Nurse Executives Leading Change to Improve Critical Access Hospital Outcomes: A Literature Review with Research-Informed Recommendations


  • Heather V. Nelson-Brantley University of Kansas Medical Center
  • Debra J. Ford Creighton University
  • Karen L. Miller University of Kansas Medical Center
  • Marjorie J. Bott University of Kansas Medical Center



Background and Purpose: Nurses have been called to lead the transformation of health care to provide more efficient, safe, high quality care.  However, little is known about how to prepare and enable critical access hospital (CAH) nurse executives to lead change.  Research indicates that Magnet®-designated hospitals have significantly better patient and organizational outcomes as compared to non-Magnet hospitals. The purpose of this study was to synthesize challenges faced by CAH nurse executives and provide research-informed recommendations for leading change to achieve Magnet standards in CAHs.

Sample and Methods: A review of the literature was conducted to understand the historical development of CAHs and to identify challenges faced by CAH nurse executives. CINAHL, PubMed, and the Rural Health Information Hub databases were searched for relevant peer-reviewed studies and expert commentary published in English from 2007 to 2016. Thirty-four articles were synthesized.

Findings: CAH nurse executives face significant challenges to ensuring their hospitals are providing high quality care including: (a) recruitment, retention, and appropriate staffing ratios; (b) the need for nursing staff with multispecialist knowledge; (c) fewer baccalaureate-prepared nurses; and (d) lack of financial and human resources to support new graduate nurse transition, continuing education, and evidence-based practice.  Recommendations for CAH nurse executives seeking to achieve Magnet standards were developed from interviews with healthcare professionals (N = 27) at the first independent CAH to achieve Magnet designation.

Conclusions: CAH nurse executives may consider the Magnet standards as a blueprint for leading change to improve organizational outcomes.  Consideration should be given to: (a) securing administrative leadership support; (b) strategically planning for small, incremental change; (c) building shared governance, quality improvement, research, and education; (d) harnessing collective power; and (e) believing and staying committed to the purpose of improving staff and patient outcomes.

Keywords: Critical access hospital, Leading change, Magnet, Nurse executive, Quality outcomes

Acknowledgements: The authors thank Dr. Kristin Stegenga, Dr. Robert Lee, Dr. Sally Barhydt, and Jennifer Nelson-Brantley for their review of the manuscript.  Dr. Nelson-Brantley obtained written permission from the CNO of Waverly Health Center to use the hospital name in this published manuscript.

Conflicts of Interest and Source of Funding: Dr. Nelson-Brantley received funding for this study from the Taunton Scholars program and the Delta Chapter of Sigma Theta Tau International.  No conflicts of interest are declared by the authors.


Author Biographies

Heather V. Nelson-Brantley, University of Kansas Medical Center

School of Nursing, Assistant Professor

Debra J. Ford, Creighton University

Interdisciplinary Leadership Doctoral Program, Associate Professor

Karen L. Miller, University of Kansas Medical Center

School of Nursing, Professor and Former Dean

Marjorie J. Bott, University of Kansas Medical Center

School of Nursing, Associate Professor and Associate Dean for Research