Health care organizations typically have a hierarchical structure, with physicians dominant and nurses subordinate. The challenge to open and honest communication between doctors and nurses is real, and communication errors contribute significantly to undesirable patient outcomes. Nurse executives (NEs) have a responsibility to help lead transformation of health care organizations to support nurses to speak up and communicate all critical information. NEs are challenged to improve safety and quality, decrease costs and increase access to care. Combining health care expertise with business ability can support these goals. Rooke and Torbert found correlations between successful business leaders and postconventional action-logics, or world-views. Action-logics can be developed to make leaders increasingly effective. The Magnet Recognition Program recognizes health care organizations that have achieved high quality care and excellence in nursing practice. The purpose of this study was to determine what action-logics the NEs demonstrate who have led their organizations to Magnet designation or re-designation in the Veterans Healthcare Administration. The study also sought to determine what actions NEs took to support nurses speaking up about their concerns, the barriers that impede those efforts, and the sources of influence these NEs implemented to support nurses speaking up. This exploratory study used a mixed methods design and each participant completed the Maturity Assessment Instrument (MAP) and an interview. The study demonstrated, in contrast with other business leaders, that conventional action- logic was sufficient for the NE to bring an organization to Magnet status. However, the study found specific limitations those possessing conventional action-logic have to support speaking up, and that those possessing postconventional action-logic have transcended these limitations. This strength of the postconventional action-logic is very important to support speaking up in health care. The use of multiple sources of behavioral influence by Magnet NEs was confirmed, as was the existence of a culture of organizational silence. Multiple speaking up behaviors were required to address every single barrier encountered to speaking up, and strong emotion routinely accompanied speaking up. The absence of sources of behavioral influence in an organization was determined to be a barrier to speaking up.

Library of Congress Subject Headings

Dissertations (EdD) -- Organizational change; Nurse administrators -- United States; Leadership -- Case studies

Date of Award


School Affiliation

Graduate School of Education and Psychology



Degree Type


Degree Name


Faculty Advisor

Nero, Susan;