I have worked in healthcare for the last 10 years. I have had the privilege to work as a registered nurse, nurse practitioner, and physical therapist. I have seen various styles of leadership in outpatient rehabilitation, primary care, the emergency department, and psychiatric inpatient/outpatient settings. All the environments are different, but all of them still require a similar set of skills from leadership in order for the staff and organization to be successful. Increasingly, I’ve seen alarming trends of poor leadership that are probably not unlike other industries. Namely, leaders are not selected on the basis of competency; rather, they are chosen based on who they know. They are chosen based on internal agendas from “higher leadership” that might run counter to the culture, ethics, and values that primary staff prioritize. They are specifically selected to be “yes men” or “yes women” in situations where the answer needs to be a resounding no. They control and command rather than collaborate with their staff.
Without directly involving the staff who are on the front lines, there is little awareness of the actual needs of the organization. There is no pulse of any pressing situations that need to be addressed. This leads to continuous disappointment and frustration, which leads to the inability to retain quality staff. The days of companies consistently retaining staff for 20-30 years is over, and for good reason. People understand now more than ever that companies do not value loyalty; everyone is a cog in the wheel that is easily disposable…and replaceable. You can go on any number of Twitter, LinkedIn, or Facebook threads and see these themes repeat themselves over and over again.
I recently read Trust & Inspire: How Truly Great Leaders Unleash Greatness in Others by Stephen R. Covey. The basic principles of Trust & Inspire leadership is one of inspiration, motivation, and modeling behavior. Covey (2022, p.24) describes a Trust & Inspire leader like this:
“It is about seeing, communicating, developing, and unleashing the potential for greatness within people: tapping into what’s inside. It’s intrinsic; it’s already there. Our job is to bring it out, to ignite the fire within, and to create an environment where that’s possible and welcome“.
As I read from cover to cover, I realized how little I have met leaders that remotely resemble the ones described in the text. It wouldn’t surprise me if others had similar experiences. Perhaps some individuals start this way, only to become corrupt by bureaucracy. If you have/had the privilege of working with a Trust & Inspire style of leader, consider yourself fortunate! You are blessed to be in the situation you are in. This contrasts with a Command & Control style of leadership. Some of the differences are highlighted in the table below:
| Command & Control | Trust & Inspire |
| Compliance | Commitment |
| Transactional | Transformational |
| Efficiency | Effectiveness |
| Status Quo and Incrementalism | Change and Innovation |
| Fixed Mindset | Growth Mindset |
| Coordination among Functional Silos | Collaboration among Flexible, Interconnected Teams |
| Control, Contain | Release, Unleash |
| Motivation | Inspiration |
| Manage People and Things | Manage Things, Lead People |
(Covey, 2022, p. 29)
Some of these principles are self-explanatory, whereas others require a little bit more detail. I’ll highlight a few examples of Command & Control so it makes sense:
Command & Control- Example 1: I recently left an organization due to persistent toxic leadership. We had no say over matters pertaining to the schedule, patient flow, admin time, patient care models, or electronic medical record (EMR) system changes. There was so much hypocrisy and a lack of transparency with any decision making that necessitated (but unfortunately lacked) stakeholder involvement. It led to the eventual departure of nearly all my colleagues that I originally started with. Physicians. Nurse Practitioners. Registered Nurses. Licensed Practical Nurses. Admin Staff. All of these staff were gone in a few years. There were veteran clinicians who had been there for 10+ years who finally said enough is enough. Rather than address the elephant in the room, the answer was to simply hire more staff to replace them. There were no real, genuine conversations about the problems that existed. Leaders hid in their ivory tower as drama unfolded, and their doors remained closed as targets were increasingly on their backs. They were the culprits…but they always had scapegoats. The problem with scapegoats is that the common denominator eventually gets revealed over time. You cannot blame staff who are no longer with the company. Eventually, the tables turned and the truth was revealed. There were no more fingers to point outward. This was a classic Command & Control style of leadership. The leaders constantly controlled and contained the staff who voiced concerns. There was no inspiration to propel the organization forward. Their mindset was fixed and there was no collaboration with any stakeholders who needed to be at the table. It was transactional, not transformational.
Command & Control- Example 2: I was briefly a part of another organization that did not value clinician autonomy or individualized decision-making for patients. Rather than value true evidence based practice (i.e. research, clinical expertise, and client/patient values), only one was prioritized, which was his personal clinical experience. The leader became disgruntled after I provided research that ran counter to his beliefs. Rather than finding middle ground, he became resentful. His narrow-mindedness about how to approach patients became increasingly evident when he disagreed with multiple clinical practice guidelines, calling their treatments and recommendations “a scam”. He also had questionable, unethical billing practices. He wanted patients to be seen for the full allotted time (regardless of the situation) because it led to higher revenue for the clinic. There were some discrepancies with his rationale that ran counter to what I had been told by other clinicians. An explanation was provided for my approach, but the rationale was inadequate for him. It was all about compliance and billing codes. This was another great example of Command & Control leadership. He had a fixed mindset, controlling and containing clinicians who deviated from his style of practice. Rather than leading people and managing things, he managed both. I thought he was a leader who valued feedback, only to find out he was a wolf in sheep’s clothing. It was his way or the highway…and thankfully the highway was open.
Trust & Inspire- Example 1: Now let’s take a look at a different type of leader. I previously worked in an outpatient physical therapy setting with another therapist who happened to be my manager. We developed a strong bond during our time together for two reasons. First, he was committed and attuned to my wants and needs as a therapist. He always made sure to check on me if I needed anything in the clinic. We had differences of opinion regarding manual therapy (ex. dry needling practices, joint manipulation effects), but we respectfully understood each other’s perspective, knowing that each point of view had merit. There was no fixed mindset about this particular practice. Second, outside of the clinic, he would text me to hang out and grab a few beers from the local burger bar. We’d sit down, chat about our life, talk about sports, and discuss topics related to PT. I didn’t think much of it at the time, but it made me realize how he was trying to build camaraderie. He took time out of his day to get to know me, and that really meant a lot. These simple acts of kindness went a long way. I eventually did not see him as just a manager: he was a leader and a friend. He was someone I respected. He inspired me to step outside of my comfort zone and demonstrate that type of behavior with other colleagues. Covey (2022) says this about Trust & Inspire:
Trust & Inspire- Example 2: I worked in the emergency department as a registered nurse (RN) for several years. It’s the only specialty I’ve ever worked in as an RN. Even though I was already a physical therapist (PT), it was still challenging. No matter what your background is, there is a large learning curve to being in that environment. Having the right mentors around you can make or break your chance of success. As a matter of fact, I was the only clinician out of 4 who made it through the new hire orientation process (the other 3 nurses were moved to a different unit based on department performance evaluation). I was blessed to work with wonderful nurses and physicians who invested their time in me to ensure I’d be proficient. One particular physician, a friend, was always open to teaching me new knowledge. He taught me ultrasound guided IV insertion, how to interpret EKG, CT and radiographic images, and expanded my understanding of pathophysiology/differential diagnosis. He was always patient and never made me feel like I was a burden when I asked questions. He was inspirational and was committed to helping me become the best RN I could be. He never acted like he was superior and he always stuck up for the nursing staff. He even valued my knowledge as a PT and often asked for advice on patients (he was a DO, so he understood my expertise with the musculoskeletal system). He truly modeled Trust & Inspire leadership. It’s no wonder that he eventually became the assistant EM director of the hospital. He had all the qualities of a great leader. He led by example. This quote by Covey (2022) sums up my colleague very well:
“Trust & Inspire, on the other hand, is about garnering heartfelt commitment that’s freely and enthusiastically given. Commitment is worlds apart from compliance, and it leads to a much higher level of engagement, innovation, and inspiration while creating far greater outcomes” (p. 28).
I look back on all of these experiences with no regret. I’m grateful because it helps me to understand what I genuinely want from leadership going forward. Here are a few lessons that I learned that you can consider for your current or future career:
–Attitude reflects leadership. If the morale is low, there is a reason why. If you’re in the process of being hired, look around and talk to multiple staff about leadership. What do people like about the organization? What do they dislike? Ask about staff retention rates. Ask them to be honest and transparent. Most folks will tell you the truth if you ask for it. Take a mental note of the red flags that pop up.
–No leader is perfect, which is why it is important that the pros outweigh the cons prior to accepting a job position. Write a list of the pros that you notice in the leader/culture/work environment. Then write a list of the drawbacks. If the latter list is longer, consider pursuing other opportunities instead. Leadership and culture are difficult to change in the short-term, let alone in the long run. Although you might be able to make a positive difference, you will be going against the tides. This can be difficult to navigate while simultaneously getting situated with the job demands. It’s unrealistic and you’re immediately at a disadvantage.
–Never settle for less than what you deserve. If certain issues were not disclosed during your hiring process and you are currently in a bad situation, be courageous and speak up. You cannot stand idle and let toxicity continue to permeate into the work environment. There may be opportunities to stand up, speak your mind, and potentially make an impact. If you say nothing, assume that nothing will change. You cannot expect others to be the change that you want to see. You have to be the change agent. There may be real consequences (ex. you might lose your job), but I’d rather be true to myself than follow someone who goes against my values. I have put myself in the line of fire a number of times, and I have never once regretted it. That is not to say that there isn’t a time and place for everything. Pick your spots and speak truthfully.
–Model the behavior you wish to see in others. I might not hold a leadership title, but I still have the capacity to be a great leader. No one is perfect, but everyone has the potential to lead in some capacity. Execute your strengths and demonstrate them to your colleagues. This type of behavior is contagious, and it will undoubtably make a positive impact on your peers. Leadership is a choice, not a position.
This is by no means a comprehensive list of what to look for. Nonetheless, if you’re searching for new job opportunities, or you’re in a tough situation, I hope this post is helpful. You’re not alone with the struggles that you face. Don’t give up and never sell yourself short.