Date of Award

January 2020

Document Type


Degree Name

Doctor of Philosophy (PhD)



First Advisor

Glenda Lindseth


Introduction: Rural residents of the United States are sicker, are at higher risk of death, and have shorter lifespans than those in metropolitan areas (Singh & Siahpush, 2014). Nurse leaders may have the opportunity to influence improved patient outcomes in rural areas. No exploration of nurse leader influence as it relates to nurse-sensitive outcomes in rural healthcare settings was found in the literature. The purpose of this study was to determine the differences among nurse leader influence and nurse-sensitive outcome scores in critical access hospitals, which are rural in nature, in North Dakota as compared to other states in the United States.

Methods: A questionnaire was sent to nursing leaders at 600 critical access hospitals in 20 states in the United States, with results coming from a total of 19 states including North Dakota. The questionnaire included demographics, the Leadership Influence over the Professional Practices Environment Scale (LIPPES), nurse communication data from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, and nursing transfer compliance data from the Emergency Department Transfer Communication (EDTC) survey. Reliability and validity have been established for these surveys. Results of the questionnaire were analyzed using descriptive statistics and comparison of means.

Results: The sample included 28 nurse leaders in North Dakota and 44 nurse leaders from across 18 other states. Demographics showed similarities across the two groups. All categories of nurse leader influence scores in North Dakota were lower than across the other 18 states. Significant differences were found among four nurse leader influence factors of collegial administrative approach, internal strategy and resolve, access to resources, and the overall influence scores. No significant differences were among scores from the Emergency Department Transfer Communication (EDTC) compliance survey nor the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) compliance survey.

Conclusions: Critical access hospital nurse leaders in North Dakota reported comparatively lower collegial administrative approach, access to resources, and internal strategy and resolve levels than those in 18 other states. Support mechanisms should be concentrated on those areas for the leaders in North Dakota. Further research should be conducted to understand the potentially different needs of critical access hospital nurse leaders from their counterparts in larger hospital settings.