This paper presents findings from an interview with a Director of Nurses at a long-term care facility, examining her leadership philosophy and evolution over a decade of service. The interview explores how the nurse leader employs primarily democratic leadership with situational authoritarian approaches during emergencies, her deliberate transformation from authoritarian to transformational leadership using Kurt Lewin's change theory, and the significant challenges she faces in contemporary healthcare including resource constraints, regulatory compliance, and workforce management. The paper also analyzes the interplay of formal and informal power structures within the organization and their effects on staff relations and organizational effectiveness.
According to the American Nurses Association (2015), "Leaders do more than delegate, dictate and direct. Leaders help others achieve their highest potential." The Director of Nurses (DON) at Meadowbrook Nursing Home has held this position for the last ten years. She began her career as a Licensed Vocational Nurse (LVN) at Meadowbrook, later returned to school and obtained her Bachelor of Science in Nursing in 2013, accepted the House Supervisor position that same year, and became the first female Director of Nurses for Meadowbrook in 2014. An interview conducted on March 18, 2015 explored her leadership style, evolution, organizational challenges, and the role of formal and informal power within her institution.
When asked to describe her leadership style, the DON responded that her approach varies depending on the task at hand. She identifies primarily as a democratic leader who, when facing serious time-sensitive issues, adopts an authoritarian style. According to AANAC (2014), "A Democratic leader encourages open communication and staff participation in decisions. Workers are given responsibility, accountability, and feedback regarding their performance." The DON stated, "I value the relationship I have with my staff. I have an open-door policy, and I encourage my staff to come to me at any time with problems." She emphasized the importance of requiring staff not only to bring problems to her attention but also to propose solutions. This expectation, she noted, allows staff to participate meaningfully in decision-making. She explained, "People go a long way to giving you their best when they feel that they are in this together with you."
During emergencies or chaotic situations where time for discussion is limited—such as a Code Blue—the DON employs an authoritarian leadership approach. According to Tomey (2009), the autocratic leader "maintains firm control, does the planning, makes the decisions, and gives the orders." During critical moments when the team works to revive a patient, she makes decisions and issues orders about patient care until the attending physician arrives. Outside these critical moments, she identifies herself as a democratic leader.
The DON reflected on her first year in the position: "The first year I became the DON was very challenging for me. I was an authoritarian. I gave orders to my staff, and they did what I asked them to do. We were not a team." Her staff responded negatively to this approach, prompting her to make a deliberate change. She aspired to foster staff participation in decision-making and build "team spirit" within the organization.
She recalled a project from her nursing education that involved Kurt Lewin's Change Theory. According to Current Nursing (2011), "Kurt Lewin theorized a three-stage model of change that is known as the unfreezing-change-refreeze model that requires prior learning to be rejected and replaced." Recognizing that her organization needed change, she drew on Lewin's framework to guide her personal and professional transformation. She understood that to change her staff, she first had to change herself. She determined that a transformational leadership style was necessary. Tomey (2009) describes a transformational leader as one "who transforms oneself first to transform others." She reconsidered her role, moving away from the view that she was "the boss" and instead practicing intentional leadership. She held frequent staff meetings, introduced the "team" concept, and modeled collaborative thinking.
As her thinking and practices evolved, the staff gradually rejected the old hierarchical approach. Staff members began participating actively in meetings and offering suggestions for organizational improvement. The "team model" became the established practice at Meadowbrook. By her fourth year as DON, the staff had become receptive to her new management style. The DON recognized that this management by empowerment approach was highly practical for achieving both organizational goals and her personal leadership objectives.
The DON stated plainly, "Being a nurse leader in today's healthcare system is very challenging. We are constantly challenged to deliver the highest quality of care possible with fewer and fewer resources." She referenced a favorite quote from John Maxwell: "Balancing optimism and realism, intuition and planning, faith and fact can be difficult. But that is what it takes to be effective in navigating the leadership." The contemporary healthcare environment presents numerous pressures on nurse leaders. Recent changes in healthcare law and reimbursement systems have intensified cost-reduction demands throughout the industry.
The DON explained the shift in payment models: "In the past, Meadowbrook and other healthcare providers were paid by the volume of care given. That is not the case today. Payment incentives are quickly moving away from volume toward a greater focus on value of services and health outcomes." Expectations for quality and outcomes continue to rise while available resources shrink. She frequently struggles to manage the mounting responsibilities facing nurse leaders. Medicare reductions directly affect patient care delivery at Meadowbrook.
The DON identified multiple specific challenges: implementation and maintenance of a complete Electronic Health Record (EHR) system compliant with HIPAA regulations has been demanding. Achieving financial balance while maintaining high-quality patient care remains difficult. Meadowbrook is working to reduce its 30-day readmission rates, adding another performance metric to manage. Managing a diverse, multigenerational nursing workforce with varying needs creates additional pressure. Justifying resources to executive leadership for continued professional nursing development is an ongoing struggle. Balancing staffing requirements with reduced budgets compounds these difficulties. Performance measures require the organization to exceed 95% on multiple metrics—doing significantly more with substantially fewer resources. Finding personal time and maintaining work-life balance while managing these demands is crucial to the success of today's healthcare system.
In organizational contexts, power refers to the ability to accomplish objectives. Formal power is derived from a position within the organizational hierarchy. The authority and power associated with a position are defined in the job description and are relinquished when one leaves that position (Tomey, 2009). Informal power, by contrast, is not officially designated by position but is earned through individual qualities, relationships, and reputation. A person with informal power can leave a position and retain that power.
When asked about power dynamics at Meadowbrook, the DON noted that her power structure was unusual. She had replaced a former DON who stepped down to the House Supervisor role due to conflicts with executive management. That predecessor remains employed at Meadowbrook in a lower position and reports directly to the current DON. During the first years of her tenure, the DON experienced frequent conflicts with her predecessor. Arguments were common, and the predecessor's informal power negatively influenced staff relations. The predecessor's reputation allowed staff to respond positively to her recommendations even when they contradicted policies and changes the DON attempted to implement. After several meetings between the two, the relationship improved substantially. Today they work well together. Additional informal power issues arise from long-tenured employees who use their seniority and relationships to influence other nurses. Overall, the DON believes formal power is distributed effectively through the organizational chart. However, informal power exists within the organization and continues to function as a force affecting the achievement of organizational goals.
This paper presents findings from an interview with the DON of Meadowbrook Nursing Home, who identifies herself as a democratic leader in most circumstances. She began her tenure as an authoritarian leader but deliberately underwent a transformational shift to become a democratic leader. The DON discussed the numerous challenges she faces in today's healthcare environment, ranging from regulatory compliance to resource management. Both formal and informal power structures within her organization have created challenges over the years, particularly in the first years of her leadership. Despite these pressures, the DON remains committed to her position at Meadowbrook Nursing Home, describing it as challenging yet rewarding.
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