The interview focused on a 50-year-old ICU head nurse who worked in a 350-bed capacity hospital. She had held that position for five years after working as an ICU staff nurse for seven years and as a supporting nurse in other units of the hospital. Rita felt that nursing was her calling and that she took pride in her daily contribution to the Intensive Care Unit.
The interviewee reported that her leadership style is situational. In other words, she sometimes adopts the democratic style of leadership when circumstances require her to do so and switch to the autocratic style during dire situations (Bondas, 2006). She believes that a nurse leader ought to engage with her subordinates. In the Intensive Care Unit, it is essential to allow nurses to build a sustainable relationship with patients. This implies granting them a certain degree of autonomy over their work. They also need to make minor decisions about patient care on their own. Furthermore, because of the enormity of work involved in the ICU, it would have been counterproductive to micromanage all aspects of nursing care. Rita, therefore, empowered her subordinates to have a relative degree of independence in their work. In addition, long-term changes in the ICU, such as the purchase of new equipment or rearrangement of the shifting policy may entail input from her subordinates. She may seek their input about areas that need improvement in the unit prior to meeting with the hospital administrators.
On the other hand, she does not always consult or grant staff nurses autonomy when the nurses are new or less experienced. In these situations, she will closely monitor their progress and ensure that they do as required. In addition, she is not consultative about emergency situations. While the interviewee accepted that the ICU is a place where emergencies are common, she also acknowledged that one can easily differentiate between life-changing activities and typical ones. For instance, ICU nurses are required to assess the temperature of hypothermia blankets, empty urimeters, alter intravenous infusions and measure venous pressures as well as other vitals. Such routine work will be done by staff nurses and any decisions to check on them will rest on the concerned nurse. On the other hand, if a cardiac arrest takes place or any other vitals indicate a cause for alarm, then Rita must avail herself and make nursing decisions in those scenarios. There is simply no time for consultation during life and death situations (Frankel, 2008).
Evolution of the leader’s style
Rita explained that her situational leadership style was not her first choice when she got the position of ICU head nurse. She was desperate for approval from her superiors, but still wanted to garner maximum respect from the staff nurses at the unit. This was quite difficult for her because people with who she had worked with her as peers now had to pay attention and listen to her. The interviewee felt that the pressure to prove to her colleagues that she was no longer one of them may have caused her to go overboard. At the time, Rita was highly autocratic and cold. She tried too hard to prevent mistakes and was unforgiving when staff nurses made them. As a result, most of them did not voluntarily report glitches. The head nurse had to identify these incidences independently.
Rita explained that she eventually stopped focusing on trivial mistakes. Instead, she expects her nurses to exercise discretion when errors occur. If it is inconsequential, then they do not have to report it; however, if it is a serious issue, then they must fill in forms and forward the matter. Her decision to give them this power has reduced her workload because she does not have to become perfect to her staff. Additionally, she started feeling isolated from her subordinates as none of them would tell her anything. She thus responded to this occurrence by opening the communication channels between the two entities. Rita remembered the kind of leaders that she looked up to when she was a staff nurse, and embraced those qualities. The interviewee now realizes that all members of the ICU need to work together as a team, and this is a goal that she always seeks when carrying out her daily duties.
Additionally, Rita stopped focusing on managerial aspects alone after she realized that the more strategic aspects of work needed to be handled as well. Usually, she gets insights from her followers concerning these challenges and then forwards their concerns to the hospital administration. Most of her staff told her that they were burnt out owing to the ICU visitation policies, poor management of the ICU shift system as well as the emotional and psychological demands of the job. After learning about these issues, Rita started working on them sequentially. She now feels that these challenges may still exist but their effects are not as weighty as they were before. It is likely that such a holistic approach to her role may not have been possible if decisions were one-sided (Bozell, 2001).
Challenges as a leader in today’s healthcare settings
The interviewee felt that her biggest problem was garnering the support of healthcare administrators. Most of them do not understand the intricacies and challenges involved in running an ICU. They often presume that it is a busier version of conventional nursing wards. Therefore, when she requests policy changes, some administrators may quickly dismiss her suggestions as far-fetched and overambitious. Such decisions are made worse when she gets back to the unit and has to implement her superiors’ instructions even when she does not support them.
The respondent also believed that handling physicians was another complicated leadership role for her. She was aware of the fact that physicians must always be readily available in an emergency unit like hers. However, the hospital often gave specialist units control over certain patients, and this made their physicians difficult to access.
Rita also felt that it was tricky to balance her role as a superintendent for the unit as well as her role as a care provider and mentor. Most of the younger nurses in the unit thought of her as a mother and they expected her to safeguard their welfare for as long as they remained in the unit. Conversely, she needed to play a supervisory role, which may entail taking disciplinary action when matters go out of hand or reporting undisciplined conduct when it arises. These roles sometimes contradict one another and involve a lot of skill in their supervision.
Leading one of the busiest units in the hospital has also taken a psychological toll on Rita. She explains that one must learn how to deal with emergencies all the time. Furthermore, the presence of visitors, 24-hours a day, may cause misunderstandings and fault finding. The interviewee was always aware of the need to avoid errors as this could endanger life. Her responsibilities as a leader were particularly burdensome.
Formal and informal power
Rita felt that her position as an ICU head nurse gave her formal power. She could enact changes concerning daily operations, infrastructure and staff satisfaction in the unit. However, these changes were often made in consultation with her subordinates and with the approval of her seniors. She exercised formal power when carrying out her express duties and used informal power when dealing with issues of mentorship and long-term change (Kuokkanen & Leino-Kilpi, 2000).
Rita found that several physicians sometimes detached themselves from patients’ families during death. This often left her with the burden of conveying the sad news to them. As such, she must exercise informal power. Sometimes some doctors were in denial about the promises of modern medicine and would place an unnecessary load on the ICU nurses to try and save a patient. It was necessary for Rita to exercise informal power and handle these reactions from physicians. This was crucial when most of them were simply coping with their perceived ‘failure’. Doctors have the duty to save lives, so when they are not able to do so, then a number of them may use withdrawal or heroic activities as coping mechanisms. The interviewee would use tactful ways of questioning the necessity of certain procedures.
The respondent in the interview gave practical and useful insights about nursing leadership today. However, her challenges were even more demanding because she supervised a unit in which emergencies were the norm. Her use of autocratic and democratic leadership styles indicates that the latter may not always be appropriate in all situations especially emergencies. Her case also teaches upcoming nurses to avoid the excesses of any leadership approach.
Bondas, T. (2006). Paths to nursing leadership. Journal of Nursing Management, 14, 332-339.
Bozell, J. (2001). Breaking the vicious cycle. Nursing Management, 32 (1), 26-28.
Frankel, A. (2008). What leadership styles should senior nurses develop? Nursing Times, 104 (35), 23-24.
Kuokkanen, L. & Leino-Kilpi, H. (2000). Power and empowerment in nursing: three theoretical approaches. Journal of Advanced Nursing, 31(1), 235-251.