Nursing Leadership: What I Wish I’d Known

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Introduction to Debby A Renner
Debby is one of our valued Interim Chief Nursing Officers who has worked for HTS3-Executive Recruiting for over a year. As a “permanent” interim nursing executive, Debby is equipped with a range of experience spanning across not only stand-alone acute care to multi-facility organizations, as well as prison organizations. Her key focus areas have been on patient safety, policy and procedure development, and staff training.

“Debby is a very knowledgeable and experienced nurse leader who was immersed in a difficult and challenging situation. She skillfully engaged staff and provided candid recommendations for improvement. I highly recommend her” – testimonial from a previous HTS3-Executive Recruiting CNO

We have pleasure in publishing Debby’s a multiple part-series blog where she shares first-hand experience as a leader in the workplace.


Inherently I am a rule follower.  This is sometimes not appreciated or well understood by my peers, organizational leaders or subordinates.  Early in my career as a nurse leader, I failed to realize that the majority of nurses I was assigned to lead were not rule followers.  It was a shocking realization!

My staff could deliberately choose not to follow the rules for a variety of reasons, and only some might be known at the time of decision; with them having taken little accountability for their actions. I wish I could say my shock only occurred once, but unfortunately it happened rather frequently – the liberating fact is that now I am simply far better equipped to deal with it.

I believe strongly it is incumbent upon us as nursing leaders to teach our staff how to become good followers and dissent in a productive, patient-centric, and nurse-safe way. Two-way communication between nursing leaders and staff offers a wealth of benefits, among which will be improved patient care.

  • Policies & Procedures: A Safety Net

One of the most important areas that nurses need to embrace and align themselves to, as a professional is policies and procedures.  Policies and procedures are in place in order to enhance patient safety and provide nurses and others with appropriate guidelines for safe patient care.  Many nurses, including nurse leaders, overlook the dire importance of following the organization’s policies and procedures, not realizing how this provides them with the much-needed protection in case of a possible inadequate outcome resulting from the performance of a particular activity.

Many years ago I was able to hear another nursing leader speak about the unfortunate circumstances leading up to her lifetime banishment from nursing, the profession that she so loved.  Within her organization there were long-standing, seemingly-sanctioned, unit work-arounds to provide patient care.  She had been at the organization quite some time and, like other nurses on the unit, used the work-arounds without a second thought.  However, there was a sentinel event regarding a patient’s outcome where the organization shifted the blame to this nurse.  Why?  Because she had not followed the organization’s sanctioned policies and procedures.  Other nursing leaders had turned a blind eye and thus tacitly approved the work-arounds.  Staff nurses had not come forward proposing a change in the policies and procedures.  If this nurse had come forward with a proposed change to policies and procedures or disregarded the work-arounds perhaps the organization would not have been able to shift the blame for the sentinel event onto her.

  • The Obligation To Dissent

Organizational policies and procedures must reflect nursing practice and vice versa. When this does not occur the two must quickly be aligned with one another. It is not unreasonable to expect that misalignment might occur, but there should be parameters within the organization to remedy the situation, in addition to highlighting the manner in which leadership and staff address each other during the process.

The blue-chip consulting firm, McKinsey & Company, is renowned for one component within its culture – “the obligation to dissent.” It was spearheaded by Marvin Bower, a former managing director of the firm who believed that all staff from a junior associate to a senior partner should be to provide candid feedback in order that clients are best served. But, this candor is also built on a position of humility and honesty, with team members always being assured of hearing transparent feedback. This culture is rarely found, which can explain many of our leadership and staff engagement problems today – in nursing, healthcare and beyond.

  • A Solution May Lie in Diversity and Change Management

As nurse leaders we need to provide serious consideration to the manner in which we engage, manage and motivate our staff.  A key step is to actively involve your team in the alignment of nursing practice to policy and procedure. I do this by intentionally inviting the participation of some of my most rebellious, non-rule following nurses along with highly-regarded, compliant, informal unit nurse leaders. The latter are often considered experts on nursing practice. My intent is to create as diverse a team as possible – not to create the same shock factor I’ve experienced in the past or to encourage conflict, but to ensure our new alignment will incentivize the best performance for all staff.

Once the team is selected, an initial meeting is held to establish expectations of individual participants, expected outcomes and a timeline.  It is important that during the initial meeting you, as the nurse leader, emphasize your role, which is to guide, coach and provide advice. Most nurses have not participated in this type of initiative and might need assistance with areas such as agenda preparation, meeting minute tracking, time management (before and after), assigning responsibilities, and conflict resolution.

As the nursing leader, your guidance might be as basic as helping to outline the initial steps in nursing practice – because most staff do it by rote instead of being able to easily write it down.  Conversely, your guidance may be as sophisticated as performing a literature search and selection of associated, relevant articles. Guidance will definitely be necessary for the actual policy write and/or rewrite.  Again, this is an area where many staff nurses have absolutely no experience and your assistance will be needed in writing the policy broadly enough to be useful and rigid enough to address the patients’ safety and well-being.

As your team works through aligning policies and procedures with nursing practice, you, as their nurse leader, have the opportunity to introduce staff to a solid foundation for:

1) a highly-reliable organization,

2) a Just Culture, and

3) continuing accreditation by the appropriate bodies.

More on this in part 2 of Debby’s blog series.