentor to the SNs was the third subtheme of Brave Leadership.

Shares knowledge was the category from which coach and mentor emerged.

According to the eNOs, being a coach/mentor to the SNs was just an incredible

experience.

Shares Knowledge.

The eNOs believed they had to be a role model to the SNs. The eNOs do not

expect the SNs to do anything they would not do themselves. This assists in the

development of the relationship between the eNO and the SNs. By being a role

model, the eNO is able to share knowledge with the SNs. Lea elaborates below on

being a role model.

Lea: So, you know, ifI expect them (the nursing directors) to round, then I
have to role model that.

Donna: So, as part of the servant leadership thing, it was, you know,
really the emphasis on us being role models and by transference
you know, our managers and directors, the behaviors are the
basic expectations so you can't be good in your job and be
miserable, like that is not okay, and it's taken a long time for that to
really kind of disseminate throughout the organization and people
to be accountable for behaviors, but we're there.

Shelly and many of the eNOs are also role models by being affiliated and active with

their professional organizations. Several of the eNOs have shared the benefits of the

being part of their professional organization. As part of brave leadership, they are not
 93

afraid to say they do not know everything but they are still engaged in learning new

things and positively impacting the profession. Margaret and Donna share their

perspective on learning new things and being knowledgeable below.

Margaret: I am part of ONEINJ and I'm on the legislative committee

and I'm out there fighting for urn the legislation to recognize
we need more nurses in the future.

Donna: I want to be perceived as you know, of course, knowledgeable,

having expertise in nursing and in you know, nursing policy, and
learning about things that are impacting our profession, at a higher
level, urn, and I think my involvement with ONEINJ and NJHA
Constituency Group, I kind ofpushed myself to kind of do that not
only to develop a network in the state but also so I could learn.

The CNOs embraced education of the SNs seriously. As a coach/mentor, the CNO

created various learning opportunities for the SNs.

Margaret shares her experience ofpromoting education with her SN s. It is significant

because as the CNO, she understands the value of SNs pursuing their education and

wants to make sure the SNs have easy access to furthering their education. The CNO

is brave by making an investment for the SNs and this ultimately both enhances and

further describes the CNOs relationship with the SNs.

Margaret: We promoted education. We brought a local University

on site so our nurses didn't have to travel to get their BSN and
their Master's degree. We have a contract with an out of state and
University and there's on-line courses that people go ...
I am an educator, you know, in training and that has really
effected the way I do things, because I am trying to teach and
develop others. Not a negative person, I feel that everybody
deserves a chance. We've got to teach them a better way... So,
I am very much into that and being a coach, being a mentor.

The CNOs really seemed to enjoy their role as coach/mentor. It provided the

CNOs with a deeper relationship with the SNs. The SNs would seek out the CNOs
 94

for advice on their career, education, or even on personal matters. 1bis allowed for

the evolution of a trusting relationship whereby the SNs respected the eNOs for their

advice and guidance and the eNOs felt validated by the SNs. Below are several

examples of the joy experienced by the eNOs as they fulfill their role as

coach/mentor to the SNs by sharing knowledge.

Donna: I really feel that career counseling and my mentoring of everybody

as well as some managers and directors, I love that. So, they kind
of know that I'm the one they can talk to off the record, about what
they want to kind of do next, or go back to school, or should they try
to another department or another area and I really love that. So, it's
kind of nice that I can give back.

Margaret: I'm a leader, I teach classes and I ask them, "Who do you

think is a good leader," and they say, "You."

Judy: I have really been working on the teaching role, the mentoring role,
leading through to be a more successful leader, it's developing
people and taking the time to bring them along, not just making
decisions that they don't understand.

All the eNOs spoke highly of the mentors they encountered in their careers.

Some of the CNOs are still in touch, to this day, with their mentors. The CNOs had

such positive experiences with their mentors and that translated to the eNOs wanting

to emulate that experience with their own SNs. Judy explains her experience with her

mentor.

Judy: I had a great mentor who really learned, uh, about you individually... she
mentored us on a daily basis; personally and professionally, on how
to make good decisions and gave us feedback when she felt we weren't
making the best decision. That mentoring was really important to me
(she shared it helped to shape her as a leader).
 95

Return on Investment (ROI) in the relationship with SN's

The fourth theme was Return on Investment (ROJ) in developing a relationship

1
1 with SNs. The eNOs believed that there was a positive return on their investment in
1

I
;j
~
the relationship with their SNs. By investing in the relationship, the CNOs believed

that the SNs provided the patients in the acute care hospital setting with quality
~
i outcomes and the organization experienced success as a whole. According to the
!
I

I
i
•i
CNOs, it was the investment in the relationship with the SNs that resulted in the

positive patient outcomes.

The subtheme for ROJ was positive patient outcomes. One category emerged from

I this subtheme: patient centered (see Figure 5).

I
I
f
1
I
I

I
i
!
1

I
Ii
\
 96

Figure 5­

Theme # 4- Return on Investment, Subtheme-Positive Patient Outcomes and

Category-Patient Centered

··········.K····

Positive Patient Outcomes.

Donna verbalized the fact that she believes the SNs are driving patient outcomes.

This sentiment was also noted by the other CNOs. The CNOs shared the same point

of view that if they invest in the SNs at the bedside, the patients would ultimately
 97

I
f
! benefit. Below are comments made by the other CNOs to support that SNs can

1
R
influence positive patient outcomes.

Lea: The focus on having employees engaged and everything else actually
helps our outcomes. So, that is why it is so important for this
facility and me, that's why if I have happy employees then I know
they're taking it to the bedside.

Margaret: They (SN s) are very happy. When you have happy staff,
you have happy patients, you have good outcomes.

Shelly: It's the RN that has the greatest impact and significance on
how well a patient will do and will reduce the incidence of
complications and adverse things at the bedside, most often
prevented by the RN. So, if you invest in the RN, in a way it
helps them to improve practice, you are investing in the future
of patient care...it's a no brainer.

Patient Centered.

Consistently, the CNOs shared wonderful stories about how the SNs demonstrated

a strong sense of patient centeredness. The CNOs were so proud of their SNs in

regards of how they went out of their way to do something special for their patients.

Each CNO did not have to give the SNs permission to be patient centered; they

empowered their SNs to make a difference in their patient's lives. Below is just one

example to illustrate patient centeredness.

Michele: I'm telling you, it could be as simple as urn just bringing

in a birthday cake for a patient who just turned ninety or the last one
we had, urn, there was a patient on ICU that wasn't going to be able
to make her daughters wedding and so the staff from housekeeping,
dietary (and the SNs) they arranged from Chaplaincy, a simple
ceremony at this mom's bedside so that she could see her daughter
married. I mean, they didn't come down asking permission from
administration, they were just allowed to do that. You know, it was
quite the ceremony in the room, but that mom got to see that and they
had a little cake and it was really cooL It's those types of things...
 98

Chapter VI

FINDING MEANING

MetaTheme

A metatheme is considered to be drawn from the entire body of the data and it is

also referred to as an overarching theme(s) (Ely, Vinz, Downing, and Anzul, 1997,

p.206). Additionally, a metatheme is a major construct that highlights the

overarching issues in a research study which may be considered against extant

literature and experience (Ely, Vinz, Downing, and Anzul, 1997, p. 206). In this

study, one metatheme emerged, connective leadership.

Connective Leadership

Connective Leadership emerged as the metatheme for this study. It captured the

essence of the relationship and the four themes of this study. The CNOs described

their relationships with the SNs as connecting with them during their daily activities,

both formally and informally. Donna shares her beliefs on CNO connectivity as

noted below.

Donna: The whole job is really about connecting with people, when
you think about it.

Judy and the other CNOs expressed how important it was to develop the

relationship with the SNs. The development ofthe relationship however was only

one component of connective leadership. Through the development ofthe

relationship, a sense of connection emerges and begins the process of connective

leadership that includes being supportive, mentoring the SNs, creating a positive
I 99

work environment, having an true appreciation for what they face each and every day

in the acute care setting, and standing up for them.

The eNOs knew that without a personal relationship, there would be no caring

connection with the SNs. Judy and Lea illustrate their leadership perspective ofeNO

connectivity as it relates to developing the relationship with the SNs.

Judy: I've also really spent a lot of time in trying to develop

relationships with front line staff.

Lea: There are a lot of things we talk about but it gives them (SNs)
a direct connection into what I am like, what I am passionate about,
and I get to know them that much better.

As the relationship evolves between the eNO and SNs, they get to know one

another; a sense oftrust with one another is gained. Once the eNO and SNs

experience this level of trust then reciprocal support ensues. It is through this

maturity of the relationship that connective leadership emerges. Specifically, the

eNO and SNs sought out each other for different reasons; some personal and some

were otherwise operational. Michele provides an example of how through connective

leadership she is available to the staff regarding personal issues.

Michele: I make an effort to know family situations those types of

things once they are hired and how they are doing and if

they are having any problems, I really put myself out

there enough to know them as people. I really do ...um,

because I really love them in there own way, even if they

are cranky, or whatever, youjust seek to find you know,

where is that middle ground.

Donna and Lea illustrate the value of being visible and accessible to the SNs as

noted below.

Donna: People need to see you and feel like they're connected, even if
maybe they don't see you as frequently as you would like but
 100

just that there is that connection.

Lea: The more they (SNs) see you, the more they get involved with you,
the more they have to come to you with concerns or issues and stuff.

By being present and making rounds, the CNO felt they could personally connect

with the SNs. A true sense of support was noted when the CNOs connected with the

SNs on a personal level. Lea and Michele explain how being connected to the SNs

lets them know you really care about them as a human being. The examples below

support the concept of connective leadership.

Lea: It's not difficult, it's just time and people have to learn that this
is what keeps your employees connected, this is what keeps them
engaged because they really feel like they need to know you, that
you care enough to know them and that, that is key.

Michele: When we get new people in the organization, I make it a point

to be able to spend at least a halfhour, a piece, with the new
nurses before she goes on the ward, just to talk to her about
her family, or wants and needs, where she wants to be
professionally so that I feel like I've got that connection.

Overall the CNOs spoke about a sense of acceptance by the SNs. The CNOs

attributed their acceptance by the SNs to their ability to connect with the SNs. Both

Michele and Lea have illustrated two different situations which lead to the support of

acceptance as a result ofconnectivity. The two examples are noted below.

Michele: I do rounds twice a month on the night shift and then we do

7p-7a so I usually come in around ~ne in the morning and I am
never not greeted with, "oh my gosh, I can't believe you are
here, what are you doing here?" So, I think that is one of the
ways I show them (meaning how the staffknow you appreciate them).
I have my face up there. I also do a lot during the day. They have
more of an opportunity to see me. It's after the office is closed and
I can go up and have some conversation, urn, I know my staff, I
know ifthey've got a child going off to college or I know if they
have a mother who is ill and I can't say that for all 225 but those
that I do know, I am blessed with, I don't have a real good
 101

j memory but if someone tells me a story about something going

on, that's really unpleasant, I always make sure that I address it to
1 see how they are feeling. It's just that personal connection.
I
l
Lea: There were petitions flying around signing for decert (decertify the union)
and everything else, and I think what happened is that the
union realized the militant bashing type of behavior does not work
in this organization and it really turned the RNs off and they went
to the union meetings and said they didn't want anything to do
with you (meaning the union leadership), you are rude and
obnoxious, and oh by the way, we really like Lea, she is a really
nice person and she really cares about us.

Connective leadership included, creating a positive work environment. The CNOs

recognized the value of the Shared Governance Model and they all established

professional practice councils whereby the SNs would have a voice and work together

as a team which would ultimately create a positive work environment for the SNs.

The relationship of the CNO and the SN now goes well beyond a personal knowing.

This is a bigger part ofthe nature ofthe CNOs relationship with their SNs. Donna

captures the feeling of the other CNOs when she describes her feelings about creating

a positive work environment for the SNs and the professional practice council impact.

Donna: You know, some is face to face (communication with the SNs),
other, urn, ways is about the open door which we talked about
and email. People email me all the time and the nurse advisory
council is really the one monthly venue when I connect with the
nurses and they formally bring, you know, issues some are good
things and whatever they want to talk about.

Additionally, the CNOs shared that through connective leadership they

experienced an increase in cooperation and teamwork relative to executing plans or

launching of new projects such as; Transforming Care at the Bedside (TCAB),

reducing medication error, or reducing skin breakdown. Below, Margaret provides an

example of how her connection with SNs led to the achievement of Magnet status.
 102

Margaret: We have just been approved for redesignation (Magnet)

and we had 0 deficiencies and 10 exemplar's so my
staff are ecstatic. We are planning a party for next
month. We already made the announcement on the
overhead system, and at every meeting we are
just cheering ourselves on, but the official
party is going to be next month. We sent out a
letter to all the staff to let them know and in the
paper, as a matter of fact, today, we are making
the announcement to the community. So, we are
doing a lot of press releases right now.

Connective leadership includes brave leadership. The CNOs expressed their

strong passion to stand up for the SNs and to make sure that everyone in the

organization knew how important the SNs were. The CNOs bravely advocated for

the SNs. The evidence of this metatheme was strong as it relates to being a brave

leader. The eNOs discussed the importance of standing up for the SNs in different

situations. Judy provides an illustration regarding the value of standing up for the

SNs.

Judy: They (the SNs) need to know that whoever is making

decisions for them and representing them, really has a

vision on how it is going to impact the front line staff,

and try to make it as easy as possible (for the SNs), and

I think you have to be a really strong negotiator, because

I am not always sure the senior management team

understands what the front line nurses is all about or, or

that a nurse is not a nurse and there are specialty areas

and there are expectations, and you know, so, sometimes

you really, uh, senior management really challenges you

at times ...you have to be very strong, supportive, and

articulate ...so, you are constantly trying to explain to your

senior management why the front line staff role in the

organization needs to be supported.

By investing in the relationship with the SNs, creating an excellent work

environment, and advocating for the SNs, the CNOs believed there was a benefit to
 103

the patient and the organization as a whole. Care to the patient was improved and

quality outcomes were achieved.

Connective leadership goes beyond having a personal, trusting, supportive

relationship between the CNO and the SNs. Connective leadership includes creating

an excellent work environment and bravely advocating and supporting the SNs.

Connective leadership captures the essence of a deeper relationship with the SNs and

makes it possible for the SNs to provide excellent patient care. This study reveals

that the nature of the CNOs' relationship is bigger than just getting to know each

other and that the relationship, now conceptualized as connective leadership, also has

benefits that the CNOs believe positively impacts the patients, and the organization as

a whole.

Support for imdings in the literature

In an effort for this lived experience to be better understood, from a leadership

perspective, the fmdings of this study were interpreted within the framework of

leadership theories.

There has been a paradigm shift in leadership theories. The fmdings from this

study are consistent with Social Exchange Theory, Relational Leadership Theory, and

Connective Leadership Theory. The findings from this study has relevance to each of

these leadership theories, extending our understanding of each theory.

Social Exchange Theory.

Social Exchange Theory explains the development and evolution of the leader­

follower relationship over time. There are three phases of the relationship in the

Social Exchange Theory. The first is the stranger phase, the second is the
I
1
I
104

1 acquaintance phase, and the third is the maturity phase. This theory supports the
I
I! fmdings of this study as it relates to the first theme; developing and sustaining the
I
l relationship along with the subthemes: getting to know each other, trust, and

II reciprocal support. Below is a description of each phase of the relationship which

mirrors the fmdings of this study and lends support to the theory.

Ii The first phase of the relationship is that the leader and followers are strangers

whereby they come together with formal interactions and exchanges with one another
I
I are contractual. The leader provides the follow with only what they need.
! The second phase ofthe relationship is an opportunity to enhance the working

relationship with an offer which is a career-oriented social exchange that is made and

then accepted. This is known as the acquaintance phase. Both the leader and the

followers exchange and share more information with one another as well as

resources; it is also a mixture of social and work related exchanges. At this phase

both parties (the leader and the followers) are testing one another. Additionally,

equitable favors are returned between the leader and the followers.

In the third phase, known as mature partnership exchanges, the relationship is

growing to the next leveL Specifically, the leader and followers can count on each

other and there is a high level of support and loyalty. It is noted, the social exchanges

at this phase are not only behavioral but they are also emotional whereby mutual

respect, trust, and an obligation to one another is demonstrated.

Relational Leadership Theory.

"Relational leadership theory is a relatively new term in leadership literature"

(Uhl-Bien, 2006, p. 654). Relational means that "an individual likes people and
 105

thrives on relationships" (Lipman-Blumen, 1996, p. 165). According to UbI-Bien

(2006) and Drath (2001) the new way to look at leadership is through relationships

rather than authority, and superiority. This theory allows us to examine leadership

processes on "social dynamics by which leadership relationships form and evolve in

the workplace" (Uhl-Bien, 2006, p. 672). Relational Leadership Theory involves

"some type of connection or bond between one individual and another" (Uhl-Bien,

2006, p. 669). In relational leadership, "people work together to define and develop

their relationships not just as questions of influence or leadership, but also as

questions of how to keep all of this moving and working together" (Murrell, 1997, p.

40). All four themes and the metatheme of this study; connective leadership, provide

support for the Relational Leadership theory and further describe the process of the

developing the relationship.

Connective Leadership Theory.

Connective Leadership Theory was described by Jean Lipman-Blumen in 1988.

Lipman-Blumen (1997) posits, to be an effective leader in today's environment,

connectivity in our everyday action is key. Additionally, the connective leader must

be brave enough to weather the storms of change, and they must be bold enough to

redefme leadership (Lipman-Blumen, 1997). The findings from this study lend

support to Connective Leadership whereby the CNOs ensure that they are connecting

with their SNs in their everyday action and interaction. The CNOs view connectivity

as paramount to their work and the positive impact that transpires as a result of being

connected to the SNs.

I
f

I•
t
t

I
 106

The connective leader will playa part in other's successes, to act as a mentor, to

construct social networks, and entrust their vision to others by bringing them together

(Lipman-Blumen, 1997). This study's findings are consistent with Lipman-Blumen's

II Connective Leadership. The CNOs established a shared governance model that

brings the SNs together to work on solving problems. Additionally, the fmdings from
1
I
this study demonstrate that the CNOs act as a mentor to the SNs and this provides

further support for Lipman-Blumen's Connective Leadership Theory.

The connective leader is authentic. The CNOs from this study felt it was very

important to be transparent and honest with their SNs. The findings from this study

support the theory of connective leadership.

Connective leaders are interested in building a community which is framed within

a sense ofbelongingness and the work environment is inclusive. Additionally, the

followers are rewarded and recognized. The CNOs from this study have clearly

demonstrated support of their SNs as evidenced by connective leadership theory in

that they create a positive working environment for the SNs and they reward and

recognized their SNs

A connective leader grows and develops their followers through coaching and

mentoring. This study found that the CNOs coached and mentored their SNs. These

fmdings are consistent with connective leadership theory.

The connective leader gives up control and does not micro-manage their followers

but entrusts them with the responsibility to execute the plan. There is a sense of

reciprocal trust and support between the connective leader and followers. Connective
 107

leaders take risks. The findings from this study are consistent with connective

leadership theory.

Connective leaders are in search of a deeper understanding of themselves, their

followers, and the organizations in which they lead. In doing so, the organizations

they lead provide the followers with opportunities to make a positive impact. Thus,

the connective leader encourages the followers to exceed their own expectations. The

fmdings of this study are in alignment with connective leadership theory.

According to Klakovich (1994), connective leadership is consistent with CNOs

fostering interdisciplinary respect and cooperation as well as understanding the SN's

concerns while representing their needs. Additionally, Murphy and DeBack (1991)

posit that CNOs are change agents and that reveals qualities of connective leadership

whereby the CNO strategically aligns SNs and other stakeholders to accomplish the

established goal, decrease the competition, and create a win for all. "Connective

leadership has great potential for empowering nursing staff and influencing positive

outcomes for patients, nurses, and the organization" (Klakovich, 1994, p. 52).

Although the fmdings of this study support components of Connective Leadership

Theory, the theory skims the surface ofnature of the CNOs relationship with their

SNs. There is more to the relationship and the findings from this study describe the

relationship more completely. A fuller understanding of the process ofthe

relationship and the outcomes of the connection is evident from these findings. Once

the relationship is formed, through the leadership ofthe CNO, a positive work

environment is created, the CNOs advocate for the SNs utilizing brave leadership,

and then there is a return on investing in the relationship with the SNs. Overall, the
 108

literature review on Connective Leadership generally supports the fmdings of this

research. The findings of this research extends our understanding of Connective

Leadership Theory.

Nursing Leadership Perspective.

Nursing leaders have adopted business leadership theories. Emphasis on nursing

leadership has been placed on relational leadership (Kosowski, Grabbe, Grams, Lobb,

Willoughby, Davis, and Sims, 1990). Additionally, the nursing leadership literature

incorporates the human aspects of leadership such as caring (Miller, 1987, Nyberg,

1989).

Interpersonal skills are an important for CNO leadership as CNO effectiveness is

dependent upon it (Moore, Biordi, Holm, and McElmurry, 1988). Interpersonal

competence is imperative for developing the relationship with the followers (Fagin,

1988). Therefore, the nursing leader must be able to advance the goals ofthe

organization by interpersonal relationships with the staff nurses (Fagin, 1988).

Nursing research has been conducted on leadership styles, personality traits,

characteristics ofnursing leaders, and behaviors, there are no studies to date which

explore the leadership process or the relationship between the CNO and the SNs until

this study. According to Lundrigan (1992, p. 49), "while an abundance of literature

exists on leadership, no studies were found that attempted to illuminate the basic

social process of nursing leadership." The findings of this study do indeed illuminate

the basic social process of nursing leadership.

 109

Chapter VII

SUMMARY, CONCLUSIONS, AND IMPLICATIONS

Summary

The aim of this study was to better understand and describe the nature of the

CNOs relationship with their SNs from an acute care hospital setting. The

methodology selected for this study was phenomenology. By utilizing this method,

the lived experience of this phenomenon was explored with six CNOs. Through

interviews with the participants, data were collected from the actual spoken words of

the CNOs.· Four themes and one metatheme were identified. The four themes were;

developing and sustaining the relationship, creating a positive work environment,

brave leadership, and return on the investment. The metatheme that captured the

essence of the relationship of the CNO with the SNs was connective leadership. The

findings from this study were compared with leader-member relational leadership

theories and a review of the literature. As a result of this research, a new

understanding of the nature of the CNOs relationship with their acute care SNs was

discovered.

Conclusions

Four themes emerged that described the nature ofthe eNOs relationship with their

acute care SNs, they are as follows:

• Developing and sustaining the relationship was an important component for

the CNOs to engage in with their SNs

 110

• Creating a positive work environment so that the SNs could thrive in their

professional practice

• Brave leadership which was demonstrated by each eNO in support oftheir

relationship with their SNs

• Return ofthe investment whereby the eNOs invested in the relationship with

the SNs and in turn the SNs gave back in many ways such as in patient care

outcomes.

One metatheme, connective leadership, captured the essence ofthe relationship of

the eNO with the SNs. The CNOs demonstrated their connection with their SNs

during their day to day activities so that a relationship could be formed. Additionally,

connective leadership included the creation of a positive work environment for the

SNs and the CNO bravely advocates for the SNs. The CNO believed that there was a

return on the investment whereby there was a benefit to the patient and the

organization as a whole so the SNs can provide excellent patient care.

The findings of this research are not consistent with the literature. The literature

suggests that CNOs are not connected, accessible, or visible with their SNs (HCAB,

2006). The CNOs in this study expressed concern for the SNs and a full appreciation

of their day to day work life challenges. The fmdings ofthis study refute the

literature that suggests that the SNs feel their CNOs did not care about them (HCAB,

2006). The fmdings from this study do provide support for several current leadership

theories such as Social Exchange Theory, Relational Leadership Theory, and

Connective Leadership Theory.

 111
•

Strengths and Limitations of the Study

Phenomenology was very useful in describing and understanding of the CNOs

personal experiences of the nature oftheir relationship with their SNs. The true

meaning of the phenomenon of interest rests with the person who is having the

experience (Munhall, 2007). In this study, it was the CNO who was the expert and

the CNO is the one who provided the deeper meaning of this experience.

Trustworthiness of this study was maintained at all times and this is considered a

strength of the study. The criteria for maintaining trustworthiness by Lincoln and

Guba (1985) was adhered to. Specifically, the four criteria of trustworthiness

included the following: credibility, transferability, dependability, and confirmability.

For this study, the rich descriptions gleaned from the CNOs allow for transferability.

Even though this was a rigorous study, it had several limitations. One limitation to

this study was related to gender. All participants were female. Although

participation was open to both male and female CNOs, only the female CNOs were

willing to participate. Another limitation was that the participants were Caucasian

and there was a lack of diversity. There was a geographic limitation as all the

participants in the study were from New Jersey. Also, there was a hospital setting

limitation as all the CNOs were from an acute care setting.

This research only examined the CNO experience of her relationship with SNs.

Interviewing both the CNO and their SNs would have strengthened the study. All six

CNOs were exemplar nursing leaders who verbalized positive relationships with their

SNs and there were no CNOs who participated that had a negative relationship with

their SNs. Therefore, the participants were a homogeneous group; this was a
 112

limitation. It is possible that eNOs who do not value their relationship with their SNs

were not interested in participating in this research.

Personal ReOections

Through data analysis, I captured the lived experience from the eNOs' perspective

on the nature of their relationship with their acute care SNs. The findings from this

study have allowed me to reconsider my own thoughts, assumptions, biases and

beliefs. Some changes to my worldview emerged as a result of the six eNOs

experience.

Through the process of data collection and analysis, I felt I had a general

understanding of what elements were necessary for a CNO to have a positive working

relationship with hislher SNs. I truly was unsure ofwhat would emerge from the

data, although I had my own hunches and hopes. All of the eNOs in the study

demonstrated a true sense of caring and concern for their SNs. They felt a

responsibility in developing and sustaining a relationship with the SNs and through

that relationship benefits were derived. I was pleasantly surprised by the findings and

felt reassured with my initial hunches.

After much pondering, my pre-research beliefs have changed. I now have a

deeper understanding of the process of developing the relationship between the CNO

and the SNs. I now see that there are three phases to the initial relationship that is

based on taking the time to get to know each other, mutual trust, and reciprocal

support of one another. I now believe that the eNO, SNs, the patients, and the

organization benefits from the relationship; all ofthis achieved by the eNO being

connected to the SNs. I also now see the relationship as part of something larger,
 113

Connective Leadership. I walked away from this experience learning so much from

these stellar CNOs.

Personal change.

During this journey, my personal philosophy resonated with the philosopher,

Epictetus (Matherson, 1968) who shared his thoughts on knowing... What is the first

order of business for one who philosophizes? It is up to the philosopher to part with

self-conceit. For it is impractical for one to learn what one thinks that one already

knows. This has become my new lens in which I view the world. I have consistently

challenged myself to unknow what I think I know. Specifically, I took to heart the

teachings of Munhall (2007) whereby she encourages the researcher to unknow what

they already know. According to Munhall (2007, p.76), "Once we believe something

or think we know something, we cease further exploration or explanation." An

important process that assisted me in remaining receptive to the CNOs experience

was by reading and reading the spoken words on the transcripts. It was also

beneficial to listen to the audio recordings of the CNOs. This opportunity allowed me

to capture the emphasis of the spoken words ofthe eNOs and the framework of the

rich descriptions regarding their own experience.

Although I maintained professional relationships with many eNOs from New

Jersey acute care hospitals, I did not have any understanding oftheir relationships

with their SNs. By interviewing the six eNOs, they knew that they were providing

me with an intimate insight about what their actual relationship was like with their

SNs. The CNOs took their role seriously as their contributions and their expressions

of their experiences were so important to this study. I believe that each CNO spoke
 114

honestly with me about the reality of their perspective relative to their relationship

with their SNs. Each CNO willingly took time out of her busy work schedule to

participate in this study. I was fortunate that none of the eNOs requested to end their

participation in the study.

Reflections on Dissertations: A eND's Experience in

Becoming a Qualitative Researcher

I thought I knew...
I thought my way was right...
I thought how else could it be?
I was ready to put up a fight.

To unknow what I know,

That is the key,
For the Qualitative Researcher is who I want to be.

I came to terms that I may not be right,

I came to terms that it was alright,
I now know that unknowing is my plight.

To unknow what I know,

That is the key,
For the Qualitative Researcher is who I want to be.

The eNOs spoken words

Are the words to be heard.
It is through their experience, that I can now say,
I know what I know, from the CNOs I met with, on those special days.

Implications for Nursing Practice

The rich descriptions of the lived experiences of these eNOs, along with the four

themes and the metatheme that emerged, provide a deeper,understanding of the

 115

experiences ofthe eNOs relationship with their SNs and the potential value of the

relationship.

The findings from this research have potential implications for nursing practice

relative to nursing administration. The potential implications are grounded in the

results of this study, which are based on the empirical data found, and the spoken

recommendations of the eNOs. The potential implications are as follows:

1. The eNOs should take the time to get to know their SNs.

Note: eNOs encouraged connecting with new hires for 1:1 time.

The eNOs encouraged the development of various forums to provide

both formal and informal meeting times with SNs to open dialogue.

They also advised that eNOs should be present and accessible to

their SNs.

2. Whenever possible the eNOs should be fair, honest, and transparent with

the SNs so that a sense of trust is felt.

Note: The eNOs shared how important it was from them to

be fair and honest with the SNs. The eNOs thought it was important

to mean what you say and say what you mean.

3. Encourage the eNOs to develop a sense of reciprocal support with the SNs.

Note: The eNO should consider taking any opportunity to demonstrate

appropriate support and recognition to the SNs on ajob well done.

The eNOs should share their appreciation of the SNs by encouraging

a sense of reciprocal support.

4. Work to create a positive work environment for the SNs.

 116

Note: By giving the SNs a platfonn to have a voice and make

decisions, they are empowered. They are recognized for their

clinical expertise. The SNs opinion matters and it is valued.

5. Be brave and encourage other CNOs to be brave in supporting their SNs.

Note: The eNOs recommended taking a firm stand on advocating

for the SNs. They will defend the SNs from harms way.

6. Whenever possible, the CNO should take the opportunity to be a coach and

mentor to the SNs.

Note: Spend time with the SNs when they seek out advice on

future career and educational pursuits.

7. Invest in the relationship with the SNs.

Note: By investing in the relationship with the SNs, there is return on

the investment whereby the patient outcomes are enhanced.

Recommendations for Future Research

In an effort to further advance the body of nursing administrative knowledge and

practice, more qualitative research is needed which will hopefully add a broader

perspective on the nature of the eNOs' relationship with their SNs. The results of

this qualitative study suggest several recommendations for future research. I have

identified five potential areas for future research they are as follows:

1. Future research needs to include male eNOs from an acute care hospital setting

and more diversity in the eND participants.

2. Future research should focus on understanding the nature of the SNs

relationship with their eND from an acute care hospital setting.

 117

3. This study should be replicated with eNOs, from an acute care hospital setting

located outside ofNew Jersey.

4. Replicate this study by exploring the nature of the Magnet eNOs relationship

to their SNs versus the nature of the Non Magnet eNOs relationship to their SNs

from an acute care hospital setting.

5. Further research is needed that explores the fit of these fmdings with existing

leadership theories.

A Final Thought

eND Relationships

It is my goal to get to know you.

I want to understand your cares and concerns
I never want you to come to work and be blue
You have to know that I am here for you

I value what you do

and I will always stick up for you
I can be there in a just a few

You put your trust in me

I put my trust in you
Together there is nothing we can't do

We are connected to each other

through genuine love and support for one another
I treasure the relationship we have just as if you were my sister or my brother.
 118

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Appendix A

Methodological Outline for Doing Phenomenology (van Manen, 1997, p. 5)

A) Turning to the nature of the lived experience

1. Orient to the phenomenon of interest

2. Formulate the phenomenological question

3. Explicating assumptions and preunderstandings

I B) Investigating the experience as we live it in everyday as opposed to

!
4 conceptualizing it;
II 4. Explore the phenomenon: generate "data"
J
1
I
4.1 Use personal experience as a starting point
1
1 4.2 Trace etymological sources
1
1

4.3 Search idiomatic phrases

4.4 Obtain experiential descriptions from subjects

4.5 Locating experiential descriptions in literature, art, poems, etc.

5. Consult phenomenologica11iterature

C) Phenomenological Reflection

6. Conduct thematic analysis

6.1.1 Uncover thematic aspects in lifeworld descriptions

6.1.2 Isolating thematic statements

6.1.3 Composing linguistic transformation

6.2 Gleaning thematic descriptions from artistic sources

7. Determine essential themes

D) Phenomenological Writing

 124

8. Attending to the speaking of language

9. Varying the examples

10. Writing

11. Rewriting
 125

AppendixB

Permission to Invite Potential Participants at the Local Level in New Jersey

Deanna Sperling,
President, ONEINJ
Organization of Nurse ExecutiveslNew Jersey
CIO The New Jersey Hospital Association
760 Alexander Road P.O. Box I
Princeton, New Jersey 08543-0001

Dear Ms. Sperling:

I am a Ph.D. candidate, at Seton Hall University College of Nursing. For my dissertation

research, I plan to conduct a qualitative study to describe and understand the nature ofthe
Chief Nursing Officer's relationship with Staff Nurses working in an acute care hospital.

The purpose of this letter is to request an opportunity to address the Chief Nursing Officer
members of ONEINJ during a regularly scheduled meeting in order to explain the purpose of
my study and request volunteers who may be interested in participating in this study. I will
need approximately fifteen minutes time to discuss the study purpose and to answer
members' questions, as well as to explain requirements for participation in the study. I also
plan to distribute written information about the study and documents the members can review
at home before making a decision about whether to participate. I am enclosing, as part of my
request, draft copies ofthese three documents for your prior review as you consider your
response to my request.

The first ofthe three documents is the script I will read to the Chief Nursing Officers as
part ofmy fifteen minute presentation. The second is a Letter ofInvitation in which the CNO
is formally described and requested. It contains directions for interested individuals to return
their signed Consent Form as well as the process I will use to contact those who are
interested. The third and last document is the formal Consent Form for the study
participation.

An important prerequisite for the Seton Hall University application for IRB approval
process is that the researcher demonstrates prior planned access to potential participants for
the study being proposed. Thus, in order to meet this requirement, and because I must
provide the SHU IRB with a Letter of Permission from those organizations from which I will
seek potential study participants. I am also asking you to forward to me, a letter agreeing to
allow me to address the membership of ONEINJ for the purpose of seeking participants for
my research study. Because I value your time, I am enclosing a form letter, indicating your
agreement to my request to address members at the ONEINJ that meets the above SHU IRB
requirement. Once the IRB approves this study I will send you the official IRB Approval of
this study, with the approved Letter of Invitation, and Consent Form. According to
University policy all documents including those attached to this request remain as draft
versions until fmal IRB approval ofthe study.

I also request permission to utilize your organization's list serve, to access members who
may not attend the meeting at which I present the proposed research. I will only use the list
 126

serve to invite participants if a sufficient number of study participants cannot be accessed at

the regularly scheduled ONEINJ meeting. If permission to use the list serve is granted and if
its use is necessary, I will provide ONEINJ with the necessary information/documents for
distribution to members such as the three documents all other potential participants will
receive and which are attached to this request in draft form.

Please accept my thanks in advance, for your consideration of my requests as outlined in

this letter. In summary, I am a.) Requesting permission to address the ONE/NJ members at a
regularly scheduled meeting, b.) Per SHU requirement, requesting your letter of permission to
attend a ONE/NJ meeting to discuss my proposed research and c.) Asking for your agreement
that I may use the ONE/NJ list serve to invite potential volunteers for my research study if
necessary. If you agree, and for your convenience, I have attached a sample letter for you to
sign and return it in the self addressed stamped envelope by January 5, 20 I O.

Ifyou have any questions, you can reach me at [Link]@[Link] or you may contact
Sharon Venino, Administrative Assistant to the Ph.D. Program, Seton Hall University
College ofNursing at (973) 313-6040. Mrs. Venino will forward your message to me and I
will contact you as soon as possible.

Thank you~ again.

Sincerely,

Mary Ellen Clyne, MSN, RN, NEA-BC

 127

Elizabeth Sheridan
Chair, Chief Nursing Officers Constituency Group
C/O The New Jersey Hospital Association
760 Alexander Road
P.O. Box 1
Princeton, New Jersey
08543-0001

Dear Mrs. Sheridan:

I am a Ph.D. candidate, at Seton Hall University College ofNursing. For my dissertation

research, I plan to conduct a qualitative study to describe and understand the nature ofthe
Chief Nursing Officer's relationship with Staff Nurses working in an acute care hospital.

The purpose ofthis letter is to request an opportunity to address the Chief Nursing
Officers Constituency Group of the New Jersey Hospital Association members during a
regularly scheduled meeting in order to explain the purpose ofmy study and request
volunteers who may be interested in participating in this study. I will need approximately
fifteen minutes time to discuss the study purpose and to answer members' questions, as well
as to explain the requirements for participation in the study. I also plan to distribute written
information about the study and documents the members can review at home before making a
decision about whether to participate. I am enclosing, as part ofmy request, draft copies of
these three documents for your prior review as you consider your response to my request.

The first ofthe three documents is the script I will read to the ChiefNursing Officers as
part of my fifteen minute presentation. The second is a Letter of Invitation in which the CNO
is formally described and requested. It contains directions for interested individuals to return
their signed Consent Form as well as the process I will use to contact those who are
interested. The third and last document is the formal Consent Form for the study
participation.

An important prerequisite for the Seton Hall University application for IRB approval
process is that the researcher demonstrates prior planned access to potential participants for
the study being proposed. Thus, in order to meet this requirement, and because I must
provide the SHU IRB with a Letter ofPermission from those organizations from which I will
seek potential study participants. I am also asking you to forward to me, a letter agreeing to
allow me to address the CNOCG-NIHA for the purpose of seeking participants for my
research study. Because I value your time, I am enclosing a form letter, indicating your
agreement to my request to address members at the CNOCG-NIHA that meets the above
SHU IRB requirement. Once the IRB approves this study I will send you the official IRB
Approval ofthis study, with the approved Letter ofInvitation, and Consent Form. According
to University policy all documents including those attached to this request remain as draft
versions until final IRB approval ofthe study.

I also request permission to utilize your organization's list serve, to access members who
may not attend the meeting at which I present my research. I will only use the list serve to
invite participants if a sufficient number of study participants cannot be accessed at the
regularly scheduled CNOCG-NIHA meeting. Ifpermission to use the list serve is granted
and if its use is necessary, I will provide CNOCG-NIHA with the necessary
 128

information/documents for distribution to members such as the three documents all other
potential participants will receive and which are attached to this request in draft form.

Please accept my thanks in advance, for your consideration of my requests as outlined in

this letter. In summary, I am a.) Requesting permission to address the CNOCG-NJHA
members at a regularly scheduled meeting, b.) Per SHU requirement, requesting your letter of
permission to attend a CNOCG-NJHA meeting to discuss my proposed research and c.)
Asking for your agreement that I may use the CNOCG-NJHA list serve to invite potential
volunteers for my research study if necessary. If you agree, and for your convenience, I have
attached a sample letter for you to sign and return it in the self addressed stamped envelope
by January 5, 2010.

If you have any questions, you can reach me at [Link]@[Link] or you may contact
Sharon Venino, Administrative Assistant to the Ph.D. Program, Seton Hall University
College of Nursing at (973) 313-6040. Mrs. Venino will forward your message to me and I
will contact you as soon as possible.

Thank you, again.

Sincerely,

Mary Ellen Clyne, MSN, RN, NEA-BC

 129

Appendix [Link] Letter Template to Organization

Name of Contact for the Organization

Title of Contact for the Organization
Street Address of the Organization
City, State, Zip Code

Dear Ms. Clyne,

I am in receipt of your letter to the (Name ofthe Organization) indicating you are

seeking pennission as a doctoral candidate from the College ofNursing at Seton Hall

University, to access our membership in an effort to invite potential volunteers for

your research study investigating the, "Nature of the Chief Nursing Officer's

relationship with StaffNurses from an acute care hospital setting."

On behalfofthe (Name of the Organization), permission is granted for you to

invite potential volunteers for your research study. You can access our membership

during our regularly scheduled meeting or if necessary through our list serve.

In closing, if I have any questions, I will contact you at the telephone number

provided or through your Seton Hall University email. If I can be of further

assistance to you, feel free to contact me.

Sincerely,

Signature of Contact from the Organization

Title of Contact Person
 130

AppendixD

Script

My name is Mary Ellen Clyne and I am in the Ph.D. Program, at Seton Hall
University College ofNursing. I am conducting a qualitative research study to
describe and understand the nature of the Chief Nursing Officer's relationship with
Staff Nurses from an acute care hospital setting.

I am here today to invite the Chief Nursing Officers of this Organization to participate
in this study. This study would entail several audio taped interviews with me. Some
interview questions may include, "Tell me about your relationship with your acute
care StaffNurses," and "Share with me how you interact with your Staff Nurses."

Your participation in this research study is completely voluntary. The data collected
for this study will be kept confidential and maintained in a secured locked drawer that
only I will have access to.

I have provided for you a packet of information for your review which includes a
Letter of Invitation, a Consent Form, and a self addressed stamped envelope. I would
appreciate it if you could read through the information and if interested in
participating, return to me the signed Consent Form by April 10, 2010.

If you have any questions when completing documents, you can feel free to contact
me via Sharon Venino, Administrative Assistant to the College ofNursing, Ph.D.
Program at Seton Hall University at (973) 313-6040. She will provide me with your
contact information and I will return your call as soon as possible or if you rather, you
can reach me via email at [Link]@[Link].

Thank you for your time and for considering to participate in this study.

Does anyone have any questions?

Thank you.
 131

Appendix E- Letter of Invitation

Dear Potential Research Volunteer:

I am in the Ph. D. Program, at Seton Hall University College ofNursing. My dissertation

is a qualitative research study of the Chief Nursing Officer's relationship with Staff Nurses

working in an acute care hospital.

Because you are a Chief Nursing Officer, you are being invited to participate in this study

investigating the nature ofthe ChiefNursing Officer's relationship with Staff Nurses from an

acute care hospital setting. The study requires your participation in several audio taped

interviews with me. Examples of interview questions that maybe included are, "Tell me

about your relationship with your acute care Staff Nurses," and "Share with me how you

interact with your Staff Nurses."

Your participation in this research is completely voluntary and there is no penalty if you

do not participate. Although you are not anonymous to me, no one else will know your

identity. Specifically, audio tapes will be coded with a number so that your identity will not

be known to anyone except to the researcher. Study data and identification of participants

will be maintained confidentially and securely locked in a drawer, to which only the

researcher has access.

I invite you to read through the information provided, in the envelope. If you think you

may be willing to participate, please read and return your signed Consent Form to me in the

self addressed stamped envelope within the next week, or by April 10, 2010 at the latest. I
 132

will personally telephone you as soon as I receive your signed consent form to answer any

questions and to discuss your possible participation. If you have any questions, before or

while you are reviewing the documents, please call Sharon Venino, Assistant to the Ph.D.

Program, College ofNursing, Seton Hall University, at (973) 313-6040 and she will forward

your message to me and I will contact you as soon as possible. If you prefer, you can reach

me via email at Mary.C1vne@[Link]. I look forward to hearing from you.

Sincerely,

Mary Ellen Clyne, MSN, RN, NEA-BC

 133

AppendixF

Consent Form

Mary Ellen Clyne is a doctoral candidate at Seton Hall University College of

Nursing. She is conducting a qualitative research study to describe and understand

the nature of the Chief Nursing Officer's relationship with acute care Staff Nurses.

You are being asked to participate in this study because you are the ChiefNursing

Officer, of your acute care hospital (the highest ranking nursing leader in the

organization), you have been/were in your position for at least three and a halfyears,

you know about the nature of the ChiefNursing Officers relationship with Staff

Nurses, and you were not tenninated from your position.

If you agree to participate in this study, you will allow for Mary Ellen Clyne, the

researcher, to conduct a minimum of 2-3 scheduled interviews. The interview

sessions will be open ended and therefore a time limitation cannot be predetennined,

but it is expected that each encounter should last no longer than 2 hours. The meeting

will be schedule at a location and a time of your choice, that will allow for an

uninterrupted, private dialogue between you and Mary Ellen Clyne. The interviews

will be audio taped and transcribed verbatim by a professional transcriptionist who

will not know your identity. The researcher will make observations about the session

which will be recorded as field notes.

 134

There are no anticipated risks or benefits to you for participating in this study.

You may withdraw from this study at any time, without reprisal. There is no cost to

you for participating in this study except your time. Funding for this study will be the

responsibility of the researcher and you will not be paid for your participation.

Overall results from this study will be published in the aggregate. Confidentiality

will be maintained and upheld. Although you may not be anonymous to the

researcher, no one else will know your identity. The researcher and Dissertation

Chair will have access to the field notes, audio tapes, and transcriptions. All data will

be kept in a secured locked drawer to which only the researcher will have access.

Your identity will not be disclosed on any field notes, audio tapes, or transcriptions as

it will be coded with a number which only the researcher will know.

You are encouraged to ask any question about this research study now or in the

future. You can direct your question(s) to Mary Ellen Clyne via email at

[Link]@[Link] or through Sharon Venino, Administrative Assistant to the

College ofNursing, Ph.D. Program at Seton Hall University at (973) 313-6040. If

you prefer, you may contact the Dissertation Chair for this study, Dr. Judith Lothian

at (973) 761-9306. If you have any questions regarding your rights as a human

participant, please contact Mary Ruzicka, Ph.D., Director of Seton Hall University

IRB, at (973) 313-6314. You will be given a copy of this signed consent fonn for

your records at the time of the first interview.

 135

I, (print your name) • hereby authorized my participation in

the research study on the nature ofthe ChiefNursing Officers relationship with acute

care StaffNurses and I consent to be audio taped. I have read the risks of this study.

and I understand that I can withdraw from this study at any time, without reprisal.

Signature of Participant Date

Thank you in advance for considering to participate in this study.

Sincerely,

Mary Ellen Clyne, MSN, RN, NEA-BC

 136

AppendixG

Introductory List Serve Cover Letter

Hello, my name is Mary Ellen Clyne. I am in the Ph.D. Program, at Seton Hall

University College ofNursing, South Orange, New Jersey. I am conducting a

dissertation research study to describe and understand the nature ofthe Chief Nursing

Officer's relationship with Staff Nurses from an acute care hospital setting.

I am writing today, to invite the ChiefNursing Officers of this Organization, to

participate in my study. The study requires you to participate in several audio taped

interviews with me. Some interview questions may include, "Tell me about your

relationship with your acute care Staff Nurses," and "Share with me how you interact with

your Staff Nurses."

Your participation in this research study is completely voluntary. The data

collected for this study will be kept confidential and maintained in a secured locked

drawer that can only be accessed by the researcher.

I have provided two documents for your review with information about this study.

The first document is a Letter of Invitation and the second document is a Consent

Form. After reading through the information, please contact me if you are interested

in participating. I will send you a self addressed stamped envelope which you can

return to me with your signed Consent Form by April 10, 2010.

If you have any questions about the study or when reviewing/completing the

documents, please contact me by telephone through Sharon Venino, Administrative

Assistant to the College ofNursing, Ph.D. Program at Seton Hall University at (973)
 137

313-6040. She will provide me with your contact information and I will return your

call as soon as possible. I can also be reached via email at [Link]@[Link].

Thank you for your time and for considering to participate in this study.

Sincerely,

Mary Ellen Clyne, MSN, RN, NEA-BC

 138

AppendixH

Interview Guideline/Outline

1. Tell me a little bit about yourself?

2. Describe your relationship with your staff nurses?

3. Share with me some examples of your interactions with your staffnurses?

4. How did you :first develop a relationship with the acute care staff nurses when

you started at this organization?